NURSING CARE PLAN

CUES

NURSING
DIAGNOSI
S

Subjectiv
es:
nag
balikbalik
iyang
hilanat
taas
pajud

Hyperther
mia :

As
verbalize
d by the
mother.

OBJECTIVES

Short term:
after 4 hours if
NI,pts
temperature
will decrease
from 39.8 to
37.

Long term:
after 3 days of
NI, the pt will
identify
underlying
factors&import
ance treatment
as well as s/sx
requiring
further
evaluation or
intervention

INTERVENTI
ONS

RATIONALE

1.Establish
Rapport
2.Monitor
Vital signs

1.To gain pts

trust
2. To obtain
baseline data

3.Asses
neurologic
response,note
LOC&
orientation
reaction
stimuli
papillary
reactions&
presence of
seizures

3.To evaluate
effects&exte
nt of
hyperthermia

4.Note
presence/abs
ence of
sweating
5.Wrap
extremities

4.To mionitor
heat & fluid
loss
5.To
minimize
shivering

EVALUATI
ON

The pt
shall have
a
decreased
body
temperat
ure from
39.8 to 37
the pt
shall have
identified
underlyin
g factors
and
importanc
e of
treatment
As s/sx
requiring
further
evaluatio
n or
interventi
on

Objectiv
es

6.Provide TSB
1 15 minutes

.temp of
39.8 or
higher
.flushed
skin

7.Apply local
ice packs
axilla
8.Instruct
client to have
bed rest

.skin
warm to
touch
.chills
.
Increase
d RR

9.Insruct clien
to increase
OFI
Dependent
10.Administer
replacement
fluids

.
sweating

11.administer
antipyretics
12Reassess
temperature q
15 minutes

6.To reduce
body
temperature
7.To reduce
body
8.To reduce
metabolic
demands/oxy
gen
consumption
9.To prevent
dehydration

10.To support
circulating
blood volume
and tissue
perfusion
11.To restore
normal body
temperature
12.To
determine
effectiveness
of
interventions
done