Wesleyan

University-Philippines
COLLEGE OF NURSING AND ALLIED MEDICAL SCIENCES
Tel. No. 044-4632162/2074; Fax no. 463-0596 local 126
NURSING CARE PLAN

NAME OF STUDENT: GROUP NO: BLOCK: DATE:

NAME OF PATIENT: MEDICAL DIAGNOSIS: ________________________________________________________
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Hypothermia Short term goal: Independent Assessment will indicate After nursing
After 2 hours of nursing intervention
the presence of
Age-related intervention the client’s bode patient’s body
“Nilalamig po ako” as temperature will gradually Monitor temperature with hypothermia. The normal temperature returns
verbalized by the changes in return to its normal limits as a low-range thermometer temperature of an older to normal range of
client thermoregulation manifested by increase of if available. 36.5
adult is 35.5°C (96°F)
and environmental temperature from 35.5°C to
Objective Goal is achieved
exposure 36.5°C Initiate slow rewarming if Increasing the room
 Shivering the patient is mildly temperature to at least
 Cool skin Long term goal: hypothermic. 23.89°C or give warm
 Tachycardia After 1 day of nursing blankets is one method to
intervention the clients is Control the heat source
 Pallor reverse mild hypothermia.
free from presence of
hypothermia
Temperature 35 Dependent
degree Body temperature should
Provide extra heat source:
be raised no more than a
 Heat lamp, few degrees per hour.
radiant warmer
These measures raise the
 Warming pads, core temperature and
 mattress, or improve circulation. Core
blankets warming is indicated when
body temperature is below
 Submersion in a
30 °C
warm bath
 Heated,
moisturized
oxygen

Clinical Instructor: RLE Coordinator: