Cues / Data Nursing Rationale Goals and Interventions Rationale Evaluation

diagnosis Objectives

Subjective: Hyperthermia Body temperature After 4 hours of After 4 hours of nursing

“Ang init – init ng related to elevated above nursing intervention intervention goals and
pakiramdam ko” physiological normal level that is client will be able to objectives was met as
As verbalized by factors usually caused by maintain core evidenced by:
the client secondary to several factors temperature within
dengue related to illness. As normal range as - Body temperature is
Objectives: hemorrhagic inoculation occurs, evidenced by: Independent: lowered to 37c
- T =38c fever proliferation of virus
- Flushed skin follows and - body temperature is - provide tepid sponge - heat loss by means of
- Warm to touch multiplication lowered to 37c bath evaporation and
occurs. Once the conduction.
virus starts to grow
in number, it will - promote surface - heat loss by means of
soon reach it cooling by means of radiation and
pathogenic level that undressing conduction
will result into
pyrexia or fever as a - provide cool - heat loss by means of
defense mechanism environment convection
of the body
- maintain bed rest or - to reduce metabolic
Reference: minimize movement demands of oxygen
Nurse’s pocket consumption
guide by Marilyn
Doeges - discuss importance of - to prevent
10th edition adequate fluid intake dehydration
particularly to the
parents.
Dependent: - pharmacological
treatment for fever
- give antipyretic as
prescribed by the
physician.