West Visayas State University
COLLEGE OF NURSING
Name:
Age: Ward/Bed Number:
Clustered Cues Nursing Diagnosis Rationale Outcome Criteria
11-20-17
5pm Hyperthermia related to Hyperthermia is After the end of shift
disease process elevated body patient must be able
Temp: 38. 7 temperature due to a to:
break in
Skin warm to touch 1.
thermoregulation that
arises when a body
Sweating noted
produces or absorbs
RR:22 bpm
more heat than it 2.
dissipates. It is a
PR: 120 bpm
sustained core
O2 sat: 93 temperature beyond the 3.
normal variance,
usually greater than 39
C (102.2 F). Such 4.
elevations range from
mild to extreme; body
temperatures above 40
C (104 F) can be
life-threatening.
Hyperthermia differs
from fever in that it is
characterized by an
uncontrolled increase in
body temperature that
Students Name: SIAN GRACE E. ASADA BSN 4C; RLE Group 2
Clinical Instructor: IAN VAN V. SUMAGAYSAY, RN
La Paz, Iloilo
Nursing Care Plan
Attending Physician:
Impression/Diagnosis:
Nursing Interventions Rationale Evaluation
Independent: 03-20-17
1. provided tepid sponge bath 1. enhances heat loss by After the end of
evaporation and conduction. shift patient was
2. Assessed intake and output able to:
2. Increases metabolic rate
Temperature 3. Provided frequent rest and diaphoresis.
periods.
within normal
3. Reduces body heat (with temperature
range 36.5-37.5 4. Monitored vital signs
production of 38.2(taken at
Exhibit stable 9pm))
5. Provided a cool 4. Baseline data
vital signs
environment
Relief signs of 5. Dissipates heat by
Dependent: conduction.
discomfort.
6. Administered antiobiotic as
Appear relaxed, prescribed.
able to rest/sleep 6. Inhibits cell wall synthesis
and participate in 7. Administered antipyretic as during bacterial
activities prescribed. multiplication
appropriately.
7. Relieve fever through
central action in the
hypothalamic heat-regulating
center
 exceeds the bodys
ability to lose heat. The
setting of the
hypothalamic
thermoregulatory center
is unchanged.
Sources: http://www.su
rgeryencyclopedia.com
/Pa-St/Post-Surgical-Pa
in.html#ixzz4bbImlDP
7

Nurses Pocket Guide

12th edition

Students Name: SIAN GRACE E. ASADA BSN 4C; RLE Group 2

Clinical Instructor: IAN VAN V. SUMAGAYSAY, RN