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Assessment Nursing Diagnosis Planning Nursing Intervention Rationale Subjective Short Term Independent

The patient presented with hyperthermia related to a bacterial infection. The nurse's short term plan was to monitor vital signs and provide a tepid sponge bath to lower the patient's temperature. The long term plan was for the patient's vital signs to return to normal range within 4 hours through appropriate nursing interventions like removing excess clothing, increasing fluids, and rest. The rationale included monitoring vital signs for accurate temperature readings and using tepid water for sponge baths to lower temperature without causing shivering.

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Moi Valdoz
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604 views3 pages

Assessment Nursing Diagnosis Planning Nursing Intervention Rationale Subjective Short Term Independent

The patient presented with hyperthermia related to a bacterial infection. The nurse's short term plan was to monitor vital signs and provide a tepid sponge bath to lower the patient's temperature. The long term plan was for the patient's vital signs to return to normal range within 4 hours through appropriate nursing interventions like removing excess clothing, increasing fluids, and rest. The rationale included monitoring vital signs for accurate temperature readings and using tepid water for sponge baths to lower temperature without causing shivering.

Uploaded by

Moi Valdoz
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOC, PDF, TXT or read online on Scribd
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NURSING NURSING

ASSESSMENT PLANNING RATIONALE


DIAGNOSIS INTERVENTION

Subjective Hyperthermia Short Term Independent


”Nurse, parang related to bacterial After 1 hour of 1. Monitor vital Vital signs provide
mainit ung nanay infection. appropriate nursing signs. more accurate
ko” as verbalized by intervention the indication of core
the relative of the Definition: patient’s temperature.
patient. Body temperature temperature will
elevated above decrease to 37.5oC. 2. Provide tepid TSB helps in
Objective normal range. sponge bath. Do lowering the body
 Temperature: Long Term not use alcohol. temperature and
38.6C After 4 hours of alcohol cools the
 RR: 26cycle appropriate nursing skin too rapidly,
per minute intervention the causing shivering.
 patient’s vital signs Shivering
 Hot, flushed will return to increases
skin normal range; with metabolic rate and
 Increased a temperature of body temperature
respiratory rate 36.5-37.5oC,pulse
 Diaphoresis rate of 60-100bpm 3. Remove excess These decrease
and respiratory rate clothing and warmth and
 Warm to touch
of 12-20 cycles per covers. increase
min. evaporative
habshqhd
cooling.

4. Promote a well- To promote clear


ventilated area to flow of air in the
patient. patient’s area. One
way of promoting
heat loss.

5. Advise patient to
increase oral Additional fluids
fluid intake. help prevent
elevated
temperature
associated with
dehydration.
6. Maintain bed
rest. Reduce metabolic
demands/ oxygen
consumption
7. Provide high-
calorie diet. To meet increased
metabolic
demands.

8. Educate and
advise support Teaching the
system (relative) Support system the
to do TSB when right way to do
patient feels hot. TSB will help in
- Luke warm knowing what to
water only. do in case the
- Make sure that patient’s
armpits and temperature
groins were increases
included in doing
TSB.
9. Monitored VS
and recheck.  To know the
effectiveness of
nursing
interventions
done and to know
the progress of
patient’s
Dependent condition.
10. Provide
antipyretic  These drugs
medications as inhibit the
indicated. prostaglandin
that serve as
mediators of
pain and fever.

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