Nursing Care Plan

Assessment Nursing GOAL AND INTERVENTION RATIONALE EVALUATION

Diagnosis OBJECTIVES
Subjective: Hyperthermia Goal: Independent: GOAL MET
S>: “kanina pa related to Within 8 hours of • Promote To promote heat Within 8 hours of
ko mainit” disease nursing surface loss by radiation,
nursing
process. interventions, the cooling by conduction, intervention the
Objective: patient will means of convection, patient
• Flushed skin maintain body undressing, evaporation, and maintained body
noted and temperature cool to decrease temp temperature
warm to within the normal environment, of areas with high
within the normal
touch. range. and or fans, blood flow. range as
• The patient cool/ tepid manifested by:
was irritable Objectives: sponge baths • Body temp of
and crying. • Demonstrate or immersion; 36.7° C
• Body temp. of behaviors to local ice • Upon
38° C . monitor and packs, To reduce palpation
promote especially in metabolic normal skin
normothermia the groin or demands/ oxygen temperature
• Be able to axillae. consumption. was noted.
avoid seizure • Maintain bed • No incidence
activity. rest. of convulsions
and shivering.
• Promote
client’s safety
(e.g., maintain
airway; raise
side rails,
never leave
the child
unattended,
skin
protection
from cold, To prevent
observation of dehydration
equipment
 safety
measures.)

Indicates need
• Discuss the for prompt
importance of intervention.
adequate fluid
intake.

• Review sing
and
symptoms of
hyperthermia
(e.g., flushed
skin,
increased
body temp,
increased To offset
respiratory increased oxygen
rate/ heart demand and
rate, fainting, consumption
loss of
consciousness
and seizures) To treat
underlying cause
such as infection.
Dependent:
• Provide
supplemental To support
oxygen. circulating
volume and
• Administer tissue perfusion.
medication as
indicated,
such as
antibiotics.
• Administer
replacement
fluids and
electrolytes.