NURSING NURSING

ASSESSMENT PLANNING RATIONALE

DIAGNOSIS INTERVENTION

Subjective Hyperthermia Short Term Independent

”Nurse, parang related to bacterial After 1 hour of 1. Monitor vital • Vital signs
mainit ung nanay infection. appropriate nursing signs. provide more
ko” as verbalized by intervention the accurate
the relative of the Definition: patient’s indication of
patient. Body temperature temperature will core
elevated above decrease to 37.5oC. 2. Provide tepid temperature.
Objective normal range. sponge bath. Do
• Temperature: Long Term not use alcohol. • TSB helps in
38.6C After 4 hours of lowering the
• RR: 26cycle appropriate nursing body
per minute intervention the temperature and
• patient’s vital signs alcohol cools the
will return to skin too rapidly,
• Hot, flushed
normal range; with causing
skin
a temperature of shivering.
• Increased 36.5-37.5oC,pulse
respiratory rate Shivering
rate of 60-100bpm 3. Remove excess increases
• Diaphoresis and respiratory rate clothing and metabolic rate
• Warm to touch of 12-20 cycles per covers. and body
min. temperature

• These decrease
4. Promote a well- warmth and
ventilated area increase
to patient. evaporative
cooling.
 • To promote
5. Advise patient clear flow of air
to increase oral in the patient’s
fluid intake. area. One way
of promoting
heat loss.

6. Maintain bed • Additional

rest. fluids help
prevent elevated
temperature
7. Provide high- associated with
calorie diet. dehydration.

• Reduce
metabolic
8. Educate and demands/
advise support oxygen
system (relative) consumption
to do TSB when
patient feels hot. • To meet
- Luke warm increased
water only. metabolic
- Make sure that demands.
armpits and
groins were
included in doing • Teaching the
TSB. Support system
the right way to
9. Monitored VS do TSB will
and recheck. help in knowing
what to do in
case the
patient’s
temperature
increases

Dependent
10. Provide
antipyretic
medications as • To know the
indicated. effectiveness of
nursing
interventions
done and to
know the
progress of
patient’s
condition.

• These drugs
inhibit the
prostaglandin
that serve as
mediators of
pain and fever.