26249191-NCP-hyperthermia PDF

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Summary

NURSING CARE PLANAssessment Nursing Diagnosis Nursing Goal Nursing Intervenion Raionale Outcome Criteria Actual EvaluaionSubjecive: “Gihilantan mana siya”, as verbalized by the S.Objecive:  Skin warm to touch with a temperature of 39°C  ↑RR: 28cpm  ↑HR: 102bpm  Weakne ss observed  Dry mucous me...

Description

NURSING CARE PLAN Assessment

Nursing Diagnosis

Nursing Goal

Subjective: “Gihilantan mana siya”, as verbalized by the S.O.

Hyperthermia related to the infectious process or cerebral edema

After 2 hours of comprehensive nursing intervention, the patient temperature will lower down to normal levels: T: 36.5°C – 37.5°C

Objective:  Skin warm to touch with a temperature of 39.1°C  ↑RR: 28cpm  ↑HR: 102bpm  Weakne ss observed  Dry mucous membranes  Flushed Skin

Scientific Basis: Pyrogens cause a rise in body temperature, it also acts as an antigen triggering immune system responses. The hypothalamus reacts to raise the set point and the body respond by producing heat. Reference: Fundamentals of Nursing -Harry & Perry

Nursing Intervention INDEPENDENT:  Provide tepid sponge bath.  Assess fluid loss & facilitate oral intake.  Promote bed rest.  Provide cool circulating air using a fan.  Assist patient in changing into dry clothing.  Provide oral hygiene.  Monitor vital signs. DEPENDENT:  Maintain IV fluids as ordered by physician.  Administer anti-pyretic as ordered.  Administer antibiotic as ordered. COLLABORATIVE:  Monitor hematologic test & other pertinent lab records.  Discuss condition of the patient with other members of the health care team.

Rationale  Enhances heat loss by evaporation & conduction.  Increases metabolic rate & diaphoresis.  Reduces body heat production.  Dissipates heat by convection.  Increases comfort.  Prevents herpetic lesions of the mouth.  Notes progress & changes of condition.  Prevents dehydration.

Outcome Criteria

Actual Evaluation

After 2 hours of comprehensive nursing intervention, the patient will:  Maintain normal temperature of 37.5°C  Be free of dehydration  Maintain vital signs at normal levels  Be alert and responsive  Be comfortable in bed.

 Reduces fever.  Treats underlying cause.

 Indicates presence of infection & dehydration.  Ensures continuous intervention.

Reference for the Rationale: Nursing Care Plans, 3rd edition by Doenges...