UPPER RESPIRATORY TRACT INFECTION

HYPERTHERMIA: Actual Nursing Care Plan

Assessment EXPLANATION OF THE OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION
PROBLEM

Subjective: Hypothalamus is the  After 4 hours of  After 4 hours on

“Agpaparaw ak” thermoregulation center Dx: effective nursing
nursing
of a human body. In intervention the interventions the
presence of infection, a  Identified underlying factors client was able to
client will
that may cause alterations of
 To obtain factors of increase body
Objective: trigger of the fever, maintain core tempearature. maintain core
 Flushed skin called a pyrogen, temperature body temperature temperature within
 Warm to touch causes a release of within normal normal range of 37.5.
 Temperature of prostaglandin E2  Monitored temperature
range of 37.5  To obtain an accurate core
38.2 (PGE2). PGE2 then in fr0m 38.1 every 30 minutes. temperature and detect for further
 Respiratory rate turn acts on the
development.
of 27 hypothalamus, which  Monitored pulse rate and
 Pulse rate of generates a systemic respiratory rate  To evaluate effectiveness of
response back to the independent nursing regimen
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rest of the body,  Assessed neurological
 Blood pressure
causing heat-creating response  To obtain level of consciousness in
of
effects increase heat response to increase body
conservation and Tx: temperature.
production resulting to
increase body  Provided surface cooling
Ndx:
temperature or such as TSB and removing  To promote core cooling by helping
 Increase body
hyperthermia. of extra clothing. reduce body temperature.
temperature
related to  Administered paracetamol
disturbance of
as ordered.  Paracetamol are classified as
the
hypothalamus analgesics and antipyretic which
due to acts on the hypothalamus to
production of regulate normal body temperature.
 Promoted rest and comfort
pyrogen, providing bed rest.
secondary to  To reduce metabolic demands that
bacterial may contribute to further
infection in the complications.
respiratory tract. Edx:

 Demonstrated to SO how to
perform TSB
 Encourage verbalization of
feelings
 Encouraged increase in fluid
intake.
 For SO.’s independent accurate
action in response to the client’s
condition of hyperthermia.
 To detect further existing
discomforts and level, whether
increased or decreased.
 To prevent dehydration because
increase in body temperature
causes fluid loss such as sweating.