ASSESSMENT DIAGNOSIS SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION

BACKGROUND
Subjective: Hyperthermia related  Body temperature Short Term: Independent:
to infection as elevated above After 8 hours of
The patient verbalized - evidenced by patient normal level that is  At the end of the  Provid tepid  Heat loss by nursing intervention
“Mainit ang usually caused by
having on and off fever shift, patient will sponge bath means of goals and objectives
pakiramdam ko. Ilang several factors
araw nang ganto ang with temperature of 38. maintain body evaporation and was met as
related to illness.
nararamdaman ko” 3° C, low platelet count, temperature conduction. evidenced by:
high WBC and RBC  Infection occurs below 37° C
Objective: count and positive to when an organism (100° F)  Provide cool  Heat loss by  Body
Dengue NS1 Ag. is able to colonize environment means of temperature
 Restlessness and multiply  Patient convection lowered to 37
 Fever within a host. maintains BP degree celcius.
 Skin warm to and HR within  Maintain bed  To reduce  BP and HR are
touch An infection
normal limits rest or minimize metabolic within normal
causing
microorganism movement demands of limits.
Vital Signs taken as
follows: must have Long Term: oxygen
 TEMP: 38.3° C virulence, be consumption At the end of shift,
transmitted from  At time of patient was free of
 Low platelet count its reservoir, and discharge,  Discuss  To prevent signs / symptoms of
of 77 x 10^9/L gain entry into the patient will be importance of dehydration infection.
(100-300) susceptible host. free of signs / adequate fluid
 High RBC (5-10) symptoms of intake
 High Pus/WBC When the immune
system is alerted
infection such as particularly to
cells (5-10) platelet count of the parents.
 High WBC: 12.67 that an invader has
entered the body, 100-400/mm3  To know if the
 Dengue NS1 Ag
positive cytokines send a and temp of <  Strictly monitor patient’s
message to 100 F. temperature and temperature
phagocytes to other vital signs. went down to
attack the the normal
infection. value.
Lymphocytes and
other white blood  Increase fluid  To lower the
cells also begin to intake temparature
attack the
microorganism.
Dependent:  To alleviate the
 Administer fever of the
paracetamol as patient.
The result of this
activity often
prescribed by
results in a fever. the physician.

(Lemone 2011 pp.