DIAGNOSIS and blood pressure increase as hyperthermia progress

DIAGNOSIS

OUTCOME

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INTERVENTION

RATIONAL

Hyperthermia
related to upper respiratory tract infection

Patient
temperature decrease within normal range that is 36.5ºC and 37.2ºC

·        
Monitor patient’s vital sign that is heart
rate blood pressure and temperature
 
·        
Adjust room temperature to the normal
range of body temperature
 
 
·        
Eliminate excess clothing and blanket
 
·        
Do tepid sponging for patient
 
 
 
·        
Encourage patient to drink lots of water
·        
Encourage patient to eat healthy fruit
and        vegetables
 

Ø 
Heart rate and blood pressure increase
as hyperthermia progress
Ø 
Room temperature must be within normal
body temperature to regulate temperature of patient
 
Ø 
To increase evaporation of heat
 
Ø 
To reduce body temperature as normal as
possible to make patient more comfortable 

 
Ø 
Fever can lead to dehydration
Ø 
vitamin c can help fight infection and
reduce fever and also keep patient hydrated
 

 

Evaluation: patient temperature reduces to normal range
that is 36? -37? 

Diagnosis

Outcome

Intervention

Rational

Deficit fluid volume related to lack of
appetite and inadequate fluid intake
 

·        
Patient
skin turgor back to normal and urine output greater than 30 ml/hr.
 
 

·        
Assess
skin turgor, dry tongue, body weakness, difficulty in speech, confusion and
mucous membrane of mouth
 
·        
Assess
color and amount of urine. Urine output that are less than 30 ml/hr. for 2 hours
must be reported
 
·        
Encourage
patient to drink enough amount of fluid
 
 
·        
Help
patient that need assistance while they are eating. Encourage caregiver or
relative to assist them while eating.
 
·        
Provide
frequent oral care for patient
 
 
 
·        
Educate
patient about possible cause and effect of fluid loss or decrease fluid
intake

Ø  sign of dehydration is detected through poor
skin turgor, tongue that is dry, dry mucous membrane and upper body weakness
 
Ø  normal range of urine output is
not less than 30ml/hr. Urine that are concentrated
show sign of fluid deficit.
Ø  older patient need to be remind to drink because
they have decrease sense of thirst. They also need to replace the inadequate volume
of fluid in their body.
Ø  Patient that having dehydration is weak and
need help from other.
 
 
 
Ø  It can stimulate patient appetite and make
the food to taste better
 
 
Ø  enough knowledge encourages
patient to take part in their plan of care
 

 

Evaluation: patient urine output back to within normal range
that is greater than 30ml/hr. and skin turgor back to normal

 

 

Diagnosis

Outcome

Intervention

Rational

Risk of nutritional imbalance related to lack
of appetite and difficulty in swallowing

·        
Patient
show no sign of malnutrition
·        
Patient
take enough number of calories and nutrient

·        
Record actual
weight of patient
 
 
·        
Take
nutritional history with patient and relatives
 
 
·        
Obtain
dietary consult to get complete
nutrition
assessment and method for nutritional support
 
 
·        
For
impaired swallowing, coordinate with speech therapist for evaluation and
instruction
·        
Provide
good oral care
 
 
·        
Encourage
family member to bring food from home to hospital
 
·        
Provide
pleasant environment

Ø  These will be used as basic for caloric and
nutrient requirement
 
Ø  Detail about patient eating habits are more
accurate from family member
 
Ø  This can help determine patient’s daily
requirement of specific nutrient to promote sufficient nutritional intake
 
Ø  Adjust thickness and consistency of food to improve
nutritional intake provided by therapist
Ø  Oral care can remove unpleasant taste which
often improve taste of food
Ø  It can increase patient appetite
 
 
Ø  Help decrease stress and provide patient with
sense of well-being

 

Evaluation: Patient are prevented from having malnutrition

Diagnosis

Outcome

Intervention

Rational

Risk
of electrolyte imbalance related to fever and inadequate fluid intake

Patient
electrolyte level can be maintaining within normal limit

·        
Monitor fluid intake and output of
patient
 
·        
Monitor the physical sign of patient’s electrolyte
imbalance
 
·        
Assess client’s weight and turgor of
skin
·        
Make sure patient have enough rest
period
·        
Make sure patient eat a well-balanced
diet
·        
Encourage patient to drink commercial
electrolyte solution
·        
Teach client and family how to maintain
electrolyte balance

Ø 
To ensure that patient fluid intake and
output within normal range if not further action will be taken
Ø 
The risk associated such as tissue breakdown,
decreased cardiac output, and neurologic signs
Ø 
This indicate that patient have poor
electrolyte and fluid intake
Ø 
Patient with electrolyte imbalance are
weak so they need enough rest
Ø 
It is important to avoid electrolyte
imbalance happened
Ø 
To replace the lost of electrolyte
 
 
Ø 
So they have knowledge and ability to prevent
electrolyte imbalance from happening
 
 

 

Evaluation: Patient can maintain normal balance of
electrolytes in body