TERMOREGULATION Nursing Care Plan of Client with Hypertermia Caused by Infection Oral Temperature Measurement

This Paper is Prepared to Fulfill The Task of Termoregualtion I Subject Coordinator : Ns. Reni Sulung Utami, S.Kep., M.Sc.

Submitted by : L.S. Lintang Kinanti Priskhila Laras Santi Quartilosia Pinastika S. Arif Tri Subekti Ade Rahmah Yulia Nur Hafizhah Widyaningtyas Harin Hidayahturochmah (22020110120006) (22020110120048) (22020110120049) (22020110120056) (22020110130093) (22020110141022) (22020110141046)

SCHOOL OF NURSING FACULTY OF MEDICINE DIPONEGORO UNIVERSITY 2012 Nursing Care Plan of Client with Hypertermia Caused by Infection

Nursing Care Plan of Client with Hypertermia Caused by Infection Data Analyze 1 DO : T : 39C P : 80 RR : 21 times/minute Bp : 100/80 mmHg Diare Nursing Problems Increase Body temperature Etiology of Infection process salmonella thypi Nursing Diagnose Increase of Body of temperature related to infection process of salmonella thypi.5

3.

DS : Family said that Patient often delirious and speech is not clear. Fatique Bittter Tongue DO : Nutrition Inadequate White colored imbalance less absorption tongue, dry skin, than body requirement DS : Patient feel nausea, and experiencing vomit, diarrhea, decresing appetite DO : Activity Weakness alert and awake , intolerance fatigability noted , weakness noted , need asistance in doing ADL ,prestlesness noted (ADL : Activity Daily Living) DS : Patient said that he feel fatigue and weak.

Nutrition imbalance less than body requirement related to inadequate absorption

Activity intolerance related to generalize weakness

No Diagnose 1

Goals and Intervention Rasional Outcome Increase of Body Independent : Independent : Body temperature 1. Monitor patient 1. Fever temperature will decrease temperature degree pattern may related to after 7 days and pattern aids in infection of nursing 2. Observe for diagnosing process of intervention. shaking chills and underline salmonella profuse diaphoresis. deases thipy T, P, RR, BP, in 3. Wash hand with normal antibacterial soap 2. Chills often condition before and after each brecede during after 7 days care of activity and high of nursing encourage proper temperature and intervention hygiene presence of 4. Provite tepid generalized sponge baths and infection avoid the use of ice 3. Reduces water and alcohol cross 5. Monitor for signs contamination of deterioratior of and prevent the condition or failure to spread of improve with infection therapy. 4. May help reduce fever. Colaborative : Use of ice water 1. Administer and alcohol antipyretics as may cause chill prescribed and can elevate 2. Administer temperature antibiotic as 5. May prescribed reflects inappropriate antibiotic therapy Collaborative : 1. Used to reduce fever by its central action on the hypotalamu s 2. To control the spread

of infection

2.

Nutrition imbalance less than body requirement related to inadequate absorption

The bodys Independent : nutritional 1. Assess clients needs are nutritional pattern fulfilled with 2. Assess clients food outcomes: preference and food Increased dislikes appetite 3. Recommended bed rest or activity restriction Ideal during the acute phase weight 4. Measure weight every day 5. Asses client to eat lessbut often Colaborative : 1. Collaboration with dietrition

Independent : 1.Know clients diet, eating habit, and mealtime. 2. Improve the status of preferred foods and avoid foods that are not favored. 3. Energy restriction reduci bodys working 4. Know the decreasing or increasing weight 5. Decrease intestine activity , avoid eating boredness Collaborative : 1. Know the recommende d and unrecommen ded food

3.

Activity intolerance related to generalize weakness

After 23hours of nursing intervention , patient will be able to do ADL as tolerated . ADL : Activity Daily Living

Independent : 1. Acess patient level of mobility 2. Acess ability to stand and move about and degree of asistance necessary 3. Acess potential for psychical injury with activity 4. Acess emotional respones to change in phsycal status 5. Assisted with ADL 6. Provide adequat res t periode esspecially before meal, other ADLs , ambulation

Independent : 1. This aids defining what patient is capable of which is necessary before setting realistic goals 2. To determine curent status and needs acociated with participation in needs or desire activities 3. injury may be related to falls or over exertion 4. depression of inabilty to perform requried activities can further aggravate the acitvity in tolerance 5. Asissting the patient with ADL allow for conservation of energy 6. rest between activies provides time energy conservation and recovery

A. DEFINITION OF ORAL TEMPERATURE MEASUREMENT

oral temperature measurement is the most common site used to measure body temperature. it is accessible and responses promptly to changes in the core temperature.1

B. ORAL TEMPERATURE MEASUREMENT2

NO 1.

STEP Asses for sign and symptoms of temperature alterations and factor that influence body temperature

2.

3.

Determine any previous activity that would interfer with accuracy of temperature measurement. When taking oral temperature, wait 20-30 minutes before measuring temperature if client has smoked or ingested hot or liquids or foods. Determine appropiate temperature site Chosen based on and device for client advantages and disadvantages for each site. Glass thermometer is used for client who is on isolation precautions.

RATIONALE Physical sign and symptoms may indicate abnormal temperature. Nurse can accurately asses nature of variations Smoking or oral intake of food or fluids can cause false temperature reading in oral cavity

4.

Explain way temperature will be taken Cliens are often curious and importance of mantaining proper about such measurements positition until reading is complete. and should be cautioned against prematurely removing thermometer to read result 5. Wash hands Reduces transmition of microorganisms 6. Asist clien in asuming comfortable Ensures comfort and posittion that provides easy access to accuracy of temperature temperature site. reading 7. Obtain temperature reading a. Glass Temperature Apply disposable gloves Maintains standart precaution when exposed to 1) items soil with body fluids (e.g., saliva) 2) Hold end ( if color-coded, tip will be Reduces contamination of blue) of glass thermometer with thermometer bulb fingertips 3) Read mercury levels while gently Mercury should be below 0 0 rotating the thermometer at eye level. 35,5 C (95.9 F). If mercury is above desired level, grasp Thermometer reading must tip of thermometer securely, stand be below clients equal away from solid objects, and sharply temperature before use. flick wrist downward. Continue Brisk shaking lowers shaking until reading is below 35,5 0C mercury level in glass tube (95.9 0F) 4) Insert thermometer into plastic sleeve Protects from contact with cover (optional) saliva 5) Ask client to open mouth and gently Heat from superficial blood place thermometer under tongue in vessels in sublingual pocket posterior sublingual pocket lateral to produces temperature senter of lower jaw. reading. 6) Ask client to hold thermometer with Maintain proper position of lips closed. Caution client against thermometer during bitting down on thermometer recording. Breakage of thermometer may injure mucosa and cause mercury poisoning 7) Leave thermometer in place for 3 min Studies vary as to proper or according to agency policy length of time for recording. Holtzclaw (1998) recommendeds 3 minutes. 8) Carefully remove thermometer, Prevents cross remove and discard plastic sleeve contamination. Ensure cover in appropiate receptacle if use. accurate reading

9)

Avoids contact of microorganisms with nurses hands. Wipe from area of least contamination to area of most contamination. Glass thermometers should not be shared between clents unless terminal disinfection is performed between each measurement. Protective storage container prevents breakage and reduces risk of mercury spill. 10) Remove and dispose of gloves in Rwduce transmission of appropriate receptacle. Wash hands. microorganisms. b. Electronic Thermometer 1) Apply disposable gloves (optional) Use of oral probe cover, which can be removed without physical contact, minimizes need to wear gloves 2) Remove thermometer pack from Charging provides battery charging unit. Attach oral probe (blue power. Ejection button tip) to thermometer unit. Grasp top of releases plastic probe cover probe stem, being careful not to apply from tip. pressure on the ejection button. 3) Slide disposable plastic probe cover Soft plastic cover will not over thermometer probe until cover break in clients mouth and locks in place (see illustration) prevents transmition of microorganisms between clients 4) Ask client to open mouth; then gently Heat from superficial blood place thermometer probe under tongue vessels of sublingual pocket in posterior sublingual pocket lateral to produces temperature center of lower jaw reading. With electronic thermometer, temperatures in right and left posterior sublingual pocket are significantly higher than in area under front of tongue. 5) Ask client to hold thermometer probe Maintains proper position with lips closed. of thermometer during recording. 6) Leave thermometer probe in place until Probe must stay in place audible signal occurs and clients until signal occurs to ensure temperature appears on digital display; accurate reading

Gently rotate until scale appear. Cleanse any additional secretions on thermometer by wiping wuth clean soft tissue. Wipe in rotating fashion from fingers toward bulb. Dispose of tissue in appropriate receptacle. Store thermometer in appropriate protective storage container.

7) 8)

remoove thermometer probe from under clients tongue. Push ejection button on thermometer stem to discard plastic probe cover into appropiate receptacle. Return probe to storage position of thermometer unit.

Reduces transmition microorganisms.

of

9) 10)

Protects probe from damage. Returning probe automatically causes digital reading to disappear If gloves worn, remove and dispose in Reduces transmission of appropriate receptacle. Wash hands. microorganisms. Return thermometer to charger. Maintains battery carge.

C. STRENGTH POINT OF ORAL TEMPERATURE MEASUREMENT 1. Accessible-requires no position change

2. Comfortable for client. It supported by a journal discussion which

mention that oral temperature measurement has an easy access to the pocket of sublingual on the mouth. It make client feel comfort.6 3. Provide accurate surface temperature reading
4. The changes of body core temperature could quickly detected.6

D. WEAKNESS POINT OF ORAL TEMPERATURE MEASUREMENT

1. Affected by ingestion of fluids or foods, smoke, and oxygen

delivery. The consumption of water with several variation of temperature will manipulate the oral temperature.3 The temperature will altered if patient do those things within 15 minutes of measurement.4 2. Should not be used with clients who have had oral surgery, trauma, history of epilepsy, or shaking chills.
3. Should not be used to infants, small children (couldnt bit

thermometer well) or confused, unconcious, or uncooperative clients.2 4. Risk of body fluid exposure. 5. Inaccurate temperature cause by breathing rate especially after doing exercise, affected by head and facial temperature

6. Take a longer time for getting the result. Because the measurement

should take long and continuous proceess to avoid the inaccuracies and wrong perception.6 7. Has a fluctuative accuracy
8. Influenced by inaccurate placement of thermometer4

REFERENCES
1. Gagel, Yeung Escalaunte. 2009. Medical care of cancer patients. USA: BC

Decker Inc.
2. Perry & Potter. 1998. Fundamentals of nursing. E/5. USA: Mosby Inc. 3. Engelen, L. et.all. 2002. The effect of oral temperature on the temperature

perception of liquids and semi-solids in the mouth chapter 7. European Journal of Oral Science
4. Kline, Andrea M. et all. Hazards in neonatal and pediatric thermometry. Safe

Practices in Patient Care. www.safe-practices.org

5. Deang, Kathleen Dianne. et.all. Typhoid fever. Angeles City. Angeles University

Foundation College of Nursing. www.scribd.com

6. Sutto, Cassandra. 1999. Oral versus axilla temperature measurement: a review

of the evidence.