NURSING CARE PLAN

ASSESSMENT NURSING OBJECTIVES NURSING RATIONALE  EVALUATION

DIAGNOSIS INTERVENTION

Subjective: Hyperthermia Short-term goal: Independent: Independent: Short-term goal:

-The patients related to After 1 hour of  Establish  To gain After 1 hour of
state that dehydration as nursing rapport. patient’s trust. nursing
“nilalamig po evidence by hot, intervention, the intervention, the
flushed skin,  To obtain
ako.” “Masakit patient will be goal unmet:
po yung ulo ko, headache, able to;  Monitor vital baseline data.
dizziness, and
pag hindi po ako signs. -The patient's body
VS: ↑T- 38.6 ͒ C,
nasasalinan ng ↑ RR- 26 bpm,
- Lower body temperature is
dugo.”    Fever pattern
↑PR- 125 cpm temperature from may aid in
higher than the
and ↓SpO2- 39◦ C to 37.5◦.  Monitor client initial temperature
Objective: temperature— diagnosis. recorded, from
91%.
-Hot, flushed -Achieve normal degree and Temperature of 38.6◦C to 39.6 ◦C.
RR: 20 bpm, PR: pattern. Note 102F to 106F
skin
100 cpm and shaking chills. (38.9C–41.1C) -The patient’s ↑ RR:
-Loss of suggests acute
appetite SpO2: 98% 28 bpm, PR: ↓ 123
infectious cpm and ↓SpO2: 93%
-Weakness disease process.
-Be free from
-Headache
headache, hot, -The patient still
-Dizziness flushed skin,  Tepid sponge experienced
-Vomiting vomiting,  Provide tepid baths may help headache, hot,
-Pale and dry dizziness, sponge baths. reduce fever. flushed skin,
lips weakness, loss of weakness, loss of
  appetite, and pale,  Keep clothing  Promotes appetite and pale,
@ 4:00 pm dry lips. and bed linens comfort and dry lips.
Vital Signs: dry. helps prevent
T: 38.6◦C Long-term goal: chilling. Long-term goal:
RR: 26 bpm After 4 hours of After 4 hours of
PR: 125 cpm nursing   Encourage  Cool liquids nursing
BP: 100/80 intervention, the adequate fluid help lower the intervention, the
mmHg patient will be intake. body goal partially met as
SpO2: 91% able to: temperature. the patient:

-Maintain lower  Review signs  Indicates a need -Didn’t reached the

body temperature. and symptoms of for prompt lower body
hyperthermia intervention. temperature as
-Remain free of (e.g., body evidence of body
life-threatening temperature temperature
complications above the normal increased from
such as brain range, hot, 38.6°C to 39.6°C.
damage or organ flushed skin,
failure from increased heart -Was free of life-
hyperthermia. rate, increased threatening
respiratory rate, complications such
 
loss of as brain damage or
-Demonstrate and consciousness, organ failure from
verbalize feeling seizures hyperthermia.
more
 
comfortable. Dependent: Dependent:
   Administer  Antipyretics -Demonstrated and
-Recognize the antipyretics, such reduce fever by verbalized feeling
underlying cause as paracetamol.  its central slightly comfortable
or contributing action on the as evidence by
factors, the hypothalamus. expresses of feeling
importance of calm and
treatment, and contentment but
any weak and loss
signs/symptoms appetite.
that require  
further evaluation -Recognized the
or intervention. underlying cause or
contributing factors,
the importance of
treatment, and any
signs/symptoms that
require further
evaluation or
intervention as
evidence by mother
encourage his son to
drink plenty of
water and
performed TSB.