Ncp Fever
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ASSESSMENT Subjective ”Nurse, parang mainit ung nanay ko” as verbalized by the relative of the patient. Objective • Temperature: 38.6C • RR: 26cycle per minute • • Hot, flushed skin • Increased respiratory rate • Diaphoresis • Warm to touch
NURSING DIAGNOSIS Hyperthermia related to bacterial infection. Definition: Body temperature elevated above normal range.
PLANNING Short Term After 1 hour of appropriate nursing intervention the patient’s temperature will decrease to 37.5oC. Long Term After 4 hours of appropriate nursing intervention the patient’s vital signs will return to normal range; with a temperature of 36.5-37.5oC,pulse rate of 60-100bpm and respiratory rate of 12-20 cycles per min.
NURSING INTERVENTION Independent 1. Monitor vital signs.
2. Provide tepid sponge bath. Do not use alcohol.
RATIONALE
•
Vital signs provide more accurate indication of core temperature.
•
TSB helps in lowering the body temperature and alcohol cools the skin too rapidly, causing shivering. Shivering increases metabolic rate and body temperature
•
These decrease warmth and increase evaporative cooling.
3. Remove excess clothing and covers.
4. Promote a wellventilated area to patient.
5. Advise patient to increase oral fluid intake.
6. Maintain bed rest.
•
To promote clear flow of air in the patient’s area. One way of promoting heat loss.
•
Additional fluids help prevent elevated temperature associated with dehydration.
•
Reduce metabolic demands/ oxygen consumption
7. Provide highcalorie diet.
8. Educate and advise support system (relative) to do TSB when patient feels hot. • - Luke warm water only. - Make sure that armpits and groins were included in doing • TSB.
To meet increased metabolic demands. Teaching the Support system the right way to
9. Monitored VS and recheck.
Dependent 10. Provide antipyretic medications as indicated.
do TSB will help in knowing what to do in case the patient’s temperature increases
•
To know the 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.
NURSING DIAGNOSIS Hyperthermia related to bacterial infection. Definition: Body temperature elevated above normal range.
PLANNING Short Term After 1 hour of appropriate nursing intervention the patient’s temperature will decrease to 37.5oC. Long Term After 4 hours of appropriate nursing intervention the patient’s vital signs will return to normal range; with a temperature of 36.5-37.5oC,pulse rate of 60-100bpm and respiratory rate of 12-20 cycles per min.
NURSING INTERVENTION Independent 1. Monitor vital signs.
2. Provide tepid sponge bath. Do not use alcohol.
RATIONALE
•
Vital signs provide more accurate indication of core temperature.
•
TSB helps in lowering the body temperature and alcohol cools the skin too rapidly, causing shivering. Shivering increases metabolic rate and body temperature
•
These decrease warmth and increase evaporative cooling.
3. Remove excess clothing and covers.
4. Promote a wellventilated area to patient.
5. Advise patient to increase oral fluid intake.
6. Maintain bed rest.
•
To promote clear flow of air in the patient’s area. One way of promoting heat loss.
•
Additional fluids help prevent elevated temperature associated with dehydration.
•
Reduce metabolic demands/ oxygen consumption
7. Provide highcalorie diet.
8. Educate and advise support system (relative) to do TSB when patient feels hot. • - Luke warm water only. - Make sure that armpits and groins were included in doing • TSB.
To meet increased metabolic demands. Teaching the Support system the right way to
9. Monitored VS and recheck.
Dependent 10. Provide antipyretic medications as indicated.
do TSB will help in knowing what to do in case the patient’s temperature increases
•
To know the 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.
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