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Nursing

Assessment Planning Nursing Intervention Rationale Evaluation


Diagnosis
Objective: Hyperthermia After 2 hours of INDEPENDENT: After 2 hours of nursing
related to the nursing  Enhances heat loss by intervention, the patient
 Skin  Provide tepid sponge bath.
infectious process intervention, the evaporation & conduction. has a temperature of 37.3
warm to touch
with a patient  Assess fluid loss & facilitate C
temperature of temperature will  Increases metabolic rate &
oral intake.
38.3°C lower down to diaphoresis.
37.5 C  Reduces body heat
 Promote bed rest.
 RR: Production.
44cpm  Dissipates heat by convection.
 Provide cool circulating air
using a fan.
 HR:
145bpm  Assist patient in changing
 Increases comfort.
into dry clothing.

 Weakne  Provide oral hygiene.


ss observed  Prevents herpetic lesions of the
mouth.
 Monitor vital signs.
 Dry  Notes progress & changes of
mucous condition.
DEPENDENT:
membranes  Maintain IV fluids as
 Prevents dehydration.
ordered by physician.

 Flushed  Administer anti-pyretic as


Skin  Reduces fever.
ordered.

 Administer antibiotic as
 Treats underlying cause.
ordered.

Interdependent:
 Monitor hematologic test &
 Indicates presence of infection &
other pertinent lab records
dehydration.
 Discuss condition of the
patient with other members
 Ensures continuous intervention.
of the health care team.

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