NURSING CARE PLAN

Nursing Nursing Nursing Outcome Actual

Assessment Rationale
Diagnosis Goal Intervention Criteria Evaluation
Subjective: Hyperthermia After 2 hours INDEPENDENT: After 2 hours of
“Gihilantan related to the of  Provide tepid  Enhances heat loss comprehensive
mana siya”, infectious comprehensi sponge bath. by evaporation & nursing
as verbalized process or ve nursing conduction. intervention,
by the S.O. cerebral intervention,  Assess fluid loss &  Increases metabolic the patient will:
edema the patient facilitate oral intake. rate & diaphoresis.  Maintain
Objective: temperature  Promote bed rest.  Reduces body heat normal
 Skin will lower production. temperature
warm to down to  Provide cool  Dissipates heat by of 37.5°C
touch with Scientific normal circulating air using convection.  Be free of
a Basis: levels: T: a fan. dehydration
 Increases comfort.
temperatur Pyrogens 36.5°C –  Maintain vital
 Assist patient in
e of 39.1°C cause a rise in 37.5°C signs at
changing into dry  Prevents herpetic
 ↑RR: body normal levels
clothing. lesions of the
28cpm temperature,  Be alert and
 Provide oral mouth.
 ↑HR: it also acts as responsive
hygiene.  Notes progress &
102bpm an antigen
changes of  Be
Weakn triggering
  Monitor vital signs. condition. comfortable
ess immune
in bed.
observed system
responses. The DEPENDENT:  Prevents
 Dry  Maintain IV fluids as dehydration.
hypothalamus
mucous ordered by
reacts to raise
membrane physician.  Reduces fever.
the set point
s  Administer anti-
and the body
 Flushe pyretic as ordered.  Treats underlying
respond by
d Skin  Administer cause.
producing
heat. antibiotic as
ordered.
Reference:
Fundamentals COLLABORATIVE:  Indicates presence
of Nursing  Monitor hematologic of infection &
-Harry & Perry test & other dehydration.
pertinent lab
records.  Ensures continuous
 Discuss condition of intervention.
the patient with
other members of
the health care
team.

Reference for the Rationale: Nursing Care Plans, 3rd edition by Doenges