DIAGNOSIS
OUTCOME
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
