Hyperthermia

Assessment Nursing Diagnosis Objectives Interventions Rationale Expected Outcome

Subjective: Hyperthermia After 4 hours of Establish good To gain patient’s The patient’s body
related to Nursing working condition trust temperature shall
inappropriate Interventions the with the pt and SO. have a maintained
Objective: clotting factor as patient’ will be normal body
• Flushed warm evidenced by maintaining a Monitor v/s q To have baseline temperature.
skin decrease in normal body 2hours. data

• Increased platelet count. temperature.

temp. of Provide TSB To maintain a

38.5OC normal body

• Irritability temperature. .

• Diaphoresis
Encourage increase To replace fluid loss
fluid intake

Encourage food rich To boost body

in Vitamin C resistance to
infection

Provide client To prevent further

safety injuries
Maintain bed rest To preserve energy

Administered Drug action to

antipyretics as lower body
ordered temperature
Risk for injury
Assessment Nursing Objectives Interventions Rationale Expected Outcome
Diagnosis
Subjective: Risk for injury After 4 hours of Establish rapport to gain patient’s After 4 hours of
r/t abnormal Nursing trust Nursing
Objective: blood profile as Interventions, pt Interventions, pt
evidenced by will demonstrate Assess level of assist in will have
 Low platelet decrease techniques consciousness and determining pt. ‘s demonstrate
count platelet count. behavior, lifestyle cognitive level ability to protect techniques
 Abnormal blood changes to risk self and comply behavior, lifestyle
profile factors and protect with required self changes to risk
self. protective actions factors and protect
self.
Provide safe Minimizes injury to
environment (pad, occur
side rails, prevent
falls)

Observe for each stool Permits detection

color, consistency and of bleeding in GI
amount tract

Observe for Indicate altered

hemorrhagic clotting
manifestation, mechanism
ecchymosis, epistaxis,
Petechiae, and
bleeding gums

Encourage intake of Promotes healing

foods with high and boost the
content of Vit. C resistance of the
body against
infection

Assess pt’s condition To obtain baseline

and monitor vital data
signs.

Provide comfort To promote

measures, such as relaxation and
stretching bed linens. alleviate .

Avoid SC, IM route of Minimizes

injection as possible tendency of
trauma or bleeding
 Assessment Diagnosis Planning Interventions Rationales Evaluation

Subjective: INDEPENDENT
Within 7 hours of nursing Within 7 hours of
Risk for Fluid
interventions, the patient Assessed skin turgor indicator of nursing
volume deficit dehydration
Objectives: will be able to maintain and moisture interventions, the
related to
adequate fluid volume at a patient maintained
increased decrease body
functional level through Monitored
• Oral Fluid metabolic rate fluids through adequate fluid
giving supplemental fluid as temperature
intake of secondary to perspiration and volume at a
ordered and increase oral increase
150 cc for inflammatory functional level as
fluid intake as evidenced by respiration.
the last 8 response evidenced by:
atleast additional 4 glasses
hours Monitored I & O to ensure a. taken
of water and continuous
• Weakness balance being accurate picture additional 5
TSB.
of fluid status glasses of
• Slightly dry aware of insensible
lips loses water
• Pallor TSB promotes b. SO continuous
Gave tepid sponge heat loss through TSB.
bath conduction and
evaporation

to maintain
Advised patient to hydration status
increase oral intake

COLLABORATIVE:

Provided Replaces lost fluid

supplemental fluids
as indicated.

Administered The drug may

antipyretics as relieve fever
through central
ordered
action in the
hypothalamic
heat-regulating
center.