NURSING CARE PLAN

Assessment Nursing Diagnosis Scientific Planning Intervention Rationale Evaluation

Explanation
1
S: “Miss pwede po Hyperthermia Idiopathic or Goal: Independent:
ba pakitingin ung related to suspected viral Client will be able to 1. Monitor vital signs Regular temperature Client was able to
temperature niya inflammatory infection. maintain normal monitoring will maintain normal
medyo mainit siya process secondary body temperature identify body temperature
eh” as verbalized by to pericardial Inflammation with out adequate with out
the patient’s father infection process of complications. thermoregulation complications.
pericarditis
O: T: 38.8 C - lead to Objectives: 2.Provide tepid To promote cooling Objectives
PR: 102bpm Accumulation of After the nursing sponge of After the nursing
RR: 70cpm fluid in the intervention: bath(if not body surface intervention:
Very Warm Skin pericardial contraindicated)
Little weak sac(pericardial Short term Short term
Always sleeping effusion) and -The patient will 3. Promote To maintain stable The patient was
increased pressure on be able to be free ventilation of body temperature of able to be free from
the heart from any skin by means of newborn and complications
-leading to complications undressing decrease
Cardiac tamponade (heat loss by the possibility of The patient was able
*Frequent or Long term radiation and complication to maintain body
prolonged episodes - Maintain body conduction) (dehydration) temperature at a
of pericarditis temperature at a normal range
-may lead to normal range 4.Promote client Besides treating the
Thickening and safety sickness safety of the
decreased and client is imporant
decreased elasticity
of the pericardium/ Depdendent
scarring may fuse the 1. Administer Treatment of mild to
visceral and parietal antipyretics moderate pain; fever;
pericardium w/ correct pediatric various inflammatory
1
Brunner & Suddarth’s Textbook of Medical-Surgical Nursing 12th edition, Smeltzer, Bare, Hinkle, Cheever, page 818
dose (as ordered) conditions
2. Administer To treat the
antibiotics underlying
w/ correct pediatric cause
dose (as ordered)

Collaborative
1. Instruct the mother To dehydrate the
to patient
increase adequate
fluid
intake( if not
contraindicated