This nursing care plan is for a patient named Princess F. Sugaton who presents with hyperthermia related to an upper tract infection. The plan includes 3 short term goals and 1 long term goal. Short term goals are to lower the patient's temperature to within normal range after 1 hour and identify underlying causes or contributing factors. Interventions include monitoring vital signs, providing tepid sponge baths, removing excess clothing, promoting ventilation, advising oral fluids, maintaining bed rest, and providing a high calorie diet. The long term goal is for the patient's vital signs to return to normal range with an oral temperature of 36.5-37.5°C within 4 hours. Interventions include continuing appropriate nursing care
This nursing care plan is for a patient named Princess F. Sugaton who presents with hyperthermia related to an upper tract infection. The plan includes 3 short term goals and 1 long term goal. Short term goals are to lower the patient's temperature to within normal range after 1 hour and identify underlying causes or contributing factors. Interventions include monitoring vital signs, providing tepid sponge baths, removing excess clothing, promoting ventilation, advising oral fluids, maintaining bed rest, and providing a high calorie diet. The long term goal is for the patient's vital signs to return to normal range with an oral temperature of 36.5-37.5°C within 4 hours. Interventions include continuing appropriate nursing care
This nursing care plan is for a patient named Princess F. Sugaton who presents with hyperthermia related to an upper tract infection. The plan includes 3 short term goals and 1 long term goal. Short term goals are to lower the patient's temperature to within normal range after 1 hour and identify underlying causes or contributing factors. Interventions include monitoring vital signs, providing tepid sponge baths, removing excess clothing, promoting ventilation, advising oral fluids, maintaining bed rest, and providing a high calorie diet. The long term goal is for the patient's vital signs to return to normal range with an oral temperature of 36.5-37.5°C within 4 hours. Interventions include continuing appropriate nursing care
Sugaton___________ Section and Group number: ___BSN3-F GRP:4__________
Assessment Nursing (Rationale)
NURSING CARE PLAN Desired Outcome Nursing Intervention Rationale Evaluation Cues Diagnosis Pathophysiologic / Schematic Diagram Subjective: Short term Goal: Independent Hyperthermia After 1 hour of “kasakit kun mag related to upper history of hypertension appropriate nursing 1. Monitor vital signs. 1.Vital signs provide more tulon ko nurse” as tract infection as and diabetes, Hyperther intervention: accurate indication of core verbalized by the evidence by high mother side mia temperature. patient. fever of 38.2 Core Temperature 2. Provide tepid sponge 2.TSB helps in lowering the Degree Celsius, is within normal Exposure to high environmental bath. Do not use alcohol. Objective: sore throat, and temperature/Humid weather range from 38.2C body temperature and Fever pain upon to 37.5oC. alcohol cools the skin too Cough swallowing. Identifies rapidly, causing shivering. runny nose Decrease in sweat response underlying Shivering increases sore throat cause/contributing metabolic rate and body febrile factors temperature episode Dehydration importance of 3. Remove excess clothing treatment and and covers. 3.These decrease warmth Vital Signs: signs/symptoms and increase evaporative -T-38.2 C Increase of Body temperature cooling. -RR-18 cpm requiring further -PR-68 bpm evaluation or 4. Promote a well- intervention ventilated area to 4.To promote clear flow of -BP-120/70 Definition: Fever patient. air in the patient’s area. Laboratorie Demonstrate Core body behaviors to One way of promoting heat s temperature monitor and loss. -Complete blood T-38.2 C, RR-18 cpm PR-68 above the normal promote 5. Advise patient to count: WBC bpm, BP-120/70 diurnal range due normothermia. increase oral fluid intake. 5.Additional fluids help (12x1000/ mm2) Temperature is higher than to failure of prevent elevated -Negative RTPC test normal thermoregulation Long Term Goal temperature associated -Platelet Count - . Hyperthermia After 4 hours or with dehydration. 250 x 10g/L appropriate nursing -Urinalysis Result - 6.Reduce metabolic intervention No pus, no hematuria noted, Source/ 6. Maintain bed rest. demands/ oxygen the patient’s vital consumption negative protein Reference signs will return to (normal Result) NANDA normal range with a 7.To meet increased - Chest Xray - No temperature of 7. Provide high-calorie diet. metabolic demands. significant findings Reference: 36.5-37.5oC, pulse rate of 60-100bpm and respiratory rate 8.Teaching the Support NANDA of 12-20 cycles per 8. Educate and advise system the right way to do min. support system (relative) TSB will help in knowing to do TSB when patient what to do in case the Absence of febrile feels hot. patient’s temperature episode - Luke warm water only. increases - Make sure that armpits and groins were included 9.To know the effectiveness in doing TSB. of nursing interventions done and to know the 9. Monitored VS and progress of patient’s recheck. condition. Strength : 10.These drugs inhibit the Dependent prostaglandin that serve as 10. Provide antipyretic mediators of pain and medications as indicated. fever.
Name of CI: _______Ms. Jean Transmonte Canillas_______ Area of Exposure: ___________Isolation ward__________