Assessment
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ASSESSMENT S>”Nagpudot manen rikna na agpudpudot piman kanayun” As verbalized by the daughter. O>Temperature of 38 degrees Celsius. >Skin is warm to touch. >Skin flushing noted. >Sweating is observed. >Removes extra clothing and blanket. >Hyperthermia related to increase metabolic demand secondary to CAP
EXPLANATION OF THE PROBLEM Infection Biologic mediators are released. Circulate to the anterior hypothalamus.
OBJECTIVES STO: After 2 hrs. of nursing intervention the patient’s temperature will decreased from 38 to37.5 or degrees Celsius.
LTO: After 72 hours of nursing intervention the Prostaglandin E2 patient’s temperature will and arachidonic maintain from a normal acid metabolites are range of 36.5-37.5 degrees produced. Celsius. Induce the formation of secondary messengers such as cyclic AMP. Rise in the thermoregulating set point. Heat production Fever
INTERVENTION Dx: > Monitor and record vital signs especially the temperature. > Assess for factors that contribute to hyperthermia such as infection. Tx: > Provide comfort measures such fixing his linens. >Do TSB. >Remove extra clothing’s. >Provide adequate ventilation and introduce fanning. > Administer antipyretics PRN as ordered. Edx: > Advise to increase fluid intake. >Encourage to eat nutricious foods such as fruits and vegetable. >Instruct the SO to do necessary cooling measures.
RATIONALE
> To determine occurrence of hyperthermia. >To know what is causing the fever.
> To lessen irritability. > To regulate body temperature thorugh heat conduction and evaporation. > To reduce source of heat. > To reduce heat using cooling mechanism of air conduction. > To reduce body heat by inhibition of prostaglandins in the CNS. > To replace fluid loss due to sweating. > To acquire nutrients that will regain strength. > Promotes cooperation and independency.
EVALUATION
EXPLANATION OF THE PROBLEM Infection Biologic mediators are released. Circulate to the anterior hypothalamus.
OBJECTIVES STO: After 2 hrs. of nursing intervention the patient’s temperature will decreased from 38 to37.5 or degrees Celsius.
LTO: After 72 hours of nursing intervention the Prostaglandin E2 patient’s temperature will and arachidonic maintain from a normal acid metabolites are range of 36.5-37.5 degrees produced. Celsius. Induce the formation of secondary messengers such as cyclic AMP. Rise in the thermoregulating set point. Heat production Fever
INTERVENTION Dx: > Monitor and record vital signs especially the temperature. > Assess for factors that contribute to hyperthermia such as infection. Tx: > Provide comfort measures such fixing his linens. >Do TSB. >Remove extra clothing’s. >Provide adequate ventilation and introduce fanning. > Administer antipyretics PRN as ordered. Edx: > Advise to increase fluid intake. >Encourage to eat nutricious foods such as fruits and vegetable. >Instruct the SO to do necessary cooling measures.
RATIONALE
> To determine occurrence of hyperthermia. >To know what is causing the fever.
> To lessen irritability. > To regulate body temperature thorugh heat conduction and evaporation. > To reduce source of heat. > To reduce heat using cooling mechanism of air conduction. > To reduce body heat by inhibition of prostaglandins in the CNS. > To replace fluid loss due to sweating. > To acquire nutrients that will regain strength. > Promotes cooperation and independency.
EVALUATION
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