NURSING CARE PLAN

Actual
Assessment Nursing Diagnosis Nursing Goal Nursing Intervention Rationale Outcome Criteria
Evaluation
Subjective: Hyperthermia After 2 hours of Maintain normal
Provide tepid sponge bath.  Enhances heat loss by
“Gihilantan mana related to the comprehensive temperature of
evaporation &
siya”, as infectious process nursing 37.5°C
Provide cool circulating air conduction.
verbalized by the or cerebral edema intervention,
using a fan.  Increases metabolic rate
S.O. the patient Be free of
& diaphoresis.
temperature will dehydration
 Assess fluid loss &  Reduces body heat
Objective: lower down to
facilitate oral intake. production.
Skin warm to Scientific Basis: normal levels: T: Maintain vital signs
 Promote bed rest.  Dissipates heat by
touch with a Pyrogens cause a 36.5°C – 37.5°C at normal levels
convection.
temperature of rise in body
 Assist patient in  Increases comfort.
39.1°C temperature, it Be alert and
changing into dry
↑RR: 28cpm also acts as an responsive
clothing.  Prevents herpetic
↑HR: 102bpm antigen triggering
 Provide oral hygiene. lesions of the mouth.
Weakness immune system Be comfortable in
 Notes progress &
observed responses. The bed.
 Monitor vital signs. changes of condition.
Dry mucous hypothalamus
membranes reacts to raise the
DEPENDENT:  Prevents dehydration.
Flushed Skin set point and the
 Maintain IV fluids as
body respond by
ordered by physician.  Reduces fever.
producing heat.
 Administer anti-pyretic
as ordered.  Treats underlying cause.
Reference:
 Administer antibiotic as
Fundamentals of
ordered.
Nursing
-Harry & Perry
COLLABORATIVE:  Indicates presence of
 Monitor hematologic infection & dehydration.
test & other pertinent
lab records.  Ensures continuous
 Discuss condition of the intervention.
patient with other
members of the health
care team.
Reference for the Rationale: Nursing Care Plans, 3rd edition by Doenge
Nursing diagnosis: Hyperthermia related (lhug lantaw sa nanda gha,haha hndi ko kblo)
Manifested: as evidence by Skin warm to touch with a temperature of 37.9°C,weakness observed, Dry mucous membranes and Flushed Skin
Goal: After 2 hours of comprehensive nursing intervention, the patient temperature will lower down to normal levels: T: 36.5°C – 37.5°C

Expected outcomes Nursing intervention Rationale

Maintain normal temperature of 37.5°C 1.Provide tepid sponge bath. Enhances heat loss by evaporation & conduction.

Reduces fever.
2.Administer anti-pyretic as ordered.

Treats underlying cause.

3. Administer antibiotic as ordered.

Notes progress & changes of condition.

4. Monitor vital signs.

Be free of dehydration 1. Assess fluid loss & facilitate oral intake. Increases metabolic rate & diaphoresis.

2. Maintain IV fluids as ordered by physician Prevents dehydration

3. Check the results of hematologic test & other Indicates presence of infection & dehydration
pertinent lab records.

Be alert, responsive and comfortable in bed. 1. Promote bed rest Reduces body heat production.

2. Provide cool circulating air using a fan. Dissipates heat by convection.

3. Assist patient in changing into dry clothing. Increases comfort

4. Provide oral hygiene Prevents herpetic lesions of the mouth