1. Nursing Diagnosis: Hypertermia related to the infection process
Goal: The temperature within normal limits
Expected outcomes are:
- Free from cold
- Stable body temperature 36-37 C
- Monitor the temperature of the client (the degree and pattern) note the chills / diaphoresis
- Monitor the temperature of the environment, limit / add the bed linen as indicated
- Give a warm compress to avoid the use of alcohol
- Give the drink as needed
- Collaboration for the provision of antipyretics
2. Nursing Diagnosis: Risk for Injury related to repetitive strain
Goal: free from injury
Expected outcomes are:
- shows the homeostatic
- no mucosal bleeding and free from other complications
- Review the signs of complications
- Assess the status of cardiopulmonary
- Collaboration for laboratory monitoring: monitor routine blood
- Collaboration for the administration of antibiotics
3. Nursing Diagnosis: Fluid Volume Deficit related to the intake of less
Goal: Adequate fluid volume
Expected outcomes are:
- vital signs within normal limits
- strong peripheral pulses palpable
- adequate urine output
- there are no signs of dehydration
- Measure / record the urine output and specific gravity. Record the input and output cumulative imbalance
- Monitor blood pressure and heart rate
- Palpation of peripheral pulses
- Review of dry mucous membranes, poor skin tugor and refined taste
- Collaboration for the administration of IV fluids as indicated
- Monitor laboratory values
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