DEFINITIONS:
Circumstances where an individual experiencing an increase in body temperature above peroral C 37.80 / 38.80 C per-rectal due to external factors (Carpenito, 1995)
PURPOSE:
Addressing the problem of increase in body temperature to prevent the lack of fluids or other complications due to hyperthermia.
CRITERIA:
Temperature 36 to 37.5 C, no complaints of fever, chills no, elastic skin turgor, vital signs within normal range (blood pressure, pulse, CVP and JVP)
NURSING DIAGNOSIS :
- Deficient fluid volume
- Altered Body Temperature
- Hyperthermia
NURSING ACTION - Care Plan for Hyperthermia:
- Monitor body temperature
- Monitor blood pressure, respiratory frequency, and pulse
- Monitor intake and output every 8 hours
- Encourage much to drink when there is no contraindication
- Maintain adequate ventilation in the room
- Give a warm compress
- Use clothing that is thin and absorbs perspiration
- Encourage clients to total bedrest
- Monitor client's hydration status
HEALTH EDUCATION:
- Teach how to properly compress
- Explain the importance of fluid to maintain normal body temperature
Act of collaboration:
- Maintain intravenous fluids according to program
- Give antipyretics according to program
- Give therapy, for the cause of fever according to program
