VI.

Nursing Care Plan

Cues Nursing Diagnosis Analysis Goals and Intervention Rationale Evaluation

Objectives

Subjective Hyperthermia RT Respiratory tract Objective (Short INDEPENDENT

Cues: Respiratory Tract infection​ is defined as Term) INTERVENTION . 1. 15 minutes After
- Mother states Infection AEB any infectious disease performing TSB,
Temperature 38.7°C of the upper or lower - Patient will -​ Assess and monitor - Monitor changes if patient’s body
that the patient
Axillary respiratory tract. verbalize a feeling client’s vital signs q1h there is temperature will
is having a Upper respiratory tract of comfort and and its fluctuations. improvement or decrease to at least
fever. . infections (URTIs) adjust accordingly Note for presence of forseeable 37.5 degrees celsius
- Deviation include the common to the environment chills / profuse worsening of __ met
from usual cold, laryngitis, within the shift diaphoresis. condition __ unmet
pharyngitis/tonsillitis, __ partially met
behavior
acute rhinitis, acute - Stabilize the - Adjust and monitor - Client comfort If not, why? ______
- mother states rhinosinusitis and patient’s body patient’s preferred must also be
that patient is acute otitis media. temperature to environmental factors considered in the 2. Patient will
abnormally Lower respiratory tract within 36.5 - 37.5 such as room treatment. If able, verbalize a feeling of
weak and infections (LRTIs) degrees celsius temperature and bed room temperature comfort within her
include acute within the shift. linens / blankets as may be adjusted to environment after
easily
bronchitis, appropriate. near normal body making the
exhausted bronchiolitis, - Patient and family temperature and necessary
pneumonia and will be educated blankets and linens adjustments
Objective tracheitis. Fever about the proper may be adjusted as __ met
Cues: usually occurs when taking of indicated to __ unmet
- Temp of there is an infection. temperature, signs regulate __ partially met
Hyperthermia due to and symptoms of temperature of If not, why? ______
38.7°C
fever is defined as worsening fever, client.
- RR 41 cpm when the core body and how to avoid - Perform tepid sponge 3.Child’s axillary
- Presence of temperature is above cross infection. bath (TSB). Avoid - It could help in temperature returns
Mucus the normal diurnal using alcohol and iced reducing to 37.5°C within two
discharge range. Pyrogens such Goals (Long Term) water. hyperthermia by hours
as bacteria or viruses virtue of __ met
- Anxiety and
that cause infections - For 3 days, patient thermodynamics; __ unmet
Irritability elevate body will have a using alcohol and __ partially met
- Erythematous temperature. they act consistent body iced water may If not, why? ______
conjunctiva as antigens, triggering temperature produce chills and
the body's immune reading within the increase client’s 5. Increased OFI to
system. A fever is normal range. temperature. at least 8 glasses
usually not harmful if it per day and patient
stays below 39 - Discuss the - Allows the patient will be able to state
degrees celsius in importance of and to understand why at least 2 reasons
adults or below 40 encourage increased OFI should why it is important
degrees celsius in fluid intake increase; to avoid __ met
children. dehydration and to __ unmet
accommodate fluid __ partially met
Reference: loss. If not, why? ______
Doenges, M. et. al
(2016). ​Nurse’s - Instruct the guardian - promotes body 6. 30 mins after
Pocket Guide (14th to dress patient in heat loss and administering
ed.). Philadelphia, lightweight clothing comfort of the antipyretics patient’s
Pennsylvania. F.A. patient body temp will return
Davis Company DEPENDENT to normal range
Potter & Perry (2018) INTERVENTION __ met
Fundamentals of __ unmet
Nursing (10th ed.). - Administer - Antipyretics act on __ partially met
Philippines. antipyretics as the hypothalamus, If not, why? ______
Wolters-Kluwer prescribed by the reducing
Publications. physician hyperthermia. 7. Patient’s family
National Institute for will be able to
Health and Clinical - Administer antibiotics - these medications demonstrate proper
Excellence (2019). as prescribed by the help address the handwashing / hand
Respiratory Tract physician patient’s respiratory hygiene technique
Infections. R ​ etrieved infection that __ met
from: COLLABORATIVE causes febrile __ unmet
https://www.ncbi.nlm.n INTERVENTION episode __ partially met
ih.gov/books/NBK536 If not, why? ______
32/ - Educate client’s - Empowers the
family / guardian of family about proper 8. Patient’s family
how to take health assessment will be able to
temperature, signs of their child and identify at least 3 of
and symptoms of helps monitor her each: symptoms of
worsening fever, and condition whether if worsening fever,
help him identify its getting better or factors related to its
factors related to worsening occurence, and how
occurrence of fever to take temp. They
are able to
- Instruct the patient’s - TSB is the first demonstrate how to
family importance, line to febrile perform TSB
how, and when to response to avoid intervention
perform TSB at home. hepatotoxicity when __ met
taking drugs __ unmet
__ partially met
- Teach hand washing - to avoid cross If not, why? ______
and hand hygiene to infection
patient and family

Reference:
Serrano, M. (2017,
December 28) ​Nursing
Management of Fever
(Hyperthermia).
Retrieved from:
https://www.rnspeak.c
om/fever-hyperthermia
-nursing-care-plan/

Reference:
Serrano, M. (2017,
December 28)
Nursing
Management of
Fever
(Hyperthermia).
Retrieved from:
https://www.rnspea
k.com/fever-hyperth
ermia-nursing-care-
plan/