Mindanao State University – Iligan Institute of Technology

Student: Salimbagat, Christine P. Group: __________

COLLEGE OF NURSING
Inclusive Dates of Duty: November 23-25, 2020
Patient: Mang Kanor Room No.: _______

NURSING CARE PLAN

Identified Problem: Elevated body temperature

Nursing Diagnosis: Hyperthermia related to infection as evidence by temperature 38°C, loss of appetite and lethargy

CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Subjective: Short Term Objectives: Independent: >Vital signs provide more Short Term:
- No data provided After 8hrs of nursing >Assess vital signs accurate indication of core (Goal Met) After 8hrs of
interventions: >Provide tepid sponge bath temperature. nursing interventions:
Objective: >Remove excess clothing and covers > TSB helps in lowering the  The patient’s
 Vital Signs:  The patient’s temperature decreased
>Promote a well-ventilated area to patient body temperature and alcohol
- Temp: 38°C temperature will >Advise patient to increase oral fluid intake cools the skin too rapidly, from 38°C to 37.5°C
 Dry skin and warm to decrease from 38°C >Maintain bed rest causing shivering. Shivering
touch to 37.5°C Long Term:
>Educate and advise support system to do increases metabolic rate and
 Shortness of breath (Goal Met) After 16 hours of
TSB when patient feels hot body temperature nursing interventions the
 Patient exhibits general Long Term Objectives:
After 16 hours of nursing
-Luke warm water only .> These decrease warmth and patient was able to:
body weakness -Make sure that armpits and groins were increase evaporative cooling.
 Decreased appetite interventions the patient will
be able to: included in doing TSB > To promote clear flow of air in  Maintain body
 Maintain body >Monitor VS and recheck the patient’s area. One way of temperature within
temperature within promoting heat loss. normal limits of 36.5-
normal limits of Dependent: > Additional fluids help prevent 37.5°C
36.5-37.5°C elevated temperature associated
>Provide antipyretic medications as with dehydration.
indicated > Reduce metabolic demands/
oxygen consumption
>T o meet increased metabolic
Collaborative: demands.
> Teaching the Support system
> Monitor laboratory studies, as indicated. the right way to do TSB will
help in knowing what to do in
case the patient’s temperature
increases
> To know the effectiveness of
nursing interventions done and
to know the progress of patient’s
condition.
> These drugs inhibit the
prostaglandin that serve as
mediators of pain and fever.
>Determine and report relevant
laboratory results changes