NURSING CARE PLAN

Problem No: 1
Date Identified: May 17, 2010
Problem Identified: Hyperthermia

CUES
Subjective: “Init, sakit akong ulo”
Objectives:
 V/S
a. T – 38.480C
b. R – 32
 Diaphoresis
 Flushed skin
 Warm to touch
 Facial grimace noted
 Irritability

Nursing Diagnosis:

Hyperthermia related to undelying disease condition

Objectives / Evaluation Criteria:

Within 4 hours of nursing interventions, the patient will be able to maintain body temperature
within normal range (36.5 – 37.50C)

NURSING INTERVENTIONS RATIONALE

1) Assess vital signs
2) Obtain age and weight
3) Measure I & O
4) Note presence / absence of sweating as body
attempts to increase heat loss by evaporation,
conduction and diffusion
5) Remove excessive clothing & covers
6) Cool with tepid sponge bath or immersion
7) Local ice packs, especially in groin and axillae
8)Provide ample fluid
9) Maintain bed rest
Collaborative
10) Administer medication, as indicated
11) administer replacement of fluid & electrolytes
Serves as baseline data
Extreme of age and weight increases the risk for
inability to control body temperature
To monitor for fluid and electrolytes imbalance
Evaporation is decreased by environmental factors
of high humidity and a high ambient temperature,
as well as body factors producing loss of ability to
sweat or sweat gland dysfunction
To allow ventilation and to reduce heat by
evaporationa and convection
To allow heat loss by evaporation and conduction
Loss of heat by conduction is effective in areas of
high blood flow
If patient is dehydrated or diaphoretic, fluid loss
contributed to fever
To reduce metabolic demands / oxygen
consumption
To lower down body temperature and/or treat
underlying cause of hyperthermia
To support circulating volume and tisue perfusion

Evaluation:

Goal met. After 4 hours of nursing interventions the patient’s temperature is 37.46 0C

Date Evaluated:

May 18, 2010

 NURSING CARE PLAN

Problem No: 2
Date Identified: May 18, 2010
Problem Identified: Risk for impaired skin integrity

CUES
Subjective:
Objectives:
 Diaphoresis
 Left sided weakness of the body
 Always lying on bed
 Needs assistance in moving
 Capillary refill of 3 seconds
 Dry skin
 Skin recoil after 1 second

Nursing Diagnosis:

Risk for impaired skin integrity r/t physical immobility socondary to left sided weakness

Objectives / Evaluation Criteria:

Within 4 hours of nursing interventions, the patient & his significalt others will be able to
demonstrate behavior changes / technique to prevent skin breakdown as evidenced by turning to sides
and drying moisten areas of the body.

NURSING INTERVENTIONS RATIONALE

1) Assess vital signs
2) Determine age
3) Assess patient’s ability to move
4)Assess for environmental moisture
5) Implement and maintain repositioning the
patient
6) Maintain meticulous skin hygeine by cleaning,
drying thoroughly the skin especially over bony
prominences
7) Support bony prominences using pillow or
rolled cloth
8)keep bedclothes dry and wrinkle-free
9) Provide safety meaures as indicated by
individual situation as clearing the bed to provide
adequate space for movement
10) Encourage ambulation if patient is able
11) Emphasize importance of adequate nutrional /
fluid intake
12) Encourage range of motion exercises
Serves as baseline data
Elderly patient’s skin is leass elastic & has less
moisture, making for higher risk of skin
impairement
Immobility is the major risk factor in skin
breakdown
May contribute to skin breakdown
To allow distribution of pressure to the body
Moisten skin is prone to breakdown
To increase circulation and limit/ eliminate
excessive tissue perfusion
To keep skin dry and to prevent friction or shear
injury
Giving space for movement is important since it
decreases physical immobility by allowing the
patient to move in the given space
To allow muscle & joint movement & increase the
blood circulation in the different areas of the body
Hydrated skin is less prone to breakedown
To maintain general good health and skin turgor
To enhace circulation

Evaluation:

Goal met. After 4 hours of nursing interventions, the patient was able to turn to sides

Date Evaluated:

May 18, 2010

 NURSING CARE PLAN

Problem No: 3
Date Identified: May 20, 2010
Problem Identified: Activity intolerance

CUES
Subjective:
Objectives:
 Perspiring
 Left sided weakness of the body
 Always lying on bed
 Needs assistance in moving

Nursing Diagnosis:

Activity intolerance related to left sided body weakness

Objectives / Evaluation Criteria:

Within 4 hours of nursing iterventions, the patient will be able to report increase in activity
tolerance as evidenced by turning to sides when tolerated

NURSING INTERVENTIONS RATIONALE

1) Assess vital signs
2) Assess patient’s level of mobility
3) Plan care to carefully balaced rest periods with
activity
4) Plan for maximal activity within the client’s
ability
5) Assist with ADL as indicated but avoid doing for
patient what he can do for himself
6) Encouraged ROM exercises
7) Teach energy conservation techniques
(Changing position frequently & sitting to do task)
8)increase exercise / activity gradually
9)refrain from performing nonessential procedures
10)encouraged adequate rest periods especially
before ambulation, diagnostic procedures, & meal
11) promote comfort measures & provide for relief
of pain
12) Provide positive atmosphere, while
acknowledging difficulty of the situation
13) provide emotional support while increasing the
activity & promote positive attitude
Serves as baseline data
Aids in defining what patient is capable of, which is
necessary prior to setting realistic goals
To reduce fatigue
Promotes the idea of need for / normalcy of
progressring in this area
To reduce energy expenditures & increases
patient’s self-esteem
To maintain muscle strength and joint range of motion
They reduces oxygen consumption, allowing more
prolonged activity
To prevetn overexerting the heart and to promote
attainment of short-range goals
To promote rest
To reduces cardiac workload
To enhance ability to participate in activity
Helps to minimize frustration and rechannel
energy
To increase patient’s ability

Evaluation:

After 1 hour of nursing interventions, the patient was able to turn to his side on his own.

Date Evaluated:

May 20, 2010