By the end of the 8hour shift, the client will maintain core temperature within normal range. Aedes aegypti Infection may be the root cause of hyperthermia. Increased cardiovascular Cerebral hypertension or peripheral / postural hypotension can occur.
By the end of the 8hour shift, the client will maintain core temperature within normal range. Aedes aegypti Infection may be the root cause of hyperthermia. Increased cardiovascular Cerebral hypertension or peripheral / postural hypotension can occur.
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By the end of the 8hour shift, the client will maintain core temperature within normal range. Aedes aegypti Infection may be the root cause of hyperthermia. Increased cardiovascular Cerebral hypertension or peripheral / postural hypotension can occur.
Copyright:
Attribution Non-Commercial (BY-NC)
Available Formats
Download as DOC, PDF, TXT or read online from Scribd
Nursing Data Analysis Intervention Rationale Evaluation Objectives Diagnosis
I: The client Hyperther Immediate Goal: By the Effectivenes
verbalizes: mia cause: end of the 8- s: “Nanghihina related to Illness hour shift, the 1. Was the pakiramdam illness client will client able ko” maintain core to accept “Mainit din Intermediate temperature the different po katawan cause: within normal measures ko.” Cytokines range. on how to 1. Monitor core Cerebral hypertension or reduce body Objectives: temperature peripheral/postural temperature O: The client 1. Evaluate and BP. hypotension can occur. ? looks weak Root cause: effects/degre Hyperventilation may ___Yes and pale. Infection from e of 2. Assess initially be present but ___No Has elevated Aedes Aegypti hyperthermia neurological ventilatory effort may be temperature response, level impaired by seizures, 2. Was the above Nursing of hypermetabolic state. client able normal implication: consciousness to restate range. Although fever and orientation. Oliguria and/or renal measure on Warm to may be 3. Monitor failure may occur due to the touch. beneficial for respirations. hypotension, promotion Flushed skin enhancing host 4. Monitor/record dehydration, shock. of wellness? defense, other all sources of ___Yes M: factors such as fluid loss such ___No T: 38 0C the patient’s as urine, P: 120 bpm comfort and 2. After vomiting and Appropriatenes R: 28 physiological nursing diarrhea s: cycles/min responses must interventions, Heat loss by radiation, Were the BP: 100/70 be considered the client will Discuss with the client conduction and health mmHg when fever be able to measures on how to convection. interventions Hgb: 120 occurs. accept the reduce body appropriate ? Hct: 0.36 Increased different temperature. __Yes ___ PC: 338 cardiovascular measures on 1. Promote No and metabolic how to reduce surface cooling Heat loss by evaporation demands may body by means of and conduction. Efficiency: be poorly temperature. undressing or Areas of high blood flow. Were the tolerated by cool nursing persons with environment actions minimal and/or fans To prevent dehydration. performed cardiopulmonar 2. Cool/tepid efficiently? y reserve, such sponge baths ___ Yes __ as those with or immersion To effectively reduce No coronary artery 3. Local ice packs body temperature and disease or especially in treat underlying cause Adequacy: heart failure. groin and (for infection) Were the axillae. available 4. Increase fluid resources intake. adequate? 5. Use of To avoid any accident __Yes hypothermia that might worsen the __No blanket condition of the client. 6. Administer antipyretics as Acceptabilit ordered and For the client’s health y: other status awareness. Did the 3. The client prescribed client accept will be able to medications the nursing restate such as intervention measure on antibiotics. s? the promotion 7. Provide safety To prevent dehydration. __Yes of wellness. of the client. __No
Indicates need for
1. Review specific prompt intervention. cause such as underlying disease process or environmental factors. 2. Discuss importance of adequate fluid intake 3. Review signs/symptom s of hyperthermia (flusjed skin, increase temperature and respiratory/hea rt rate).