Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Hyperthermia After 4 hrs. Independent: Dysrhythmias and ECG After 4 hrs.
related to Of nursing • Monitor heart rate changes are common Of nursing
infectious interventions and rhythm. due to intervention
“Nilalagnat ang
process and , the client • Record all sources of fluid electrolyte imbalance s, the client
anak ko” as dehydration will maintain loss such as urine, vomiting and was able
verbalized by the core and diarrhea. dehydration anddirect maintain
mother. temperature • Promote surface cooling by effect of hyperthermia core
within normal means of tepid sponge on blood and cardiac temperature
Objective: range. bath. tissues. within
• • Wrap extremities • To monitor or normal
Flushed skin, with cotton potentiates fluid range
warm to touch. blankets. and electrolyte
• • Provide supplemental loses.
oxygen. • To decrease temperature by
• Administer replacement means through evaporation
Increased fluids and electrolytes. andconduction.
respiratory • Maintain bed rest • To minimize
rate. Provide high calorie diet, tube shivering.
feedings, or parenteral • To offset increased
nutrition. oxygen demands and
•
• Administer antipyretics consumption.
V/S taken as
orally or rectally as • To support circulating
follows:
prescribed by he volume and tissue
perfusion.
T: 37.8 • To reduce metabolic
P: 110 demands and oxygen
R: 45 consumption.
To increased metabolic
demands
• To facilitate fast
recovery