Fever
Fever
Fever
Bumababa yung temperature niya tapos tumataas din as verbalized by the mother. Objective: Febrile (38.5C) Skin warm to touch Irritable PR of 142 bpm
DIAGNOSIS Ineffective thermoregula tion: Hyperthermia related to released pyrogens secondary to inflammatory response.
RATIONAL E Damaged tissues stimulate initial inflammato ry response that resulted to stimulation of hypothala mus, secreting pyrogens which are responsible for increasing bodys core temperatur e.
PLANNING
INTERVENTI ON
RATIONALE
To provide a baseline data of clients existing disease condition To determine the progress of clients condition. To promote heat loss by convection, evaporation and conduction.
After 4 hours Assessed clients of nursing condition. intervention client will be able to:
Monitored vital Decrease signs core body temperature especially the temperature. to 37 - 38.0 C. Promoted surface cooling Demonstrat through tepid e sponge bath behaviours and to monitor and promote maintaining a normotherm cool quiet environment ia. Encouraged increase fluid intake. Encouraged to take adequate rest. Aeknil given @6pm as ordered
To avoid dehydration and decrease clients temperature. To reduce metabolic demands and oxygen consumption. To provide pharmacologic effect on the patient
Goal met