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Fever NCP

The patient presented with hyperthermia related to a bacterial infection as evidenced by a temperature of 39.1°C. The nursing diagnosis was that the patient will establish and maintain normal vital signs within 3 days. The short term goal was to decrease the patient's temperature to 38.2°C within 1 hour. Independent nursing interventions like monitoring vitals and tepid sponge baths were used. The goal was met after 1 hour. The long term goal was for vital signs to return to normal within 3 days with dependent and collaborative interventions like medications and monitoring labs.

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Nikael Patun-og
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5K views

Fever NCP

The patient presented with hyperthermia related to a bacterial infection as evidenced by a temperature of 39.1°C. The nursing diagnosis was that the patient will establish and maintain normal vital signs within 3 days. The short term goal was to decrease the patient's temperature to 38.2°C within 1 hour. Independent nursing interventions like monitoring vitals and tepid sponge baths were used. The goal was met after 1 hour. The long term goal was for vital signs to return to normal within 3 days with dependent and collaborative interventions like medications and monitoring labs.

Uploaded by

Nikael Patun-og
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 PDF, TXT or read online on Scribd
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ASSESSMENT NURSING OUTCOME PLANNING NURSING EVALUATION

DIAGNOSIS IDENTIFICATION INTERVENTION

Subjective Hyperthermia The patient will Short Term Independent Short Term
”Napansin ko po related to establish and maintain
na mainit ang bacterial body temperature, After 1 hour of 1.Monitor vital After 1 hour of
nanay ko tuwing infection as respiratory rate, and appropriate Signs. appropriate
hahawakan ko evidenced by heart rate within nursing nursing
siya” as body normal range after 3 intervention, Rationale: vital signs intervention, the
verbalized by temperature days of nursing the provide more patient’s
the relative of above the intervention. patient’s accurate temperature was
the patient. normal range, temperature indication of decreased to
hot, flushed will core 38.2°C.
Objective skin, and decrease to temperature.
• Temperature: increased 38.2°C. Goal was met
39.1°C respiratory 2. Provide tepid
• RR: 26 cycles rate. Long Term sponge bath. Long Term
per minute
• PR: 160 beats After 3 days Rationale: TSB helps After 3 days of
per minute of in appropriate
• Hot, flushed appropriate lowering the nursing
skin nursing body intervention, the
• Diaphoresis intervention, temperature by patient’s vital
• Warm to touch the evaporation. signs was
patient’s vital returned within
signs will 3. Remove excessive normal range; as
return clothing, blankets and manifested by a
within normal linens. Adjust the temperature of
range; with a room temperature.
temperature 36.8°C, pulse
of Rationale: These rate of 86 bpm
36.5°C – decrease and respiratory
37.5°C, pulse warmth and rate of 14 cycles
rate of 60- increase per
100bpm evaporative minute.
and respiratory cooling.
rate of 12-16 Goal was met
cycles per 4. Promote a well-
minute. ventilated area
to patient.

Rationale: to promote
A clear flow of air
in the patient’s
area—one way
of promoting
heat loss
5. Raise the side rails
and lower the bed at
all times.

Rationale: to ensure
the patient’s safety
even without the
presence of seizure
activity.

Dependent
1. Give antipyretic
medications as
prescribed.

Rationale:
to lower body
temperature by
blocking the
synthesis of
prostaglandins that
act in the
hypothalamus.

2. Infuse
intravenous cooled
saline as ordered.

Rationale:
administered over 10-
20 minutes to
decrease core
temperature.

3.Administer
sedatives as ordered.

Rationale: to
facilitate effective
temperature
reduction by
preventing shivering.

4. Administer
diazepam (Valium) as
ordered.

Rationale: to prevent
excessive shivering
that increases heat
production, oxygen
consumption, and
cardiorespiratory
effort.

Collaborative

1. Collaborate with
the dietitian to
support nutritional
intake.

Rationale: to meet
the increased energy
demands and high
metabolic rate
caused by
accompanying
hyperthermia.
2. Monitor
hematologic test and
other pertinent lab
records.

Rationale: to indicate
presence of infection
and dehydration.

3. Discuss condition
of the patient with
other members of
the health care
team.

Rationale: to ensure
continuous
intervention.

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