Cebu Institute of Technology – University

COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES

NURSING CARE PLAN

ASSESSMENT NURSING DIAGNOSIS SCIENTIFIC BASE GOAL OF CARE OUTCOMES CRITERIA NURSING INTERVENTION RATIONALE EVALUATION

Subjective Data: The -Throbbing of the head Hyperthermia is an After the 8 hours of After the 8 hours of nursing Independent nursing actions: - The patient’s
patient verbalized (headache) abnormally high nursing intervention. intervention client will: temperature was
“Nurse init kaayo temperature or - Do a sponge bath for - Taking a sponge bath lowered to 37.4 C
ang lawas sa akong -Increased body overheating. Hyperthermia -The patient will - Lowering of body the baby. helps reduce body - The patient has now a
temperature is one of the have a normal body temperature from 39 - Lower room temperature.
baby nya reddish occurs when your body pulse rate of 146 bpm
kaayo iyang nawng.” signs of body infection. absorbs or generates more temperature. C to 37 C temperature, and close - The patient is no
- it can help them keep
heat than it can release. - The pulse rate will be the windows. cool longer crying.
-Fluid volume deficit is normal from 165 bpm - Instruct the mother to
related to dehydration due to Due to the presence of an to 140 bpm. wipe the baby’s sweat. - The best technique to
high body temperature infectious agent, - The patient will - Ask the mother to treat a fever is not to
evidenced by (39 C) stimulation of the become hydrated. hydrate the patient.` make the patient sweat.
Objective Data: monocytes triggers the - Blood pressure will
-Low blood pressure - to help reduce the
release of the pyrogenic be normal from 56/32 Dependent nursing Actions:
T: 39 C (hypotension) as evidenced fever.
cytokines that stimulate the mmHg to 64/41
by a blood pressure of 52/32 anterior hypothalamus - The patient can sleep - Give an IVF to the
PR: 165 BPM mmHg. patient as advised by
which results in an peacefully and will
elevated thermoregulatory stop crying. the doctor.
RR: 38 BPM -High pulse rate.
set point that leads to - Give the patient
BP: 56/32 mmHg increased heat paracetamol as advised
conservation by the physician
- Flushed skin; cold (Vasoconstriction) and
increased heat production
-clammy extremities
which results in fever.
-Hypotension;
tachycardia chills

REFERENCE:
https://my.clevelandclinic.org/health/diseases/22111-hyperthermia#:~:text=Hyperthermia%20is%20an%20abnormally%20high%20body%20temperature%20%E2%80%94%20or%20overheating.,heat%20than%20it%20can
%20release.

Anos, Johannah Ray T. and Calvo, Sarah Jane Ms. Nur-Fadzilah M. Anyaman

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