NURSING CARE PLAN

Defining Characteristics Nursing Diagnosis Scientific Analysis Goal of Care Nursing Interventions Rationale
(short term)

Subjective Cues:
(verbalization from the
patient)
EX: “Ghilantan ko” as
verbalized
Altered thermoregulation: (Explain the nursing diagnosis) After 3-4 hours of appropriate Independent:
Hyperthermia related nursing intervention, the patient’s 1. Regulate IVF to prescribed 1. ________________________
to_________________________ body temperature will be reduced rate.
___________________________. to _____________________. 2. Increase fluid intake. 2. _______________________
3. Provide adequate rest. 3. _______________________
4. Provide tepid sponge bath. 4. _______________________
5.

Dependent:
1. Administer antipyretic as 1. ____________________
Objective Cues: ordered.
(assessment findings,
observations)
- Received with IVF Plain LR
1L @ 30 gtts/min
- With NGT
(clamped/closed)
- With FBC attached to
urine bag
- Body temp: 38.9 degree
Celsius
- Skin is dry and warm to
touch
- Lips are dry and cracked

Reference/Source: ________________________________________________________________________________________________________________________________________________________________