Haguisan, Joseph Theodore A.

Topics: Care of Patient with problems in Thermoregulation 6/20/2012 Assessment Sub: taas iyang hilanat gabii, pero ni ubos man pagka buntag As verbalized by the mother Obj: - skin warm to touch - shivering - RR 25cpm - temp 38.9 degrees diagnosis Hyperthermia related to infection Planning At the end of the shift, patient will have a temp of 37.0 37.6 degrees.

CI: Ms. Grace Casino

Intervention independent: - perform tepid sponge bath - increase fluid intake - provide extra blankets if client is chilled dependent: - administer antipyretics

evaluation At the end of the shift, patients temperature is at 37.4 degrees

HPI: 6 hours PTA, client had an onset of fever of 39.8 degrees Celsius. 1 hour PTA, client had a sudden convulsion attack, and was immediately rushed to the ER. Thus, the admission Past: patient was admitted before at MRXUH @ Jan 16 2011, due to extremely temperature which lasted for 3 days. Review of Systems: the system that regulates the body temp has 3 main parts, sensors in the shell and core, integrator in the hypothalamus, and effector that adjusts the production and loss of heat. The hypothalamic integrator, the center that controls the core temperature, is located in the preoptic area of the hypothalamus. When the sensors in the hypothalamus detect heat, they send out signals intended to reduce the temperature, that is, to decrease heat production and increase heat loss. In contrast, when the cold sensors are stimulated, signals are sent out to increase heat production and decrease heat loss. The signals from the cold-sensitive receptors of the hypothalamus initiate effectors, such as vasoconstriction, shivering, and the release of epinephrine, which increases cellular metabolism and hence heat production. When the warmth-sensitive receptors in the hypothalamus are stimulated, the effector system sends out signals that initiate sweating and peripheral vasodilatation. Also, when this system is stimulated, the person consciously makes appropriate adjustments, such as putting on additional clothing in response to cold or turning on a fan in response to heat. Nursing Mgt: tepid sponge bath every 15 mins until temperature goes down to normal. Advised to increase fluid intake to avoid dehydration, provided extra blankets. Medical Mgt: Administration of Anti Pyretics (Paracetamol)

Discharge planning: Meds: Paracetamol if fever spikes up again Exercise: walking exercises to promote blood circulation Treatment: compliance to treatment regimen, and give appropriate dose of meds, to ensure client recovery and safety Health Teachings: medication compliance, increase fluid intake, daily exercises, self care OP follow up: advised to have a follow up check up at dr. patriana next week, to ensure client recovery Diet: increased fluid intake, to prevent dehydration Spirituality: advised to keep on praying, even after recovery