PATIENT’S NAME (OPTIONAL):_____________________________________ HOSPITAL NO: _____________________________

AGE:___________________ SEX: __________________________________ DATE: ____________________________________

ADDRESS: _____________________________________________________ CHIEF COMPLAINTS: ________________________

NURSING CARE PLAN

CUES NURSING SCIENTIFIC RATIONALE PLANNING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS (NURSING DIAGNOSIS) (DESIRED OUTCOME) (INTERVENTIONS)
.
Subjective Data: Ineffective : Core body After 8 hours of 1. monitor Vital Signs 1. Serves as baseline After 8 hours of
"Tugnaw ako thermoregulation temperature above the 2. Increase fluid intake. data.
paminaw" as r/t increased normal diurnal range continuous Tepid Sponge 3. Maintain bedrest. 2. To help cool down continuous Tepid
verbalized by the body temperature due to failure of 4. Provide sufficient clothing core temperature.
Bath, the patient’s Sponge Bath, the
as thermoregulation. 5. Perform TSB 3. To decrease
patient. temperature will patient’s temperature
manifested by 6. Administer antipyretics as order. metabolism that
decrease from 39.0 c to will decrease from 39.0c
- warm to touch 7. Identify underlying cause. produce heat.
Objective Data: - flushed face
37.5 c
8. Note chronological and 4. Facilitate comfort.
to 37.5 c
- febrile with developmental age of client 5. Facilitate heat loss
✓T-39 c, PR- 105 bpm, • Maintain core
atemperature of by means of
RR-22 cpm temperature within
38.2 c evaporation.
normal range.
6. Helps lower
• Be free of
Chills and shivers temperature within
complications, such as
Flushed skin normal range.
irreversible brain or
7. These factors can
neurological damage and
include (1) excessive
acute renal failure.
heat production,
• Identify underlying
such as occurs with
cause or contributing
strenuous exercise,
factors and importance of
fever, shivering,
treatment, as well as
tremors,
signs/symptoms requiring
convulsions,
further evaluation or
hyperthyroid state,
intervention.
infection or sepsis,
• Demonstrate behaviors
malignant
to monitor and promote
hyperpyrexia,
normothermia.
heatstroke and use
• Be free of seizure
of sympathomimetic
activity.
drugs lesions,
8. Infants, young
children, and elderly
persons are most
susceptible to
damaging
hyperthermia.
Environmental
factors and relatively
minor infections can
produce a much
higher temperature
in infants and young
children than in
older children and
adults
Submitted by: Submitted to:

STUDENT NURSE: JAY DEBBY R. RUIZO__________________ CLINICAL INSTRUCTOR: MR. GIOVANNI ENERO_______________
YEAR LEVEL & SECTION: _BSN 1- SECTION 4________________________