NAME: ARIOLA,WINNIE S.

COURSE & SECTION: BSN III - B

NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

Subjective Data: Hyperthermia related After 4 hours of 1. Assess and monitor1. Temperature 38.9ᴼC – After 4 hour of nursing
“Nakapudpudot to bacterial infection nursing intervention client’s temperature and note41ᴼC may suggest acute intervention the client’s
isuna ma’am.” as as manifested by Client will be able to presence of chills/ profuse infectious disease process. temperature decreased
verbalized by the flushed skin increased resume and maintain diaphoresis; also note for A sustained fever may be from 38.6 C to 37.7 C
mother. respiratory rate of 31 normal body degree and pattern of due to pneumonia or as evidenced by
cpm, diaphoresis temperature. occurrence. typhoid fever while a decreaseand calm
Objective Data: warm to touch with a remittent fever may be due breathing.
- Flushed skin temperature of 38.6 C 2. Adjust and monitor to pulmonary infections; and
- Increase environmental factors like an intermittent fever may be V/S:
respiration room temperature and bed caused by sepsis or PR: 86
- Diaphoresis linens as indicated. tuberculosis. RR: 28
- Warm to touch T: 37.3 C
3. Apply tepid sponge bath 2. Room temperature may
V/S: sponge bath. be accustomed to near
PR: 72 normal body temperature
RR: 31 4. Administer antipyretics as and blankets and linens may
T: 38.6 C prescribed by the physician, be adjusted as indicated to
utilizing the 10 Rs in giving regulate temperature of
medication. client.
5. Encourage the client to 3. It could help in reducing
increase fluid intake. hyperthermia; avoid using
alcohol and iced water
6. Provide a high caloric diet
which may even produce
or as indicated by the
chills and increase client’s
physician.
temperature.
7. Educate client of signs and
4. Antipyretics acts on the
symptoms of hyperthermia
hypothalamus, reducing
and help him identify factors
hyperthermia.
related to the occurrence of
fever; discuss the importance 5. Water regulates body
of increased fluid intake to temperature.
avoid dehydration.
6. To meet the metabolic
demand of the client.

7. Providing health
teachings to client could
help client cope with disease
condition and could help
prevent further
complications of
hyperthermia