SALVADOR, JHON KELVIN C.

BSN 211 Cues Subjective Cues: Nilagnat ako kanina pagkagaling ko sa ultrasound (2d-Echo) ang lamig kasi as stated by the client. Sobra lamig dun sa kwarto nanginginig nga ako eh as stated by the client. Oo masakit ang ulo ko as stated by the client. Mainit na ngayon ang pakiramdam ko as stated by the client. Nursing Diagnosis Hyperthermia related to illness (High Blood Pressure) as evidenced by increase in body temperature greater than normal range and flushed skin Analysis Stimulation of the Hypothalamus Goals and Nursing Objectives Interventions GOALS: Independent By the end of the 8 hour Monitor shift, the Temperature. clients temperature will drop from 38.1 to normal range OBJECTIVES: After 8 hours of nursing interventions, the clients temperature will maintain core temperature within normal range. After 3 mins. of discussion, the client will be able to identify the Rationale Evaluation The clients temperature drops to 37.5 which is within normal range.

Increase or alteration of Thermoregulation

The baseline temperature can guide the treatment. (Textbook of basic nursing, Rosdahl, Kowalski pg. 698) Increased metabolic rate and diaphoresis associated with fever cause loss of body fluids. (Nursing Diagnosis Handbook, 8th Edition, Ackley) Bathing and clothing changes increase comfort and decrease the

Increase in Body Temperature

Assess fluid loss and facilitate oral intake or administer intravenous fluids to replace fluids.

The clients core temperature was maintained within normal range.

Hyperthermia

When diaphoresis is present, assist the client with

The client was able to identify normal range of

Objective Cues: Temperature: 38.1 OC BP: 220/110 mmhg RR: 21 bpm PR: 82 bpm Sweating is present Chilling is present Flushed skin Restlessness Weak appearance Difficulty in moving

normal range of temperature in the span of 1 min. After 3 hours of nursing interventions, the client will demonstrate behaviors to monitor and promote normothermia.

bathing and changing into dry clothing.

possibility of continued shivering caused by water evaporation from the skin. (Nursing Diagnosis Handbook, 8th Edition, Ackley)

temperature within 1 minute.

Advise to maintain bed rest

To reduce metabolic demands / oxygen consumption (Nurses Pocket Guide, 11th ed., Doenges, Moorhouse, Murr, pg. 386) Fans: heat loss by convection Tepid sponge bath: heat loss by evaporation. (Nurses Pocket Guide, 11th ed., Doenges, Moorhouse, Murr, pg. 385)

The client was able to demonstrate behaviors to monitor and promote normothermia

Promote surface cooling by means of cooling environment and/or fans; tepid sponge baths.

Dependent: Administer antipyretics orally as ordered.

Antipyretics work by getting the "thermostat" in the hypothalamus to override the interleukininduced increase in temperature. The body will then work to lower the temperature to the new, lower temperature and the result is a reduction in the fever. (Kasper DL et al, editors: Harrison's principles of internal medicine, 16th ed, New York, 2005, McGraw-Hill.) It is generally more important to treat the underlying cause

Collaborative: Work with the physician to help determine the cause of the

temperature increase, which will often help direct appropriate treatment.

of the temperature increase than to treat the symptom of fever (Henker R, Carlson KK: Fever: applying research to bedside practice, AACN Adv Crit Care 18(1):7687, 2007) Such methods reduce exposure to high environmental temperatures, which can cause heatstroke and hyperthermia. (Worfolk JB: Heat waves: their impact on the health of elders, Geriatric Nursing 21:70, 2000.)

Teach the client to stay in a cooler environment during periods of excessive outdoor heat or humidity. If the client does go out, instruct him or her to avoid vigorous physical activity, wear lightweight, loose-fitting clothing, and wear a hat to minimize sun exposure.