ANALYSIS /

NURSING GOALS AND RECOMMEN-

ASSESSMENT PATHOPHYSIO- IMPLICATION RATIONALE EVALUATION
DIAGNOSIS OBJECTIVES DATION
LOGY
Subjective: Hyperthermia Post-surgical state Goal: After 8 Monitor vital  Vital signs EFFECTIVENESS Alert nurses for
"mainit ang related to increase (craniotomy) hours of nursing signs provides accurate Was the patient able reoccurrence
katawan ng anak ko body temperature interventions, the indication of core to experience gradual
sa verbalize by the as manifested by patient will have a http://www. reduction/relief of increase parental
pt.'s mother" sweating, flushed Depletion of the normal body scribd.com/ pain and demonstrate knowledge
skin, warm to induced temperature doc/19783269/ a decrease body about fever in
touch, high body anesthesia ncp-fever temperature after 8 children
temperature( )  to obtain factors hours of nursing
Secondary to post- identified of increase body interventions? teaching
op craniotomy response to a underlying factors temperature  YES. The parents/client on
variety of stimuli that may cause http://www. patient is able self tsb
Objective: Primary Cause: alterations of scribd.com/ to convey a
 At right High body body temperature doc/36285890/ decrease of
metacarpal temperature () cytokine release Ncp-for-Fever body
vein, IVF of Secondary Cause: Objective:  Room temperature
PNSS 1L Sweating, warm to After a series of Monitor temperature and from ( ) to (
650 ml touch, flushed skin Inflammatory nursing environmental linens should be )
remaining Root Cause: process intervention, the temperature. altered to EFFICACY
to run @ Decrease effect of patient will be Limit or add bed maintain near- Were the human
650 anesthesia able to: linens, as normal body resources, time and
ugtts/min. affects the indicated. temperature. materials used
 sweating hypothalamus 1. Identify http://hanieyah29- economically
 warm to negative factors nursingcareplan.  YES. They
touch affecting blogspot. were used
 flushed skin Implication: increase body hyperthermia com/2012/01/ economically.
Postoperative temperature and eliminate or hyperthermia- APPROPRIATENESS
Measurement: fever is often a reduce their ncp.html Were the
 Vital Signs normal effect when  to detect further interventions suitable
T- inflammatory possible existing to patient’s situation?
P- response to Promoted rest and discomforts and  YES. The
R- surgery, but it can 2. Use identified comfort providing level, whether patient’s
BP- also be a techniques to bed rest increased or situation is in
 Pain Scale manifestation of a reduced body decreased. need to have
7/10 serious underlying temperature http://nsc- those
infectious or ultimatex. interventions.
 Intake
noninfectious 3. Participate blogspot.com ACCEPTABILITY
etiology. willingly in /2010/11/ncp- Were the
 Output Therefore, it is necessary/ fever-click- interventions
important to desired here.html accepted by the
 Weight approach each intervention  To prevent patient (without any
instance of dehydration signs of rejection
postoperative fever 4. Report Encouraged because increase from the patient and
in a systematic measurable increase in fluid in body family members)?
manner. decrease of intake. temperature  YES. The
body causes fluid loss patient and
www.ncbi.nlm.nih. temperature such as sweating her family
gov/pumbed/ http://nsc- accepted the
20409256 ultimatex. interventions
blogspot.com and they
/2010/11/ncp- verbalize
fever-click- gratitude and
here.html willingness to
 Tepid sponge cooperate.
baths may help ADEQUACY
Provide tepid reduce fever. Was the number of
sponge baths. Note: Use of ice interventions
Avoid use of water or alcohol sufficient to meet the
alcohol. may cause chills, desired goal and
actually objectives?
elevating temperat  YES. The
ure. Alcohol can interventions
also cause skin are sufficient
dehydration. to reduce both
http://hanieyah29- pain and
nursingcareplan. physiological
blogspot. signs of
com/2012/01/ intolerance
hyperthermia-
ncp.html
 Antipyretics
reduce fever by its
Administer central action on
antipyretics as the
ordered hypothalamus; fev
er should be
controlled in
clients who are
neutropenic or
asplenic.
However, fever
may be beneficial
in limiting growth
of organisms and
enhancing
autodestruction of
infected cells.
 to maintain
acceptable level
Administer pain of pain
reliever as ordered http://www.
scribd.com/doc/
11901203/Ncp-
acute-Pain