Cues Nursing Analysis Goals & Objectives Intervention Rationale Evaluation

Diagnosis
Subjective: Hyperthermia Ndx: Goal: Independent: Goal Evaluation:
R/T Infection
The patient AEB Weakness Core body After 2 hours of 1. Obtain client’s To establish a In 2 hours of nursing
verbalized, and Body temperature above nursing interventions, vital signs. database of interventions, the
Temperature of the normal diurnal the patient temperature record serving patient temperature
“Hindi 38.9 C range due to failure will be at normal range as a baseline was at normal range
maganda ang of thermoregulation and demonstrate for and demonstrated
pakiramdam behaviors to monitor assessment. behaviors to monitor
ko, nanghihina Reference: and promote and promote
ako.” normothermia. Potter, P. A., normothermia.
Doenges, M. E., & Perry, A. G.
“Ang init ng Moorhouse, M. F., Objective: (2018). Objective Evaluation:
pakiramdam & Murr, A. C. Fundamentals
ko.” (2019). Nurse's 1. Maintain vital of nursing (9th 1. Maintained
pocket guide: signs at normal ed.). Elsevier. vital signs at
“Ang sakit din Diagnoses, levels p. 487. normal levels
ng ulo ko.” prioritized 2. Stabilize body 2. Stabilized
interventions, and temperature body
“Ang hirap rationales (15th 3. Promote 2. Review client’s To validate temperature
gumalaw ng ed.). F.A. Davis. p. Hydration. result of and extend the 3. Promoted
maayos”. 453. 4. Promote sense laboratory information Hydration.
of comfort. studies. collected in 4. Promoted
Objective: Etiology: 5. Free patient patient history. sense of
Temperature of from comfort.
An infection is a complications. Potter, P. A., 5. Freed patient
38.9 C host organism’s & Perry, A. G. from
Heart Rate of response to a (2018). complications.
95 bpm pathogen, or Fundamentals
disease-causing of nursing (9th
Respiratory substance. It results ed.). Elsevier.
rate of 22 cpm when tissue p. 949.
destroying
microorganisms
enter and multiply To detect
in the body. Some 3. Monitor heart
abnormalities
Distressed infections take the rate and in rate and
form of minor rhythm. rhythm.
Weak illnesses, such as
colds and ear Potter, P. A.,
Frowning infections. Others & Perry, A. G.
Flushed skin result in a life (2018).
threatening Fundamentals
Dry mucuosa condition called of nursing (9th
sepsis, which causes ed.). Elsevier.
widespread p. 499.
vasodilation and
multiple-organ
dysfunction 4. Monitor To note
syndrome (MODS). respirations. sudden change
in the
References: character of
the respiration.
Wilkins, L. W.
(2018). Potter, P. A.,
Pathophysiology & Perry, A. G.
made incredibly (2018).
easy. LWW. p. 433. Fundamentals
of nursing (9th
Defining ed.). Elsevier.
Characteristic: p. 501.
Fever, or pyrexia
occurs because heat- To identify
loss mechanisms are 5. Monitor and
appropriate
unable to keep pace record all
treatment to
with excessive heat sources of fluid
administer.
production, loss.
resulting in an Potter, P. A.,
abnormal rise in & Perry, A. G.
body temperature. (2018).
References: Fundamentals
of nursing (9th
Potter, P. A., & ed.). Elsevier.
Perry, A. G. (2018). p. 946.
Fundamentals of
nursing (9th ed.). To meet liquid
Elsevier. p. 490. 6. Encourage needs of the
drinking of body.
water.
Potter, P. A.,
& Perry, A. G.
(2018).
Fundamentals
of nursing (9th
ed.). Elsevier.
p. 1055.

Dependent:

1. Administer
To reduce
antipyretics.
fever.

Potter, P. A.,
& Perry, A. G.
(2018).
Fundamentals
of nursing (9th
ed.). Elsevier.
p. 496.

2. Promote
To increase
surface cooling
heat loss by
by means of
evaporation,
tepid sponge
conduction,
bath or
convection, or
immersion.
radiation.
 Potter, P. A.,
& Perry, A. G.
(2018).
Fundamentals
of nursing (9th
ed.). Elsevier.
p. 496.

To allow
3. Promote Client patient to
Safety. function
optimally.

Potter, P. A.,
& Perry, A. G.
(2018).
Fundamentals
of nursing (9th
ed.). Elsevier.
p. 374.

To rehydrate
4. Administer and restore
replacement fluids in
fluids. normal
balance.

Potter, P. A.,
& Perry, A. G.
(2018).
Fundamentals
of nursing (9th
ed.). Elsevier.
p. 954.