NURSING CARE PLAN

CUES DIAGNOSIS PLANNING INTERVENTIONS EVALUATIONS

Subjective: Hyperthermia Within 4hrs of nursing 1. Assess the patient’s vital signs to After 4hrs of
Objective: related to intervention the patient will be determine if there still a progress nursing
-Left facial swelling and redness underlying infection able to maintains body of his condition. intervention the
noted (sepsis) temperature below 39° C. 2. Monitor fluid intake and urine patient was able to
-limited range of motion as output. If the patient is maintains body
observed unconscious, central venous temperature below
-febrile (39.1 C) Within 3 days of nursing pressure or pulmonary artery 39° C as evidence
-tachycardia to 120 interventions the patient will be pressure should be measured to by 37.6 C.
-chills noted able prevent from complications monitor fluid status because fluid Goal met.
such as neurological damage. resuscitation may be required to
correct dehydration.
3. As indicated, adjust and monitor
environmental variables such as
room temperature and bed sheets After 3 days of
to regulate temperature of the nursing
patient. interventions the
4. Prepare and ready oxygen therapy patient was able
for extreme cases since prevent from
hyperthermia increases the complications such
metabolic demand for oxygen. as neurological
5. Provide cooling mechanisms such damage as
as cooling mattress, cold packs evidence by the
applied to major blood vessels to patient follows
promote cooling and lower core order of the nurse
temperature. such as moving his
6. Perform tepid sponge bath sponge feet, hand and
bath helps to reduce opening his mouth.
hyperthermia. Take note, using
alcohol and iced water which may N.ZAFRA FSUU/SN
even produce chills and increase 8-30-21
client’s temperature.
7. Raise the side rails at all times to
ensure patient’s safety even
NURSING CARE PLAN
without the presence of seizure
activity.

Dependent interventions:
8. Give antipyretic medications as
prescribed to lower body
temperature by blocking the
synthesis of prostaglandins that act
in the hypothalamus.
9. Provide chlorpromazine
(Thorazine) and diazepam (Valium)
when excessive shivering occurs.
Shivering increases the metabolic
rate and body temperature.

Collaboration
10. Educate patient and family
members about the signs and
symptoms of hyperthermia and
help in identifying factors related
to occurrence of fever.