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Subjective Elevated body Invasion of infectious After 30 Determined Identification and The client’s
cues: temperature agent (Virus) triggers minutes of precipitating management of temperature decreased
“Nilalagnat above normal the immune system to nursing factors. underlying cause are as evidenced by :
na naman siya.” related to sent neutrophil and interventions, essential to recovery. temperature
Objective Cues: respiratory tract kill offending the client will (Nursing Care Plan, =36.4 ºC
infection. organism through be able to 6th edition,
>Hyperthermic- inflammatory decrease body Gulanick/Myers pg. warm to touch
38.3ºC response that leads to temperature. 105)
elevation of body
>Tachycardic- temperature. Obtained age and Extremes of age and
190 beats per weight. weight increase the
minute risk for inability to
(Medical-Surgical
control body
Nursing
>Tachypneic- 58 temperature.
Pathophysiological
breaths per (Nursing Care Plan,
Concept, pge 496)
minute 6th edition,
Gulanick/Myers pg.
>hot to touch 105)
>Flushed cheeks Monitored axillary Provide information
temperature. about the
effectiveness of care.
>result of CXR, (Pediatric Nursing
basal pneumonia, Care Plans, 3rd
left edition,Karla L.
Luxner,RNC,ND,pg.
>nasal flaring 453)
Discussed to the
mother the
precipitating
factors and Additional fluids help
prevent elevated
preventive temperature
measures, associated with
including dehydration.
maintenance of (Pediatric Nursing
adequate fluid Care Plans, 3rd
intake, change in edition,Karla L.
environment, Luxner,RNC,ND,pg.
taking medications 454)
as prescribed.
Decreases fever by
Provided inhibiting effects/ heat
supplemental regulating centers
fluids and by hypothalamic
-IV - D5IMB IV action leading to
fluid regulated at sweating &
34 – 35 gtts per vasodilation.
minute,as per ( Pediatric Nursing
doctor’s order. Care Plans, 3rd
edition,Karla L.
Luxner,RNC,ND,pg.
454)
Administered
antipyeretic
medicine as
ordered
-Paracetamol 100
mL TID.