Nursing Care Plan

Names: Casia, Marie Ashley

Nursing Diagnosis: Hyperthermia r/t dehydration as manifested by flushed skin

Defining
Characteristics Scientific Basis Expected Outcome Nursing Intervention Rationale

Short term: Independent :

Subjective Data: Hyperthermia is elevated After 2 hrs. of rendering
“luya kay ako lawas ug init body temperature due to a nurse-patient interaction  Encourage - To promote
kay ako pamati ” - as break in thermoregulation the patient’s elevated patient to express cooperation and
verbalized by patient. that arises when a body temperature will lower feelings To establish
produces or absorbs more down and return to the rapport
heat than it dissipates. It is normal range and be free  Monitor body - To note any
a sustained core of chills . temperature progress and
Objective Data: temperature beyond the every 2 hrs changes on the
 Flushed skin noted normal variance, usually patient’s
 Warm skin to touch greater than 39° C (102.2° Long term: condition
 Irritability noted F). Such elevations range After 1 to 2 days the
 Dry skin noted from mild to extreme; body patient should maintain a  Increase fluid - To replace loss
 Dry mucous temperatures above 40 °C stable vital signs, free of Intake fluid and to
membrane noted (104 °F) can be life- dehydration and prevent
 Restlessness noted threatening. responsive. dehydration
 Patient lying in bed c ̅
 Provide tepid - To reduce
IVF hook at right arm
Reference: sponge bath increased body
at 40 gtts/min
Wayne, G. (2017, temperature
With the ff. vital September 24).
 Raise the side - To promote
signs: Hyperthermia Nursing Care
rails patient safety
 TPR: 38.5 °C Plan.
 PR: 55 bpm
 Encourage
 RR: 21 cpm patient to wear
loose clothing - To promote
comfort
  Assess skin color

- To note any
progress and
changes on the
 Monitor Intake patient’s
and Output of the condition
Patient - To assess if the
patient has
proper intake of
fluid and
 Provide oral nutrients
hygiene
- To keep the
mucous
 Provide warm
membrane moist
blanket
- To assist client
comfort
 Encourage the
patient to eat
high calorie diet - To monitor if the
patient meet the
 Educate the required nutrition
patient and
guardian about
the possible - To gain
cause and effect knowledge about
of fluid loss or the patient’s
decreased fluid condition and to
intake know his/her plan
of care

Dependent :
  Administer
antipyretics as
ordered
 Monitor - Used to lower body
Intravenous temperature
Therapy as
ordered - To replace the
fluid lost and to
have a balanced
electrolytes
References: NANDA Book, Nursing Care Plans Guideline for Planning and Documenting Patient Care
Five Nursing Diagnosis when the Patient is Dehydrated:
1. Deficient Fluid Volume r/t dehydration as evidenced by dry skin
2. 2. Risk for Impaired skin integrity r/t decreased skin turgor
3. Risk for Imbalanced body temperature r/t improper clothing for environmental temperature
4. Impaired Oral mucous membrane r/t decreased salivation
5. Impaired tissue integrity r/t extreme temperature