A 65 year old male client with a history of an open fracture is now admitted in the ICU because of
septic shock. BP 90/60 HR 110, RR 30, Temp 39. Patient is restless with warm and flushed skin.
ASSESSMENT
NURSING
ANALYSIS
GOALS
DIAGNOSIS
INTERVENTION AND
EVALUATION
RATIONALE
Subjective:
Hyperthermia
Temperature
Within 4 hours of
INDEPENDENT
After 4 hours of
data indicated
evidenced by
celsius can
interventions,
vital signs at least
interventions the
Objective:
celsius, restless
infection which
have a stabilized
patient’s vital sign
relieve his fever
No subjective
related to sepsis as
temperature of 39°
with 39 degree
cause sepsis
nursing
the patient will
- Restless
with warm and
can lead to
temperature
- Warm and
flushed skin.
tissue damage
within the
and organ
normal range
flushed skin
Vital Signs:
BP: 90/60 mmHg
HR: 110 bpm
RR: 30
Temp: 39° Celsius
failure.
and experience
no associated
complications.
- Monitor patient’s
every hour until the
becomes stable.
Rationale: To create
an accurate
diagnosis and
monitor
effectiveness of
medical treatment,
particularly the
fever-reducing drugs
administered.
- Provide a sponge
bath. Avoid use of
alcohol
Rationale: To
facilitate the body in
cooling down.
Alcohol can also
cause skin
dehydration.
- Remove excessive
clothing, blankets or
linens and adjust the
room temperature.
Rationale: To
regulate the
nursing
patient was able to
with no associated
complications.
temperature of the
environment and
make it more
comfortable for the
patient.
DEPENDENT
- Administer
antipyretics such as
Acetylsalicylic acid
(Aspirin) or
Acetaminophen
(Tylenol) as
prescribed.
Rationale: To
address the
underlying sepsis
resulting in
hyperthermia to the
patient.
COLLABORATIVE
- Collaborate with a
Hematologist to
review laboratory
results for culture
and sensitivity.
Rationale: Positive
culture findings may
suggest bloodstream
infection.