8/7/2019 36893609-NCP-hyperthermia

1/3

Nursing Care Plan

Assessment NursingDiagnosis

GOAL ANDOBJECTIVES

INTERVENTION RATIONALE EVALUATION

Subjective:S>: kanina pa

ko mainit

Objective:

Flushed skinnoted andwarm totouch.

The patientwas irritableand crying.

Body temp. of38 C .

Hyperthermiarelated to

diseaseprocess.

Goal:Within 8 hours of

nursinginterventions, thepatient willmaintain bodytemperaturewithin the normalrange.

Objectives:

Demonstratebehaviors tomonitor andpromotenormothermia

Be able toavoid seizureactivity.

Independent:

Promotesurfacecooling bymeans ofundressing,coolenvironment,and or fans,cool/ tepidsponge bathsor immersion;local icepacks,especially inthe groin oraxillae.

Maintain bedrest.

Promoteclients safety(e.g., maintain

airway; raiseside rails,never leavethe childunattended,skinprotectionfrom cold,observation ofequipment

To promote heat

loss by radiation,conduction,convection,evaporation, andto decrease tempof areas with highblood flow.

To reducemetabolicdemands/ oxygenconsumption.

To preventdehydration

GOAL METWithin 8 hours of

nursingintervention thepatientmaintained bodytemperaturewithin the normalrange asmanifested by:

Body temp of36.7 C

Uponpalpationnormal skintemperaturewas noted.

No incidenceof convulsionsand shivering.

8/7/2019 36893609-NCP-hyperthermia

2/3

safetymeasures.)

Discuss theimportance of

adequate fluidintake.

Review singandsymptoms ofhyperthermia(e.g., flushedskin,increased

body temp,increasedrespiratoryrate/ heartrate, fainting,loss of consciousnessand seizures)

Dependent:

Providesupplementaloxygen.

Administermedication asindicated,such asantibiotics.

Indicates needfor promptintervention.

To offsetincreased oxygendemand andconsumption

To treatunderlying causesuch as infection.

To supportcirculatingvolume andtissue perfusion.

8/7/2019 36893609-NCP-hyperthermia

3/3

Administerreplacementfluids andelectrolytes.