Patient: Arlando Salazar Age: 65 yrs.

old Date: 09/09/2010

Hyperthermia

ASSESSMENT NURSING INFERENCE PLANNING NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTIONS
Short-term Goal Short-term Goal
Subjective Cues: Hyperthermia r/t Hepatitis
hepatitis as ↓ Goal Met
manifested by Inflammation of hepatic After 8 hours of nursing After 8 hours of nursing
 “Ang init ng cells
pakiramdam ko increased body interventions, the interventions, the
temperature, ↓ patient will be: patient was:
pero and lamig ng Release and activation of
aking balat,” as tachycardia,
tachypnea. Interleukin-1
verbalized by the ↓
patient.  Able to retain  Establish rapport  To make an  Able to retain
• Fever efficient patient- optimal physical
optimal physical
• Tachycardia nurse well-being
Objective Cues: well-being
↓ communication
↑ metabolic rate
 Vital signs as
↓  Monitor and  To monitor
of 10 am ↑ demand for oxygen document vital signs the present
↓ health status of
• T: 38.5 oC Tachypnea the patient
• PR/HR: 112
bpm
 Perform physical  To
• RR: 30 cpm assessment of the determine
• BP: 110/80 patient abnormal
findings
 Monitor patients
input and output  To assure
patient has fluid
balance Goal Partially Met
After 3 hours of nursing After 3 hours of nursing
interventions, the interventions, the
patient will be: patient was:

 Able maintain  Give patient  Able maintain

tepid sponge bath temperature within
temperature within
normal range
normal range  To help the
body relive from
 Carefully fever  Vital signs as
monitor the patient of 1 pm
temperature • T: 37.7
 To properly • PR: 114 bpm
know if there is • RR: 28 bpm
deviation in the • BP: 110/70
patients
temperature
 Kirby R. Contaoi
PLM SN Batch 2012 Group F