NURSING CARE PLAN

Nursing Cues and Scientific Analysis Objectives Nursing Interventions Rationale Evaluation
Diagnosis

Hyperthermia related Hyperthermia occurs After 4 hours of INDEPENDENT: After 4 hours of

to inflammatory when the body nursing interventions, 1. Identify underlying 1. To assess nursing interventions,
response produces or absorbs the patient will be able cause causative or the patient was able
more heat than it can to: contributing to maintain normal
dissipate. For factors core temperature
Objective Cues: example, in response  Maintain core 2. Monitor core 2. To evaluate from 39 C to 37.4 C.
 Vital signs: to a bacterial or viral temperature temperature degree of
T – 39 C infection, the body within normal hyperthermia
P – 108 bpm will raise its range 3. Assess neurological 3. To monitor level
R – 45 cpm temperature, much  Be free of response of consciousness
BP – 90/60 like raising the complications and occurrence of
mmHg temperature. In the such as seizures
 Skin is warm to case of dengue fever, irreversible 4. Monitor heart rate 4. Dysrhythmias are
touch after being bitten by brain damage and rhythm common due to
 Tachypnea a mosquito carrying  Demonstrate electrolyte
 Convulsions the virus, the behaviors to imbalance
 Platelet count of incubation period promote normal 5. Monitor sources of 5. To note for signs
61,000 per ranges from three to body fluid excretion such of dehydration
microliter 15 days before the temperature as urine, nausea
signs and symptoms  Be free of and vomiting
of dengue. The seizure activity 6. Note presence or 6. To check for
temperature rises absence of sweat sweat glands
quickly as high as 40 glands dysfunction
C with relative low 7. Perform tepid 7. To promote heat
heart rate. sponge bath loss through
conduction
Reference: Canada. 8. Promote surface 8. To minimize
Public Health Agency cooling by taking off shivering and to
of Canada. "Dengue patient’s blanket promote heat loss
in South East Asia." through
Aug. 23, 2007.  conduction
9. Increase fluid intake 9. To prevent
by at least 1.5 liters dehydration
per day

COLLABORATIVE:
1. Administer 1. To eliminate
antipyretics fever by
hypothalamic
effort
2. Administer 2. To control
medications such shivering and
as diazepam seizures
3. Provide 3. To offset
supplemental increase
oxygen as oxygen
needed demands and
consumption
4. Administer 4. To support
replacement circulating
fluids and volume and
electrolytes tissue
5. Provide high perfusion
calorie diet 5. To meet
increased
metabolic
demands