NCP 1: Hyperthermia related to the body's response to infection characterized by flushed skin, hypotension, skin warm to touch, tachycardia

and tachypnea.
Assessment Explanation of the problem Objectives Nursing intervention Rationale Evaluation

Subjective: Hyperthermia is elevated body STO: Dx: STO: Goal met

temperature due to a break in
“Madmadi riknak kasla thermoregulation that arises Within 4 hours of effective a. Assessed and identified contributory a. Determination and management of the After 4 hours of effective
nagpudut”, as verbalized when a body produces or nursing intervention the patient factors to fever. contributory factors are necessary to nursing intervention the
by the patient absorbs more heat than it will stabilize temperature within recovery. patient will stabilize
dissipates. In the case of the normal range from 38.1 to 37 temperature within normal
degree Celsius. b. To assist in creating an accurate range from 38.1 to 37 degree
patient, he experienced elevated b. Monitored the patient’s vital signs at diagnosis and monitor effectiveness of Celsius.
body temperature. Because of least every 4 hours. medical treatment, particularly the
the obstruction in the ureter,
antibiotics and fever-reducing drugs
Objective: retention of urine within the LTO: administered.
kidneys occur. The abnormal LTO: Goal met
-Temperature of 38.1 urine flow gives bacteria at the Within 72 hours of effective
degree celsius opening of the urethra a chance nursing intervention the patient After 72 hours of effective
c. Monitor fluid intake and urine output. nursing intervention the
to infect the urinary tract. In will stabilize temperature within c. Fluid resuscitation may be required to
- Tachycardia patient will stabilize
response to this, the body’s the normal limits, fever will not correct dehydration. The patient who is
immune system releases temperature within the
- Tachypnea reoccur and verbalize feeling significantly dehydrated is no longer able
normal limits, fever will not
cytokines to fight off the more comfortable. to sweat, which is necessary for reoccur and verbalize feeling
- Pale and weak infection then further evaporative cooling. more comfortable.
inflammation occurs.
- Skin is warm to touch
Normally, the hypothalamic d. Observed changes in vital signs.
-Chills noted thermoregulatory center d. Changes in vital signs will indicate the
maintains the internal condition of the body and helps in
- WBC of 10.56 identifying what interventions will be next.
temperature between 37° and
- Platelet of 464 38° C. Fever results when
something raises the Tx:
hypothalamic set point, a. Room temperature may be accustomed
triggering vasoconstriction and a. Adjusted and monitored
to near normal body temperature and
shunting of blood from the environmental factors like room
blankets and linens may be adjusted as
periphery to decrease heat loss; temperature and bed linens as indicated.
indicated to regulate temperature of the
sometimes shivering, which
increases heat production, is patient.
induced. These processes
continue until the temperature
of the blood bathing the
b. Administered antipyretic medications b. Antipyretic medications lower body
hypothalamus reaches the new
as prescribed such as paracetamol. temperature by blocking the synthesis of
set point. Resetting the
prostaglandins that act in the
hypothalamic set point
hypothalamus.
downward (eg, with antipyretic
drugs) initiates heat loss
through sweating and
vasodilation. c. Eliminated excess covers. c. Exposing skin to room air decreases
warmth and increases evaporative cooling.

SOURCE:

Bush, L.M. (2020). Fever.

Retrieved from: Edx:

https://www.msdmanuals. a. If the patient is dehydrated or
a. Encouraged ample fluid intake by
com/professional/infectious- diaphoretic, fluid loss contributes to fever.
mouth.
diseases/biology-of-infectious-
disease/fever

b. Head elevation helps improve the

expansion of the lungs, enabling the patient
b. Elevate the head of the bed. to breath more effectively.

c. Providing health teachings to the patient

and family aids in coping with disease
conditions and could help prevent further
complications of hyperthermia.
c. Educated patients and family members
about the signs and symptoms of
hyperthermia and helped in identifying
factors related to occurrence of fever. d. Helps in decreasing body warmth and
induces evaporation.

d. Encouraged patients to wear loose

clothing. e. For the watcher to learn how to properly
perform Tepid Sponge Bath which
decreases temperature by means of
evaporation and conduction.
e. Instructed and demonstrated the
proper Tepid Sponge Bath (TSB) to the
patient’s watcher.
f. Appropriate diet is necessary to meet the
metabolic demand of the patient.

f. Encouraged patients to have a high g. This is important to determine if there

caloric diet as instructed by physicians. are any complications or changes in the
patient’s condition.

g. Encouraged patients to verbalize

feelings and concerns immediately.