Emergency Room

Care Plan

Submitted by:
Cayabyab, Natasha Alaine E.
BSN IV E-2

Submitted to:
Ma’am Marites Cabansag

October 26, 2018

Discussion of the case
A. Demographics of Hyperthermia is elevated  Assisted to ER Bed and  To have comfort while Admitted and endorse to
the Patient
R. I., a 37 years old female
accompanied by her
husband into the emergency
room with chief complaint
of fever and cough for 4
days. She lives here in
Baguio City.
Chief Complaint: Fever and
Cough
B. History
 History of Present
Illness
4 days prior to admission,
patient experience high grade
fever (39 degrees celcius) with
severe coughing episodes. She
consulted to their health
center which she was
prescribed with Paracetamol
500 mg q 4, Azithromycin 500
mg 1 tab BID and Deflam
throat spray. She was relieved
for quite some times but few
hours prior to admission,
patient’s cough and fever
persists which prompted her to
take consultation at SLUHSH
Explanation of the Problem Interventions Rationale Evaluation
body temperature due to a Positioned in ER Palliative Ward
break in thermoregulation Comfortably
that arises when a body
produces or absorbs more  Assessed vital signs
 To have baseline data
heat than it dissipates. It is  Provided tepid sponge
a sustained core bath  Enhances heat loss by
temperature beyond the conduction and
evaporation
normal variance, usually
greater than 39° C (102.2°
F). Such elevations range  Assisted in collecting  To check what
from mild to extreme; Sputum for GSCS microorganisms or
pathogens is present in
body temperatures above
40 °C (104 °F) can be the sputum of the
life-threatening. client
Hyperthermia differs from  To prevent
fever in that it is
dehydration
characterized by an  Assisted in IV insertion
uncontrolled increase in  Thought to produce
body temperature that analgesia by blocking
exceeds the body’s ability  Administered generation of pain
to lose heat. The setting of Paracetamol impulses, probably by
inhibiting prostaglandi
the hypothalamic
thermoregulatory center is n synthesis in the CNS
unchanged. In contrast to or th synthesis or action of
fever in infections, other substances that
hyperthermia does not sensitize pain
receptors to mechanical
involve pyrogenic
molecules. or chemical stimulation.
It is thought to relieve
In the case of my client, fever by central action
pyrogens cause a rise in in the hypothalamic
body temperature it also
 acts as an antigen heat-regulating center.
triggering immune system
 Past Medical  Azithromycin blocks
response. Due to the
History pathogens entering the transpeptidation by
body, the hypothalamus binding to 50s
She was never been admitted ribosomal subunit of
or brought into the reacts to raise the set point
and the body respond by susceptible organisms
emergency room before and
it was her first time to be in producing heat. and disrupting
the hospital.Patient has no RNA-dependent
history of diabetes mellitus, protein synthesis at the
hypertension, bronchial chain-elongation step.
References:
asthma, PTB/exposure,
 Administered  It selectively binds to
cancer, CVD and CAD. Fundamentals of Nursing
Patient has no known Azithromycin inflamed
by henry and
allergies to food and tissues(Prostaglandin
perry.https://www.scribd.
medications. synthetase inhibitor) and is
com/doc/26249191/NCP
normally free of adverse
-hyperthermia
systemic effects.Unlike
 Family History of other NSAIDs, it does not
inhibit cyclooxygenase or
Illness lipooxygenase ,and is not
She claimed to have a family ulcerogenic
history of hypertension and
diabetes mellitus. But no  Decreases viscosity of
history of stroke, asthma, respiratory tract
cancer, PTB/exposure, CVD secretions and
and CAD.  Administered Difflam promote their removal
by breaking disulfide
bonds. In
acetaminophen
overdose, it protects
Subjective Data: the liver from injury
by restoring
“ Hindi naman ako dapat glutathione levels or
magpapacheck up eh pero by acting as alternate
sobrang taas na kasi ng substrate for
lagnat ko tapos inuubo pa acetaminophen
ako. Uminom din akong metabolism
paracetamol pero meron
pa rin kaya natatakot ako
na baka dengue. Tapos
medyo greenish na din
plema ko” patient  Administered
verbalized N-Acethylcysteine

Objective Data:
 Skin warm to touch
 Temperature of 38.7
C
 Increase RR: 28 cpm
 Increase HR: 120 bpm
 Hoarse voice
 Flushed Skin
 Noisy breathe sounds

Nursing Diagnosis:
Hyperthermia related
to inflammatory
process secondary to
disease process

Objectives:
After 1 hour of joint
medical and nursing
interventions, the
client’s temperature
will lower down from
38.7 to atleast 37