Nursing Care Plan No, 2

Date identified: April 13, 2010

Date evaluated: April 13, 2010

Assessment
Subjective Cues:
“init lagi ang paminaw sa akong anak karon” as verbalized by the pt.’s mother.
Objective Cues:
 Flushed face
 Diaphoretic
 Restlessness
 Warm to touch
 Glassy-eyed appearance
 Pt. wearing damp clothes
 Warm environment
 Thick fabric clothes
 Febrile
 Tachypnea
 Temperature: 38.1°C
 Respiratory rate: 52 breaths/min.

Nursing Diagnosis
Hyperthermia related to underlying disease process secondary to Pneumonia.

Planning
Within 2 hours of nursing interventions the patient’s temperature will decrease
within the normal levels of 36.5 to 37.5°C

Interventions
Independent
1.) Assess the general condition of the patient; noting also the physical appearance
of the patient.
Rationale: Initiated to provide baseline data; a basis for patient care.
2.) Monitor the patient vital signs, closely eyeing on the patients temperature and
respiratory rate.
Rationale: To plot facts regarding the patient’s vital signs, closely monitoring the
temperature and respiratory rate will alert the student nurse for prompt actions
against cases of severity of problem.
3.) Monitor white blood cell count, hematocrit value, and other pertinent laboratory
reports.
Rationale: This is indicates that there is an infection, or to alert the health team if the
patient is dehydrated.
4.) Monitor and regulate the patient’s IVF accordingly;
Rationale: IV therapy plays an important role of patient’s suffering under cases of
hyperthermia as it replaces excess fluid losses brought about by the illness.
5.) Demonstrate and return demonstrate tepid sponge bath to the patient and to the
significant others. Also noting patient’s hot spot such as the groins, armpit, neck and
head.
Rationale: to inculcate to the patients significant others the means to cool down the
patient’s body with the use of tepid sponge bath, also help reduces patient’s
temperature to tolerable levels.
6.) Modify the patient’s environment by removing the extra linens on the patient’s
bed.
Rationale: cluttered clothing’s and excess blankets can contribute to patient’s
predicament, therefore must be intervene immediately.
7.) Offer alternatives on patients clothing preferences; light fabric clothes versus
thick fabric clothes.
Rationale: Provides options for the patient’s significant others to choose clothing for
the patient, not only it promotes the significant others independence but also his
critical skills as well.
8.) Assist the patient in changing to light-fabric clothes with the patient’s significant
others.
Rationale: Provides comfort with the means of changing dampened thick clothes
with dry and light fabric ones to the patient.
9.) Consider the need to modify patient’s environment around the bed (e.g. keeping
the ward doors open an opening of hospital windows.)
Rationale: According to Florence Nightingale, modifying the patient’s environment
can help promote health, it promotes proper air ventilation for the patient, promotes
cooling comfort with the means of nature’s breeze.
10.) Advise the patient’s significant others on the other ways to promote
bodily cooling for the patient such as fanning.
Rationale: it promotes bodily heat loss through convection.

11.) Expound more ideas on reducing the patient’s body temperature by

adhering to water therapy (to increase patient’s fluid intake to the tolerable level)
Rationale: Prevents water imbalance in the body as well as to promote cooling the
body by means of fluid intake.
12.) Provide emphasis on the importance of increasing vitamin C intake for the
patient. (e.g. calamansi juices, oranges and other citrus foods)
Rationale: Vitamin C helps to protect the body from diseases by the increasing the
body’s natural resistance to infection.
13.) Emphasize the importance of increasing the intake of iron rich foods (e.g.
malunggay, kamote leaves and other green leafy vegetables)
Rationale: Iron along with vit. C is the team to build immunity against diseases, as
iron supplements the absorption of vitamin C inside the body.
14.) Instruct the patient’s significant others to schedule the patient’s activities
accordingly with rest periods in between activities.
Rationale: Increasing the patient’s activity levels can expend the body to metabolize
more thereby increasing the patient’s temperature this must be intervened
accordingly with proper planning of activities.
 15.) Emphasize the importance of increasing intake of carbohydrate rich foods
(e.g. cereals, breads and rice foods)
Rationale: Hyperthermia wears out the patient’s energy levels to a scarce minimum
as tool for metabolizing much for defense purposes; therefore it is important to
replace such losses as to prevent complications brought about by the increased
metabolic state.
16.) Provide adequate rest for the patient.
Rationale: Promotes comfort and prevents unnecessary loss and consumption of
energy.
Collaborative
17.) Administer Anitpyretic/Analgesic meds; Paracetamol 125/5ml 5ml every
4 hours PRN for fever.
Rationale: this drug produces antipyresis by an action on the hypothalamus; heat
dissipation is increased as a result of vasodilation and an increased peripheral blood
flow.

Evaluation
After 2 hours of nursing interventions the patient’s temperature has decreased to
36.5°C which is in the normal range; 36.5 to 37.5°C.