Nursing Care Plan

November 8, 2009

Cues Nursing Scientific Planning Nursing Intervention Rationale Evaluation

Diagnosis Explanation

• serves as
S: ø Alteration in Body increased After 30 min. – 1 • monitored baseline After 30 mins. – 1
Temperature. pyrogens hr. of nursing V/S data hr. of nursing
Hyperthermia r/t circuating in the intervention pt.’s • to promote intervention pt.’s
O: increase blood body • performed heat loss body
pyrogens temperature will TSB through temperature was
• warm to circulating in the be able to conduction decreased as
touch blood decrease from and evidenced by
• flushed skin normal range of evaporatio temperature of
• (+) stimulates heat 36.5˚ to 37.5˚. n 36.5˚.
irritability regulating center • to reduce
• observed to • promoted metabolic
be weak adequate bed demand/
• teary-eyed increased
rest oxygen
• v/s: thermoregulation consumptio
T: 39˚ n
PR: 73bpm • heat loss
RR: 20 cpm by
BP: 120/70 • provided convection
enough • to avoid
flushed skin
ventilation dehydratio
• encouraged n
pt. to
increase oral • to promote
fluid intake comfort
warm to touch
• encouraged and surface
the pt. to
 Nursing Care Plan

November 8, 2009

loosen tight cooling

clothing/ use
thin and
fever loose • to provide
• administered pharmacolo
medications -gical
as ordered manageme
nt