PHINMA UNIVERSITY OF PANGASINAN

COLLEGE OF ALLIED HEALTH SCIENCES – DEPARTMENT OF NURSING

NURSING CARE PLAN

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION
SUBJECTIVE Hyperthermia related Hyperthermia or commonly DESIRED COUTCOME:  Assess and  Temperature The goal is met
DATA: to infection as known as fever is present Client will be able to monitor client’s 38.9ᴼC – 41ᴼC as evidenced by
“May lagnat po evidence when the body temperature report and show temperature may suggest no signs of
yung anak ko for by temperature is higher than 37ᴼC which manifestations that and note for acute hyperthermia
7 days na. On and 102.4 orally, loss of can be measured orally, but fever is relieved with presence of infectious and the patient’s
off po ang lagnat appetite, weakness, 37.7ᴼC if measured per temperature of 36.8ᴼC chills/ profuse disease vital signs came
niya. Sinusuka din and dehydration. rectum. It occurs when the per axilla, respiratory diaphoresis; process. A back to its
po niya mga body is invaded by some rate of 12- 18 breaths also note for sustained normal state.
kinakain niya.” bacteria, viruses, or per minute, pulse rate of degree and fever may be
parasites. Sometimes the 60- 75 beats per minute, pattern of due to
OBJECTIVE DATA: occurrence of fever may stable blood pressure, occurrence. pneumonia or
Hot, flushed skin also be due to non- absence of muscular  Adjust and typhoid fever
Teary eyes infectious factors like rigidity/ chills and monitor while a
injury, heat stroke or profuse diaphoresis after environmental remittent
Temperature: dehydration. Some 4 hours of nursing care. factors like fever may be
38.1ᴼC underlying conditions can room due to
RR: 43 bpm also cause hyperthermia, SHORT TERM GOALS: temperature pulmonary
PR: 94 bpm4 like thyrotoxicosis, heart  Client will be and bed linens infections;
Weight: 14 kg attack and other forms of able to resume as indicated. and an
cancer. If not treated and maintain  Encourage the intermittent
properly, a client may be at normal body client to fever may be
risk for its complications temperature increase fluid caused by
involving febrile after 4 hours. intake. sepsis or
convulsions, happening LONG TERM GOALS:  Educate client tuberculosis.
mostly to pediatric clients  Client will be of signs and  Room
aging from 6 months to 6 free from symptoms of temperature
years of age, and brain complications hyperthermia may be
damage; which could be such as and help him accustomed
because of prolonged and irreversible identify factors to near
repeated febrile brain or related to the normal body
convulsions. neurologic occurrence of temperature
damage. fever; discuss and blankets
the importance and linens
of increased may be
fluid intake to adjusted as
avoid indicated to
dehydration. regulate
temperature
of client.
 PHINMA UNIVERSITY OF PANGASINAN
COLLEGE OF ALLIED HEALTH SCIENCES – DEPARTMENT OF NURSING

NURSING CARE PLAN

 Water
regulates
body
temperature.
 Providing
health
teachings to
client could
help client
cope with
disease
condition and
could help
prevent
further
complications
of
hyperthermia

SUBMITTED BY: MENDOZA, ROVIC U. SUBMITTED TO: JOHN EMAR DE GUZMAN

YEAR & BLOCK: UP-FA1-BSN2-09 (Clinical Instructor)