ILOILO DOCTORS’ COLLEGE
COLLEGE OF NURSING
West Avenue, Molo, Iloilo City
NURSING CARE PLAN
Defining Characteristics Nursing Diagnosis Outcome Nursing Rationale Evaluation
Identification Interventions
Subjective: Hyperthermia related to Long Term: Independent:
“Gulpi lang siya natumba, heatstroke and vigorous ● Establish rapport ● To gain patient trust and Goals are met.
● Patient
gin kombulsyon kag activities with failure cooperation. After 24 hours of
maintains body nursing
nalipong.” as verbalized by regulating mechanism of ● Assess and
temperature ● Monitoring the changes in intervention the
the folk. the body temperature monitor client’s
below 36.5-37 HR, BP, and the changes patient’s
possibly evidenced by ℃ temperature, HR, in body temperature. consciousness
Objective: elevated body temperature, became less
● Patient and BP.
● Convulsion pale, tonic seizure, and disturbed and his
maintains BP
● Staggering tachycardia. condition
and HR within
● Loss of ● Raise the side ● This is to ensure patient’s improved. His
normal limits. safety even without the body temperature,
consciousness Rationale rails at all times.
● Pale presence HR and BP are
Heatstroke is a condition
Short Term: of seizure activity. within normal
● Sweating caused by the body
ranges
● Dehydration overheating, usually because of ● Monitor fluid ● Fluid resuscitation may be
● Tachypnea prolonged exposure to or intake
After 24 hours of required to
physical exertion in high
● Tachycardia nursing and urine output. correct dehydration. The
temperatures that can cause
● Tonic Seizure intervention, the patient who is significantly
hyperthermia. Hyperthermia is
● Glasgow Coma patient will be able dehydrated is no longer
characterized by an
Scale: 8 to resume and able to sweat, which is
uncontrolled increase in body
maintain body necessary for evaporative
Vital Signs temperature that exceeds the
temperature and cooling.
● Temp: 40.0⁰C body’s ability to lose heat. The
regain
● PR: 160/min setting of the hypothalamic ● Adjust and
consciousness ● Room temperature may be
thermoregulatory center is
● BP: 90/50 mmHg. monitor accustomed to near normal
unchanged.
● RR: 40/min environmental body temperature and
● O2 Sat: deteriorating factors like room blankets and linens may be
temperature and adjusted as indicated to
regulate temperature of the
bed linens as
patient.
ILOILO DOCTORS’ COLLEGE
COLLEGE OF NURSING
West Avenue, Molo, Iloilo City
NURSING CARE PLAN
indicated.
● Exposing skin to room air
● Eliminate excess
decreases warmth and
clothing and increases evaporative
covers. cooling.
● Non-invasive: ● These measures help
cooling mattress, promote cooling and lower
cold packs core temperature.
applied to major
blood vessels
Dependent:
● Intravenous normal saline
● Plain NSS 3500 solution
ml replenishes fluid losses
intravenous start
ed
Defining Characteristics Nursing Diagnosis Outcome Identification Nursing Interventions Rationale Evaluation
ILOILO DOCTORS’ COLLEGE
COLLEGE OF NURSING
West Avenue, Molo, Iloilo City
NURSING CARE PLAN
Subjective: Independent:
Long Term:
Risk of infection related to ● Establish ● To gain patients' trust Goals are met. The
● Client will remain and cooperation. patient’s vital signs
multiple organ dysfunction rapport.
free of infection, as are within normal
Objective: syndrome evidenced by
● Monitor the ● Vital signs are ranges and the
acute renal, hepatic, and evidenced by normal important markers of patient's
patient's vital
● Convulsion cardiac injury, sepsis. vital signs and signs and signs of infection that can help consciousness
● Staggering infection raise suspicion so tests becomes less
absence of signs and can be conducted to disturbed.
● Loss of
Rationale
consciousness symptoms of confirm the presence
● Pale MODS is the development of of infection.
potentially reversible infection.
● Sweating
physiologic derangement Short Term: ● Position in regular
● Dehydration ● Promote proper
involving two or more organ position changes
● Difficulty of ● After 8-10 hours of positioning or
systems not involved in the prevent the pooling of
breathing regular position
disorder including sepsis. This nursing intervention mucus, therefore
changes.
● Tachycardia can make an individual at risk preventing infection
for infection, vulnerable to the patient’s vital
● Tonic Seizure
● Glasgow Coma invasion of and multiplication signs are normal.
of pathogenic organisms which ● Aseptic technique
Scale: 8 ● Maintain strict
may compromise health. decreases the chances
● Major clotting asepsis for
of transmitting or
disturbances dressing changes,
spreading pathogens to
Vital Signs wound
or between patients.
care, intravenous
● Temp: 40.0⁰C
therapy.
● PR: 160/min
● BP: 90/50 mmHg. ● Hand washing
● Encourage and
between procedures
● RR: 40/min perform hand
reduces the risk of
● O2 Sat: deteriorating hygiene
transmitting pathogens
Laboratories from one area of the
● Serum creatinine body to another.
2.46–2.75mg/dl
ILOILO DOCTORS’ COLLEGE
COLLEGE OF NURSING
West Avenue, Molo, Iloilo City
NURSING CARE PLAN
● GFR 45.3 ml ● Proper nutrition and a
● Creatinine kinase balanced diet support
1378 U/l – 14460 ● Encourage intake the immune systems’
of protein-rich responsiveness and
U/l
and calorie-rich enhance the health of
● Lactate levels 79 foods and all the body’s tissues.
mg/dl encourage a Adequate nutrition
● ALT of 316 IU/L balanced diet. enables the body to
● AST of 1319 IU/L maintain and rebuild
● Myoglobin of 8632 tissues and helps keep
μg/L the immune system
functioning well.
● INR 2.65
● Uric Acid 40.45
mg/dl
● Serum Potassium 4.2 Dependent: ● used to determine if
mmol/L you've had a recent
● Antistreptolysin infection caused by
titre (ASO) as group A streptococcus
ordered bacteria.
● Intravenous normal
saline solution
● Plain NSS replenishes fluid losses
3500ml
intravenous
started ● Decrease the risk of
uric acid precipitation
● Administer in renal tubuli
Allopurinol 20
mg/dl ● Improves the flow of
blood through blood
● Administer vessels and decreases
Pentoxyfilline neutrophil adhesion
ILOILO DOCTORS’ COLLEGE
COLLEGE OF NURSING
West Avenue, Molo, Iloilo City
NURSING CARE PLAN
and cytokine release.
● used to treat fluid
build up due to heart
● Furosemide 40- failure, liver scarring,
200 mg/24 hrs kidney disease. It
may also be used for
the treatment of high
blood pressure.
