36893609-NCP-hyperthermia
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Transcript of 36893609-NCP-hyperthermia
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Nursing Care Plan
Assessment NursingDiagnosis
GOAL ANDOBJECTIVES
INTERVENTION RATIONALE EVALUATION
Subjective:S>: kanina pa
ko mainit
Objective:
Flushed skinnoted andwarm totouch.
The patientwas irritableand crying.
Body temp. of38 C .
Hyperthermiarelated to
diseaseprocess.
Goal:Within 8 hours of
nursinginterventions, thepatient willmaintain bodytemperaturewithin the normalrange.
Objectives:
Demonstratebehaviors tomonitor andpromotenormothermia
Be able toavoid seizureactivity.
Independent:
Promotesurfacecooling bymeans ofundressing,coolenvironment,and or fans,cool/ tepidsponge bathsor immersion;local icepacks,especially inthe groin oraxillae.
Maintain bedrest.
Promoteclients safety(e.g., maintain
airway; raiseside rails,never leavethe childunattended,skinprotectionfrom cold,observation ofequipment
To promote heat
loss by radiation,conduction,convection,evaporation, andto decrease tempof areas with highblood flow.
To reducemetabolicdemands/ oxygenconsumption.
To preventdehydration
GOAL METWithin 8 hours of
nursingintervention thepatientmaintained bodytemperaturewithin the normalrange asmanifested by:
Body temp of36.7 C
Uponpalpationnormal skintemperaturewas noted.
No incidenceof convulsionsand shivering.
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safetymeasures.)
Discuss theimportance of
adequate fluidintake.
Review singandsymptoms ofhyperthermia(e.g., flushedskin,increased
body temp,increasedrespiratoryrate/ heartrate, fainting,loss of consciousnessand seizures)
Dependent:
Providesupplementaloxygen.
Administermedication asindicated,such asantibiotics.
Indicates needfor promptintervention.
To offsetincreased oxygendemand andconsumption
To treatunderlying causesuch as infection.
To supportcirculatingvolume andtissue perfusion.
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Administerreplacementfluids andelectrolytes.