Fever
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DATE: July 17, 2009 TIME: 10:15am ASSESSMENT: Received pt lying on bed, conscious and coherent, with ongoing IVF of D5LR at 660cc level in 40gtts/min regulation intact and infusing well on the left arm. CUES Subjective: @ Objective: > teary eyes >dry mucous membrane >flashy face > warm to touch >Temp: 38 Laboratory Analysis: >Lymphocytes: Increased
NX DIAGNOSIS Fever r/t increase pyrogens associated with increase in lymhocytes as to immunoresponse
SCI-EXP Lipopolysaccharides LPS (exogenous pyrogens) ↓ LPS binds to Lipopolysaccharidebinding protein LBS ↓ LPS-LBP complex binds to macrophage receptors ↓ Release of Interleukin 1 and 6 (endogenous pyrogens) ↓ Activate arachidonic pathway ↓ Release of Prostaglandin E2 (PGE2) ↓ Initiates hypothalamus ↓ Generates sytem response ↓ fever
PLANNING After 30min to 1hr of nursing intervention the pt will be able lessen her fever
INTERVENTION > Monitored vs > Provided TSB > Encouraged pt to loosen clothes > Encouraged pt to drink lots of h2o 1-2L/day if tolerated >Applied moisturizer such as cotton with h2o on lips > Removed blankets > Changed position q2hrs > Put pillows along the axilla and inguinal area
> Encouraged pt to change clothes when moistened > Provided cooling techniques such as lightcold blankets > Encouraged pt to eat foods rich in Vit C such as pineapple, grapes juice without artificial color > Administered Paracetamol 1amp IV q6hrs
RATIONALE >For baseline data > To lessen fever > to facilitate heat loss by convection >H20 plays an important role in maintaining the homeostasis of heat > to prevent mucous breakdown resulting to bleeding tendencies > to facilitate heat loss through convection > to facilitate heat loss at the back > This areas are highly warm and needs to lessen heat by not touching both skin to lessen heat > to prevent pulmonary effectation > to lessen heat thereby minimizing fever > Immunoboosters
> Antipyretic
EVALUATION After 30min to -1hr of nursing intervention the pt will be able to lessen her fever as evidenced by: > Temp from 38 to 37.4
NX DIAGNOSIS Fever r/t increase pyrogens associated with increase in lymhocytes as to immunoresponse
SCI-EXP Lipopolysaccharides LPS (exogenous pyrogens) ↓ LPS binds to Lipopolysaccharidebinding protein LBS ↓ LPS-LBP complex binds to macrophage receptors ↓ Release of Interleukin 1 and 6 (endogenous pyrogens) ↓ Activate arachidonic pathway ↓ Release of Prostaglandin E2 (PGE2) ↓ Initiates hypothalamus ↓ Generates sytem response ↓ fever
PLANNING After 30min to 1hr of nursing intervention the pt will be able lessen her fever
INTERVENTION > Monitored vs > Provided TSB > Encouraged pt to loosen clothes > Encouraged pt to drink lots of h2o 1-2L/day if tolerated >Applied moisturizer such as cotton with h2o on lips > Removed blankets > Changed position q2hrs > Put pillows along the axilla and inguinal area
> Encouraged pt to change clothes when moistened > Provided cooling techniques such as lightcold blankets > Encouraged pt to eat foods rich in Vit C such as pineapple, grapes juice without artificial color > Administered Paracetamol 1amp IV q6hrs
RATIONALE >For baseline data > To lessen fever > to facilitate heat loss by convection >H20 plays an important role in maintaining the homeostasis of heat > to prevent mucous breakdown resulting to bleeding tendencies > to facilitate heat loss through convection > to facilitate heat loss at the back > This areas are highly warm and needs to lessen heat by not touching both skin to lessen heat > to prevent pulmonary effectation > to lessen heat thereby minimizing fever > Immunoboosters
> Antipyretic
EVALUATION After 30min to -1hr of nursing intervention the pt will be able to lessen her fever as evidenced by: > Temp from 38 to 37.4
