Patient: X Medical diagnosis: Cellulitis in right lower extremity and Diabetes Melllitus type 2.

Address: Bitaog, Bansalan, Davao Su Attending physician: Dr. Sarno

Age: 79 yrs. Chief complaint: Wound Swelling at Right Leg
Hyperthermia
DATE/TIME CUES NEED NURSING GOAL OF CARE NURSING EVALUATION
DIAGNOSIS INTERVENTIONS

F Subjective: N Alteration in within 8 hour span of 1.) Established rapport February 05, 2010
E “Murag init man U thermoregulation; care, our patient will ® to gain trust @
B ko day.tungod T Hyperthermia related to be able to reduce 1.) Determine 7 am
R tingali sakong R inflammatory process body temperature as Precipitating factors.
U samaod” as I secondary to cellulitis evidenced by: ® To know the cause “ Goal Met”
A verbalized by the T of the alteration in
R patient. I ® With fever induced by a. reduce body body temperature and After 8 hour span
Y O inflammations, the heat; help to guide future of care our patient
Objective: N hypothalamic thermostat interventions. was able to
 VS: A may be reset at a higher b. Verbalize reduced body
05, Temp.= 38◦ C L temperature, then return relief from 2.) Assess vital signs, temperature as
PR= 111 bpm to normal when the fever increase in especially axillary evidenced by:
RR= 28 cpm - abates. The increase in body temperature.
2010 BP= 150/80 body temperature is temperature. ® Provide accurate

105
 mmHg M achieved through indication of core a.Reduced body
E physiologic mechanisms/ temperature. heat.
 Warm to T responses (inflammatory
@ touch noted; A response and immune 3.) Remove excess b. Verbalized
 Pallor noted B reaction) of the body to clothing. relief from

 swelling O the presence of infection. ® To release the heat increase in body

8am right foot- L in the body. temperature.

redness and I Bibliography:

heat noted C Smeltzer, Suzanne & 4.) Do tepid sponge “ Salamat ha… dili
Brenda Bare. “Bruner & bath to the patient. na kaayo init

 Impression: Suddarth’s Textbook of ® To cool the akong paminaw

cellulitis Medical-Surgical patient’s skin and pareho ganina”

Right Nursing”.10th body temperature. as verbalized.

Edition.Lippincott
Williams & 5.)Encourage to eat
Wilkins.Philadelphia.2004 foods rich in vitamin
P C
A ® To boost the
T immune system.
T 6.) Continually
E monitor the body

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R temperature.
N ®To know if the body
temperature is stable
or not.

8.) Encouraged to
increase oral fluid
intake (8-10 glasses of
water/ day)

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