Nursing Diagnosis Inference Plan of Care Nursing Intervention Rationale Evaluation

Hyperthermia Hyperthermia is a At the end of •Monitor the patient •To provide baseline data and After the end of
related to presence condition where 2hours of nursing vital signs especially fever pattern may aids in 2hours of nursing
of infection an individual's intervention, the temperature diagnosis underlying disease intervention, the
secondary to body temperature patient will have a •Adjust and monitor •To regulate temperature of patient temperature
dengue infection as is elevated temperature within environmentat factors the patient decrease from
manifested by beyond normal normal range like room temperature temperature 39.1 to
due to failed and blankets and 37. 7
thermoregulation.
Subjective: linens may be
The person's
Father verbalize adjusted
body produces or
“nilagnat yan •Eliminate excess •To room air decreases
absorbs more
kahapon tapos ang heat than it clothing and covers- warmth and increases
taas ng lagnat niya” dissipates exposing skin evaporative cooling
•Observe for shaking •Chills often precede during
Objective: and chills high temperature
Increase in body •Provide tepid sponge •May help to reduce fever.
temperature above bath and avoid the use Use of ice water and alcohol
normal range of ice water and may cause chills and can
T=39.1 alcohol elevate temperature
Increase •Encourage patient to •To prevent dehydration
respiratory rate increase fluid intake
RR=30 •Advise to eat healthy •To enhance immune system
Skin is flushed and foods especially high against infection
warm to touch, in vitamin C (fruits)
body weakness and •Administer anti- •Used to reduce fever by its
presence of chills pyretics central action on the
hypothalamus
•Maintain and •To prevent dehydration
regulate properly the
IV fluids as ordered
•Administer •To control the spread and
antibiotics as treat the infection
prescribed