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Saturday, November 27, 2010

NCP- FEVER (Click Here)




ASSESSMENT
NURSING DIAGNOSIS
INFERENCE
OBJECTIVES
NURSING INTERVENTIONS
RATIONALE
EVALUATION
Subjective:
Opo nilalagnat anak ko. Mainit po cia” as verbalized by the mother


Objective:
Ø  Flushed skin
Ø  Warm to touch
Ø  Temperature of 38.2
Ø  Respiratory rate of 27
Ø  Pulse rate of 125

Hypertermia related to increase metabolic rate
 ( illness)
Hypothalamus is the thermoregulation center of a human body


presence of infection

 trigger of the fever, called a pyrogen


release of prostaglandin E2 (PGE2). PGE2 then in turn acts on the hypothalamus


causing heat-creating effects increase heat conservation and production resulting




increase body temperature



hyperthermia.

After 30 mins. of nursing intervention the client will  maintain core temperature within normal range of  37.5  fr0m 38.1
Ø  Identified underlying factors that may cause alterations of body temperature

Ø  Monitored temperature every 30 minutes.



Ø  Monitored pulse rate and respiratory rate




Ø  Provided surface cooling such as TSB and removing of extra clothing.



Ø  Promoted rest and comfort providing bed rest


Ø  Encouraged increase in fluid intake.


Dependent function:
Ø  Administered paracetamol as ordered.


Ø  To obtain factors of increase body tempearature.





Ø  To obtain an accurate core temperature and detect for further development.





Ø  To evaluate effectiveness of independent nursing regimen




Ø  To promote core cooling by helping reduce body temperature.






Ø  To detect further existing discomforts and level, whether increased or decreased.

Ø  To prevent dehydration because increase in body temperature causes fluid loss such as sweating


Ø  Paracetamol are classified as analgesics and antipyretic which acts on the hypothalamus to regulate normal body temperature.

After 30 mins on effective nursing interventions the client was able to maintain core temperature within normal range of 37.5.
Goal met
Latest temp: 37.2

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