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 !" ³Hyperthermia Presence of #$$%  &   After 1 hour of
´Nurse, parang related to pneumonia After 1 hour of 1. Monitor vital 1.Vital signs
nursing
mainit ung tatay bacterial infection appropriate signs. provide more
ko´ as verbalized as manifested by nursing 2. Provide tepid accurate intervention,
by the daughter of flushed skin, intervention the sponge bath. indication of core
the client¶s
the patient. increased Caused by patient¶s Do not use temperature.
respiratory rate of invasion of temperature will alcohol. temperature
 !" 45cpm, microorganisms in decrease from 2.TSB helps in
decreased from
Flushed skin diaphoresis, warm the lungs 38.6 oC to 37 oC. 3. Remove lowering the body
to touch with a excess clothing temperature and 38.6 oC to 37 oC
Increased temperature of 
$% and covers. alcohol cools the
as evidenced by
38.6 oC´ After 4 hours or skin too rapidly,
respiratory rate Human body¶s appropriate 4. Promote a well - causing shivering. decreased
immune system nursing ventilated area Shivering
diaphoresis and
Diaphoresis reacts to infection intervention the to patient. increases
patient¶s vital metabolic rate calm breathing.
Warm to touch signs will return to 5. Advise patient and body
normal range with to increase oral temperature
VS: Resulting to a temperature of fluid intake. After 4 hours of
-BP: increased of 36.5 oC - 3.These decrease
nursing
180/90 respiratory rate 37.5oC,pulse rate 6. Maintain bed warmth and
-PR: of 60-100bpm. rest. increase intervention the
109 evaporative
patient¶s vital
-RR: 45 7. Provide high- cooling.
-Temp: Excessive calorie diet. signs returned to
38.6 oC sweating 4.To promote
normal range.
clear flow of air in
the patient¶s area.
8. Educate and One way of
Skin warm to advise support promoting heat
touch system loss.
(relative) to do
 TSB when 5.Additional fluids
patient feels help prevent
Increased in body hot. elevated
temperature - Make sure temperature
that armpits associated with
and groins dehydration.
were included 6.Reduce
in doing TSB. metabolic
demands/ oxygen
9. Monitored VS consumption
and recheck.
 7.To meet
increased
metabolic
demands.

8.Teaching the
Support system
the right way to do
TSB will help in
knowing what to
do in case the
patient¶s
temperature
increases

9.To know the

effectiveness of
nursing
interventions
done and to know
the progress of
patient¶s
condition.