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Date/Time
Cues Need Nursing Diagnosis Objective of Care Nursing
Interventions
J
U
L
Y
2
8
2
0
1
0
@
3PM
SUBJECTIVE:
medyo init akong paminaw
maam
OBJECTIVE:
Flushed skin
Dry lips
Slightly febrile
T=37.8oC
N
U
T
R
T
IO
N
A
L
M
E
TA
B
O
L
I
C
PA
T
T
E
R
N
Hyperthermia r/t
inflammatory response 2o
post Extra Capsular Cataract
Extraction
Inflammation is adefensive reaction intended
to neutralize, control, or
eliminate the offending agent
and to prepare the site for
repair. Fever is the most
common sign of a systemic
response to injury and it ismost likely caused by
endogenous pyrogens
(internal substances that
cause fever) released from
neutrophils and macrophages
(specialized forms of
leukocytes). These
substances reset thehypothalamic thermostat
which controls body
temperature and produces
fever.
After 2 hours span of my
nursing interventions, the
patient will be able to
demonstrate improvement
in maintaining bodys
temperature within thenormal range as evidenced
by:
a.) temperature within the
normal range
(35.5 37.5oC)
b.) (-)flushed skin
c.) (-) dry lips
a.) perform tepid sponge bath
heat is loss by evaporation andconduction
b.) encourage to increase oral fluidintake
hydration helps in regulating bodytemperature and it replaces
fluid loss
preventing dehydration
c.) recheck temperature
to evaluate the effectiveness of theinterventions
d.) Encourage to wear loose clothing
Excessive clothing and covering canresult to a temperature
elevation
e.) provide cool environment and
adequate ventilation
heat is loss by convection
f.) encourage adequate rest and sleep
July 28,
After 2 h
nursing
patient demons
maintai
tempera
normal
by:
a.)T=37
b.) (-)flu
c.) (-) dr
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Reference:
Smeltzer, S., Bare, B., Hinkle,
J., Cheever, K. (2010).Brunner and
Suddarths Textbook
of Medeical-Surgical
Nursing. (12th
Ed.).
Philadelphia: Wolters
Kluwer/ Lippincott
Williams & Wilkins
to decrease metabolic demand andO2 consumption
g.)administer paracetamol as ordered
antipyretic med reduces fever byacting on the hypothalamic
heat-
regulating center to cause vasodilation
and sweating which helps dissipate
heat
Reference:
Doenges, M. E., Moorehouse, M. F.,
Murr, A. C. (2008). Nurses
Pocket Guide Diagnoises,
Prioritized Interventions and
Rationales. (11th
Ed.).
Philadelphia: F. A. DavisCompany
