Name of Student: _______Princess F.

Sugaton___________ Section and Group number: ___BSN3-F GRP:4__________

Assessment Nursing (Rationale)

NURSING CARE PLAN
Desired Outcome Nursing Intervention Rationale Evaluation
Cues Diagnosis Pathophysiologic /
Schematic Diagram
Subjective: Short term Goal: Independent
Hyperthermia After 1 hour of
“kasakit kun mag related to upper
history of
hypertension appropriate nursing 1. Monitor vital signs. 1.Vital signs provide more
tulon ko nurse” as tract infection as and diabetes, Hyperther intervention: accurate indication of core
verbalized by the evidence by high mother side mia temperature.
patient. fever of 38.2  Core Temperature
2. Provide tepid sponge 2.TSB helps in lowering the
Degree Celsius, is within normal
bath. Do not use alcohol.
Objective: sore throat, and Exposure to high environmental range from 38.2C body temperature and
 Fever pain upon to 37.5oC. alcohol cools the skin too
temperature/Humid weather
 Cough swallowing.  Identifies rapidly, causing shivering.
 runny nose underlying Shivering increases
 sore throat Decrease in sweat response cause/contributing metabolic rate and body
 febrile factors temperature
episode importance of 3. Remove excess clothing
Dehydration treatment and and covers. 3.These decrease warmth
 Vital Signs:
signs/symptoms and increase evaporative
-T-38.2 C
requiring further cooling.
-RR-18 cpm Increase of Body temperature
-PR-68 bpm evaluation or 4. Promote a well-
intervention ventilated area to 4.To promote clear flow of
-BP-120/70 Definition: patient. air in the patient’s area.
 Laboratorie fever  Demonstrate
Core body behaviors to One way of promoting heat
s
temperature monitor and loss.
-Complete blood
above the normal promote 5. Advise patient to
count: WBC
diurnal range due normothermia. increase oral fluid intake. 5.Additional fluids help
(12x1000/ mm2)
to failure of prevent elevated
-Negative RTPC test
thermoregulation Long Term Goal temperature associated
-Platelet Count -
. After 4 hours or with dehydration.
250 x 10g/L
appropriate nursing
-Urinalysis Result - 6.Reduce metabolic
intervention
No pus, no
hematuria noted,
Source/ Reference: 6. Maintain bed rest. demands/ oxygen
 the patient’s vital consumption
negative protein Reference signs will return to
(normal Result) NANDA NANDA normal range with a 7.To meet increased
- Chest Xray - No temperature of 7. Provide high-calorie diet. metabolic demands.
significant findings 36.5-37.5oC, pulse
rate of 60-100bpm
and respiratory rate 8.Teaching the Support
of 12-20 cycles per 8. Educate and advise system the right way to do
min. support system (relative) TSB will help in knowing
to do TSB when patient what to do in case the
 Absence of febrile feels hot. patient’s temperature
episode - Luke warm water only. increases
- Make sure that armpits
and groins were included 9.To know the effectiveness
in doing TSB. of nursing interventions
done and to know the
9. Monitored VS and progress of patient’s
recheck. condition.
Strength :
10.These drugs inhibit the
Dependent prostaglandin that serve as
10. Provide antipyretic mediators of pain and
medications as indicated. fever.

Name of CI: _______Ms. Jean Transmonte Canillas_______ Area of Exposure: ___________Isolation ward__________