DELA CENA, Patricia Beatrice S.

BSN 303 | GROUP 1 | SUBGROUP 3

NURSING CARE PLAN

NDx: Hyperthermia RT bodily response to infection AEB skin warm to touch, temperature above normal range, and chills.

Nursing Goals and

Cues Analysis Intervention Rationale Evaluation
Diagnosis Objectives

Subjective Hyperthermia Elderly Goal

 “Nahihilo RT bodily individuals After 3 days of nursing Perform nursing care and Monitors any changes or signs
ako, feeling response to continually go intervention, the client continuous monitoring of of development in the patient’s
ko mainit infection AEB through must be able to patient’s vital signs in condition and to maintain
katawan ko skin warm to physiological maintain core order to ensure normal body temperature within
tapos touch, changes as they temperature within body temperature and a normal range.
mabigat na temperature increase in age. In normal range (36.0ᵒC – wholistic functional level.
mabigat din above normal urinary tract 37.5ᵒC)
yung range, and infection (UTI),
pakiramda chills. two of the most Objective
m ko.” pertinent changes After 1 hour of nursing
 “Wala that must be intervention, the client
akong looked upon are and/or the client’s
ganang the guardian must be able
kumilos immunological to: Independent Independent Effectiveness
dahil and physiological 1. Identify and 1. Helps client and/or Was the client able to
nilalamig systems. The  Identify the discuss the client’s guardian to identify the contributing
ako. Gusto immunological contributing underlying understand the cause factor of the onset of
ko lang response of an factor of the cause of the of the elevated body hyperthermia?
magpahinga older client is onset of elevated body temperature. _Met
.” mostly decreased, hyperthermia. temperature _Partially Met
thereby rendering  Demonstrate which is due to _Unmet
Objective them more behaviors to urinary tract
 Skin is predisposed to monitor and infection (UTI). Did the client demonstrate
warm to different types of promote behaviors to monitor and
touch. illnesses. This is normothermia. 2. Monitor core 2. Provides baseline promote normothermia?
 Temperatur linked to the  Explain in temperature via foundation and _Met
e during diminished his/her own appropriate whether there are _Partially Met
time of responsiveness of words the route every 4 any changes to the _Unmet
assessment: the T cells to importance of hours. client’s body
4:00 PM: antigens and the treatment. temperature that Did the client explain in
38.2ᵒC, B cells producing would need further his/her own words the
8:00 PM: fewer antibodies. intervention. importance of treatment.?
36.4oC, and As with such, the 3. Promote 3. Heat loss by _Met
physiological surface cooling radiation and _Partially Met
 12:00 AM: aspect of the through convection; heat loss _Unmet
39.4oC. urinary tract also undressing, by convection.
 Client was contributes to the cool Efficiency
having further environment/pr Were the nursing
chills when proliferation of a ovision of fans. interventions efficient in
she reached disease and its 4. Heat loss by improving the client’s
a probable 4. Provide cool evaporation and condition?
temperature reoccurrence. bath to the conduction. __ Met
of 39.4oC. Structural client, if __ Partially Met
abnormalities tolerated. __ Unmet
secondary to 5. Replaces insensible
decreased bladder 5. Advise client to loss of fluids; water Appropriateness
tone, neurogenic increase oral diuresis also aids in Were all the nursing
bladder secondary fluid intake. “flushing” the interventions appropriate to
to stroke, or pathogen present in the client’s condition?
autonomic the urinary tract __ Met
neuropathy of through frequent __ Partially Met
diabetes may voiding. __ Unmet
prevent the
complete 6. Monitor fluid 6. Fluid resuscitation Adequacy
emptying of the intake and urine may be required to Were the number of nursing
bladder which output. correct dehydration. interventions enough to
results to Sweating, which answer the problem of the
incontinence. requires client?
Since the client is normohydration, is __ Met
a female, she is necessary for surface __ Partially Met
also at a higher cooling. __ Unmet
risk of having
UTI since the Dependent Acceptability
presence of Dependent 1. Antipyretics lower Were the nursing
estrogen is absent 1. Administer body temperature by interventions acceptable to
post-menopause. antipyretics as blocking the the client?
Due to these prescribed by synthesis of __ Met
changes, the the physician. prostaglandins that __ Partially Met
resulting effect is act in the __ Unmet
an increased hypothalamus.
susceptibility of
the urinary tract 2. Administering
to be colonized by 2. Administer antibiotics targets
pathogens (i.e. ciprofloxacin causative factor of
bacteria). The 500 mg for 7 disease.
initial response in days, as Ciprofloxacin is a
some older adults indicated by the fluoroquinolone,
who already have anti-infective agent,
the infection can physician. which acts by
be those that are inhibiting the DNA
observed in the gyrase and
present case of topoisomerase IV,
Client R.A.O, essential in bacterial
particularly DNA replication,
hyperthermia or transcription, repair,
pyrexia. and combination.

Hyperthermia is 3. Phenazopyridine azo

the response of 3. Administer dye that exerts an
the bodily phenazopyridin analgesic effect in
immune system to e 500 mg PRN, the urinary tract.
the invading as indicated by
pathogens, the physician.
thereby resulting 4. Replaces fluid loss if
in an 4. Administer the oral route is
inflammation. replacement contraindicated.
fluid and
Reference: electrolytes
through IV, if
Alpay, Y., Aykin, indicated by the
N., Korkmaz, P., physician.
Gulduren, H. M., Collaborative
& Caglan, F. C. Collaborative 1. Confirms causative
(2018). Urinary 1. Monitor factors of the
tract infections in laboratory proliferation of the
the geriatric results pertinent infection.
patients. Pakistan to causative
journal of factors.
medical
sciences, 34(1), References:
67–72. Doenges, M. E., Moorhouse,
https://doi.org/10. M. F., & Murr, A. C. (2019).
12669/pjms.341.1 Nurses pocket guide:
4013 diagnoses, prioritized
interventions, and rationales.
Berman, A. T., & Philadelphia: F.A. Davis
Snyder, S. (2019). Company. 633-639.
Kozier & Erb’s
Fundamentals of Monthly Index of Medical
Nursing (9th Specialities. (n.d.-a).
Edition) (9th ed.). Ciprofloxacin: Indication,
Dosage, Side Effect,
Pearson. Precaution | MIMS
Philippines. Retrieved March
Hinkle, J. L., & 1, 2021, from
Cheever, K. H. https://www.mims.com/philip
(2017). Brunner pines/drug/info/ciprofloxacin?
& Suddarth’s mtype=generic
Textbook of
Medical-Surgical Monthly Index of Medical
Nursing (Brunner Specialities. (n.d.).
and Suddarth’s Phenazopyridine: Indication,
Textbook of Dosage, Side Effect,
Medical- Precaution | MIMS
Surgical) (14th Philippines. Retrieved March
ed.). LWW. 1, 2021, from
https://www.mims.com/philip
Meiner, S. E., & pines/drug/info/phenazopyridi
Yeager, J. J. ne?mtype=generic
(2018).
Gerontologic Wayne, G., Wayne, G., &
Nursing (6th ed.). Wayne. (2017, September 23).
Mosby. Hyperthermia – Nursing
Diagnosis & Care Plan.
Retrieved March 03, 2021,
from
https://nurseslabs.com/hyperth
ermia/
NURSING CARE PLAN
NDx: Risk for deficient fluid volume RT compromised thermoregulatory process

Nursing Goals and

Cues Analysis Intervention Rationale Evaluation
Diagnosis Objectives

Subjective Risk for Goal

 “Nahihilo deficient fluid After 3 days of nursing Perform nursing care and Monitors any changes or signs
ako, feeling volume RT intervention, the client continuous monitoring of of development in the patient’s
ko mainit compromised must be able to patient’s vital signs in condition and to maintain
katawan ko thermoregulato Reference: maintain core order to ensure normal body temperature within
tapos ry process Berman, A. T., & temperature within body temperature and a normal range.
mabigat na Snyder, S. (2019). normal range (36.0ᵒC – wholistic functional level.
mabigat din Kozier & Erb’s 37.5ᵒC)
yung Fundamentals of
pakiramda Nursing (9th Objective
m ko.” Edition) (9th ed.). After 1 hour of nursing
Pearson. intervention, the client
Objective and/or the client’s
 Skin is Hinkle, J. L., & guardian must be able
warm to Cheever, K. H. to: Independent Independent Effectiveness
touch. (2017). Brunner 7. Identify and 7. Helps client and/or Was the client able to
 Temperatur & Suddarth’s  Identify the discuss the client’s guardian to identify the contributing
e during Textbook of contributing underlying understand the cause factor of the onset of
time of Medical-Surgical factor of the cause of the of the elevated body hyperthermia?
assessment: Nursing (Brunner onset of elevated body temperature. _Met
4:00 PM: and Suddarth’s hyperthermia. temperature _Partially Met
38.2ᵒC, Textbook of  Demonstrate which is due to _Unmet
8:00 PM: Medical- behaviors to urinary tract
36.4ᵒC, and Surgical) (14th monitor and infection (UTI). Did the client demonstrate
12:00 AM: ed.). LWW. promote behaviors to monitor and
39.4ᵒC. normothermia. 8. Monitor core 8. Provides baseline promote normothermia?
Meiner, S. E., &  Explain in temperature via foundation and _Met
Yeager, J. J. his/her own appropriate whether there are _Partially Met
(2018). words the route every 4 any changes to the _Unmet
Gerontologic importance of hours. client’s body
Nursing (6th ed.). treatment. temperature that Did the client explain in
Mosby. would need further his/her own words the
intervention. importance of treatment.?
9. Promote 9. Heat loss by _Met
surface cooling radiation and _Partially Met
through convection; heat loss _Unmet
undressing, by convection.
cool Efficiency
 environment/pr Were the nursing
ovision of fans. interventions efficient in
10. Heat loss by improving the client’s
10. Provide cool evaporation and condition?
bath to the conduction. __ Met
client, if __ Partially Met
tolerated. __ Unmet
11. Replaces insensible
11. Advise client to loss of fluids; water Appropriateness
increase oral diuresis also aids in Were all the nursing
fluid intake. “flushing” the interventions appropriate to
pathogen present in the client’s condition?
the urinary tract __ Met
through frequent __ Partially Met
voiding. __ Unmet

12. Monitor fluid 12. Fluid resuscitation Adequacy

intake and urine may be required to Were the number of nursing
output. correct dehydration. interventions enough to
Sweating, which answer the problem of the
requires client?
normohydration, is __ Met
necessary for surface __ Partially Met
cooling. __ Unmet

Dependent Acceptability
Dependent 5. Antipyretics lower Were the nursing
5. Administer body temperature by interventions acceptable to
antipyretics as blocking the the client?
prescribed by synthesis of __ Met
the physician. prostaglandins that __ Partially Met
act in the __ Unmet
hypothalamus.

6. Administering
6. Administer antibiotics targets
ciprofloxacin causative factor of
500 mg for 7 disease.
days, as Ciprofloxacin is a
indicated by the fluoroquinolone,
physician. anti-infective agent,
which acts by
inhibiting the DNA
gyrase and
 topoisomerase IV,
essential in bacterial
DNA replication,
transcription, repair,
and combination.

7. Phenazopyridine azo
7. Administer dye that exerts an
phenazopyridin analgesic effect in
e 500 mg PRN, the urinary tract.
as indicated by
the physician.
8. Replaces fluid loss if
8. Administer the oral route is
replacement contraindicated.
fluid and
electrolytes
through IV, if
indicated by the
physician.
Collaborative
Collaborative 2. Confirms causative
2. Monitor factors of the
laboratory proliferation of the
results pertinent infection.
to causative
factors.

References:
Doenges, M. E., Moorhouse,
M. F., & Murr, A. C. (2019).
Nurses pocket guide:
diagnoses, prioritized
interventions, and rationales.
Philadelphia: F.A. Davis
Company. 633-639.

Monthly Index of Medical

Specialities. (n.d.-a).
Ciprofloxacin: Indication,
Dosage, Side Effect,
Precaution | MIMS
Philippines. Retrieved March
1, 2021, from
https://www.mims.com/philip
pines/drug/info/ciprofloxacin?
mtype=generic

Monthly Index of Medical

Specialities. (n.d.).
Phenazopyridine: Indication,
Dosage, Side Effect,
Precaution | MIMS
Philippines. Retrieved March
1, 2021, from
https://www.mims.com/philip
pines/drug/info/phenazopyridi
ne?mtype=generic

Wayne, G., Wayne, G., &

Wayne. (2017, September 23).
Hyperthermia – Nursing
Diagnosis & Care Plan.
Retrieved March 03, 2021,
from
https://nurseslabs.com/hyperth
ermia/