NURSING CARE PLAN

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

Independent:
Subjective: • Hyperthermia Infectious agents • After 4 hrs. Of • Monitor heart • Dysrhythmias • After 4 hrs.
related to (Pyrogens) nursing rate and and ECG Of nursing
“Mainit ang dehydration. stimulate interventions, rhythm. changes are intervention
pakiramdam ko” Monocytes the patient will common due s, the
as verbalized by maintain core to electrolyte patient was
release
the patient. temperature imbalance able
Pyrogenic cytokines
within normal and maintain
Objective: stimulate range. dehydration core
Anterior hypothalamus and direct temperature
• Flushed skin, effect of within
results in
warm to Elevated thermoregulatory set point
hyperthermia normal
touch. on blood and range.
leads to cardiac
• Restlessness Increased Heat conservation
tissues.
. (Vasoconstriction/behaviour changes) • Record all • To monitor or
Increased Heat production sources of fluid potentiates
(involuntary muscular contractions)
• V/S taken as loss such as fluid and
result in urine, vomiting electrolyte
follows:
FEVER and diarrhea. loses.
T: 38.1 • Promote • To decrease
P: 70 surface cooling temperature
R: 19 by means of by means
BP: 110/90 tepid sponge through
bath. evaporation
and
conduction.
• Wrap • To minimize
extremities with shivering.
cotton blankets.
• Provide • To offset
supplemental increased
oxygen. oxygen
demands and
consumption.
• Administer • To support
replacement circulating
fluids and volume and
electrolytes. tissue
perfusion.
• Maintain bed • To reduce
rest. metabolic
demands and
oxygen
consumption
• Provide high • To increased
calorie diet, metabolic
tube feedings, demands.
or parenteral
nutrition.
• Administer • To facilitate
antipyretics fast recovery.
orally or rectally
as prescribed
by the
physician.