NURSING CARE PLAN

Problem and Cues Nursing Diagnosis Objectives Interventions Rationale Evaluation

Objective Cues: Hyperthermia After 2hrs. of Monitor vital Vital signs After 2 hrs. of
related to nursing signs. provide more nursing
bacterial intervention the accurate intervention
Temperature 38.2C degree
infection patients indication of patient
RR 22 cpm (ventilator) temperature will core temperature was
decrease to Promote a well- temperature. decreased from
HR 102bpm
37.5C. ventilated area 38.2C to 37.4C
Warm to touch to patient.

Administer
antipyretic These drug
medications as inhibit the
indicated. prostaglandin
that serve as
mediators of
pain and
fever.
 Problem and Nursing Objectives Interventions Rationale Evaluation
Cues Diagnosis

Objective Cues: Impaired After my shift Monitor vital signs To check the After my shift of
verbal of nursing q1. condition of the nursing intervention
communicatio intervention patient in the patient was able to
Patient was
n related to patient will be absence of verbal met her needs
intubated. structural able to meet communication. through non verbal
problem her needs Anticipate patient To set aside communication and
(Intubation). through non needs and pay enough time to closed monitoring
verbal attention to attend to all the with my assigned
communication nonverbal cues. details of patient patient.
. care.
Praise patients The inability to
accomplishments communicate
during nursing enhances a
interventions such patients sense of
as following isolation and may
instructions (time promote a sense
of NGT feeding and of helplessness.
ETT suctioning).
.
 Problem and Nursing Objectives Interventions Rationale Evaluation
Cues Diagnosis

Objective: After my shift Reposition the Positioning After my shift of

of nursing patient every two interventions nursing intervention
Patient was Risk for intervention hours. reduce pressure patient was able to
intubated. impaired skin patient will be and shearing force maintain good skin
integrity able feel of to the skin. integrity and free
Patient is related to comfortable Keep the skin clean Moisture softens from any skin
physically immobility. and free from and dry. the skin and breakdown.
immobile any skin causes a break in
and unable breakdown the skin integrity.
to get out of such as
bed. bedsores .