NURSING CARE PLAN

(A systematic method guide for client)

ASSESSMENT Subjective (verbalize by Objective (using your observation using IPPA. Use V/S at the end)
the patient)
Ex: Febrile (fever)
Ex: “Nilalagnat ako at - Skin hot to touch
masakit ang pag-ihi” - Blushing
Vital signs (v/s)
- RR 12-20bpm normal for (adult)
- Pulse/ Heart rate
- BP 100/70 normal. (below 120- below 90) (120-80 and 139/89 that are pre hypertensive
if below 90-60 that is pre hypotension- lower than normal)
- 2 Types
Systolic (top higher number)- pumps blood
Diastolic (bot lowest number)- the heart start to relax
- Pain scale (use palpation) 0-10

DIAGNOSIS - Hyperthermia
- Pain
PLANNING To lower/ reduce the body temperature to 38.5-37c

HYPERTHERMIA
After 1hr of nursing intervention the patient’s temperature will reduce from 38.5-37c.

PAIN
After 1hr of nursing intervention patient complaint of pain will reduce from scale 7/10-3/10

BE SMART
- Specific
- Measurable
- Attainable
- Realistic
- Time-bound

INTERVENTION/ 2 Types
IMPLEMENTATION 1. Independent- without assistance from other medical personnel.
 2. Dependent- with assistance from medical personnel like medication.
RATIONALE HYPERTHERMIA/FEVER:
INDEPENDENT
- Tepid Sponge Bath (TSB.
- Loosen clothing
- Encourage to increase fluid intake to prevent dehydration
- Vital signs to provide base line data.
- Nutrition well balance diet- to boost immunity.

DEPENDENT
- Give/ administer of antipyretic medication
- Paracetamol (Biogesic), an analgesic (for pain-antipyretic(reliever and fever reducer).
- Note* Mefenamic acid is a nonsteroidal antiinflammatory drug (NSAID) used largely for acute treatment of pain.

PAIN
Check the localation (where masakit, scale duration etc.
EVALUATION During this stage, the nurse assesses the patient's progress and determines whether the plan of care was effective. The
nurse may also make changes to the plan of care based on the patient's progress and needs.
 Goal met
 Goal unmet
 Partially met