ASSESSMENT

DIAGNOSIS

SCIENTIFIC RATIONALE

PLANNING

INTERVENTION Obtained vital signs especially temperature

RATIONAE To determine the severity of hypothermia

EVALUATION

Subjective: Nilalamig ako.

Altered

Hypothermia is

Short term goals: After 15-20 minutes of nursing intervention , the patients will have a body temperature within normal limits as manifested by an increase of temperature from 34.7 C to 35 C

The patients temperature increased to 35.9 C. Goal met.

thermoregulation: divided into two types: primary and secondary.

As verbalized by hypothermia the patient Objective: shivering noted Skin cold to touch Has a temperature of 34.7 Pale in appearance related to post-

operative surgery Primary hypothermia occurs when the body's heatbalancing mechanisms are working properly but are subjected to extreme cold, whereas secondary hypothermia affects people whose heatbalancing mechanisms are

Wrapped the patient in a thermo blanket

To reduce loss of heat and to provide warmth

Added a blanket for the patient.

To reduce loss of heat and to provide warmth

impaired in some way and cannot respond adequately to moderate or perhaps even mild cold. (medicadictionary.thefree dictionary.com/ hypothermia)

above. Long term goals: To facilitate the maintenanc e of regulatory mechanism and functions Turned off or lowered the air conditioner in the room. To reduce cold in the room