ASSESSMENT NURSING PATHOPHYSIOLOGY PLANNING NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTION

Fever Hyperthermia Presence of After 2 Independent: After 3 hours

related to infectious agents in hours of • Increase • To of Nursing
Subjective viral Infection the body Nursing the support intervention,
Cues: as intervention, patient’s circulati the patient was
“mainit ung manifested the patient fluid intake ng able to:
pakiramdam by increase in Lymphocytes are will: Achieved a
volume
ko.” body stimulated Achieve a lower body
As verbalized temperature lower body temperature,
by the patient. above Lymphocytes temperature • Promote • To from 37.8°C to
normal, and Release Pyrogenic , from surface decreas 37.5°C
Objective flushed skin. cytokines 37.8°C to cooling by e
Cues: 37.5°C means of tempera Goal met.
Pyrogenic cytokines tepid ture by
· Flushed skin, Stimulates Anterior sponge evapora
warm to bath tion and
hypothalamus
touch. conducti
Leads to Elevated on.
· Restlessness
. thermoregulatory set
• Have the • Facilitat
· Above point
patient e heat
normal body lightly loss by
temperature Results to Increased dressed radiatio
of Heat conservation n and
37.8°C (Vasoconstriction/be conducti
haviour changes) on
And Increased Heat
production • Maintain • To
(involuntary bed rest reduce
muscular metabol
contractions) Dependent: ic
demand
• Administer s
paracetam
FEVER
ol
500mg/tab • To
 q4 hrs prn facilitat
for T≥37.8 e fast
as ordered recover
y
Collaborative:

• Provide
high- • To meet
calorie diet increase
d in
metabol
ic
demand
s