NILO, KLARENZ MEDICAL SURGICAL WARD

BSN IV-B2 NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

Subjective data: Hyperthermia Short term: After • Establish rapport with • For the Short term: Goal Met
N/A related to infection 2 hours of nursing the client cooperation of After 2 hours of nursing
as evidenced by intervention the the client intervention the patient
temperature of patient and/ or • Assess the vital signs • For baseline and/ or significant other
38.4 C. significant other of the patient. data. has verbalized at least 3
will be able to • Eliminate excess • Exposing skin to causes of fever as
verbalize at least clothing and covers. room air evidenced by the
3 causes of fever. decreases verbalization of the
Objective Data: warmth and client.
Body temperature increases
above the normal evaporative
range cooling.
Hot, flushed skin • Explain to the patient • This will add
Loss of appetite Long term: After some causes of fever. some Long term: Goal Met
VS: 8 hours of nursing -Infections information to After 8 hours of nursing
-BP: 120/90 intervention the -some immunizations, the client or to intervention the client’s
-PR: 85 client’s body such as diphtheria or the SO. body temperature
-RR: 24 temperature will tetanus decreased from 38.4 C to
T: 38.4 C decrease from -Heat exhaustion 37.4 C as evidenced by
38.4 C to 37.4 C. • Initiate Tepid Sponge • This will help to the reading of
Bath to the patient. lower the body thermometer.
temperature of
the patient.
• Noninvasive: cooling • These measures
mattress, cold packs help promote
applied to major cooling and
blood vessels lower core
temperature.
• Start intravenous • Intravenous
normal saline normal saline
solutions or as solution
indicated. replenishes fluid
losses during
shivering chills.
• Provide high caloric • Appropriate diet
diet or as indicated by is necessary to
the physician. meet the
metabolic
demand of the
patient.
• Give antipyretic • Antipyretic
medications as medications
prescribed. lower body
temperature by
blocking the
synthesis of
prostaglandins
that act in the
hypothalamus.