University of Perpetual Help System DALTA

Alabang Zapote Rd., Pamplona Las Pias City COLLEGE OF NURSING NURSING CARE PLAN Name of Patient: MSM ASSESSMENT SUBJECTIVE:  SaawangDiyos, hindinasyanagsusuka at nagtatae, kaya langnilalagnatsya e. as verbalized by the clients mother. OBJECTIVE:  Alert, awake and responsive  Good skin turgor, warm to touch  Capillary refill less than 4 seconds  (+) irritability  Clear breath sounds  Febrile (37.9C)  PR 120 bpm  RR 48 cpm Name of Student: Bartolome, Rhoel John V Age: 1 year old NURSING DIAGNOSIS Hyperthermia related to viral infection as evidenced by elevated body temperature. Sex: M PLANNING After 4 hours of nursing intervention, the client will be able to maintain normal core temperature. Diagnosis: AGE w/ some DHN INTERVENTIONS  Established Rapport  Monitored and recorded vital signs  Monitored and recorded Intake and Output  Noted inability/decrease d perspiration  Promoted surface cooling (loose clothing, cool room temperature)  Administered Paracetamol oral drops (1.6 mL) as ordered Yr. Sec. &Grp No.: BSN 4D Group 4 Rm. / Bed No.: 520 RATIONALE  To gain clients trust and cooperation  To establish baseline data  To determine fluid volume relative to body temperature increase/decrease  To determine possible cause of increased body temp  To promote decrease in body temperature  Antipyretic drugs help decrease body temperature Area & Shift: MCI 5th Floor Ward (2-10pm) EVALUATION  Goal Met. After 4 hours of nursing intervention, clients temperature decreased to 37.1C.