Davao Medical School Foundation. Inc.
Medical School Drive, Bajada, Davao City
                                                               College of Nursing
 Assessment       Diagnosis          Planning        Intervention                                                                               Evaluation
 Objective:       hyperthermia       At the end of      Independent:                                                                            Goal partially
 Flushed skin     R/T to infection   my shift the    1. Monitor white blood cell (WBC) count                                                    met as
 with body        secondary to       patients          Rationale: An increasing WBC count indicates the bodys efforts to combat               evidenced by
 temperature      urinary tract      temperature        pathogens; Very low WBC count may indicate a severe risk for infection.                 decreased
 of 38.3 C per    infection          will decrease   2. Assess and monitor nutritional status, weight, history of weight loss, and serum        temperature
 axilla                              into normal        albumin.                                                                                from 38.3 to
                  ratioanle:         levels, the        Rationale: Patients with poor nutritional status may be anergic or unable to muster a   37.9, (-) chills
 Patients skin   macrophages        patient will       cellular immune response to pathogens making them susceptible to infection.
 warm to          produce a          report          3. Provide high caloric diet or as indicated by the physician.
 touch            pyrogen is         absence of         Ratioanle:To meet the metabolic demand of client.
                  called             chills and      4. Monitor patients temperature and note for presence of chills/ profuse diaphoresis
 Patient is       Interleukin-1      fever              Rationale: temperature of greater than 37.7 (99.8 F) may indicate infection; very
 experiencing     when they                             high temperature accompanied by sweating and chills may indicate septicaemia.
 chills           come into                          5. Adjust and monitor environmental factors like room temperature and bed linens as
                  contact with                          indicated.
 VS taken as      certain bacteria                      Rationale: Room temperature may be accustomed to near normal body temperature
 follows:         and viruses                           and blankets and linens may be adjusted as indicated to regulate temperature of
 T: 38.3          that increases                        client.
 P:87             the bodys                         6. Apply tepid sponge bath
 R:24             temp. and                             Rationale: It could help in reducing hyperthermia;
 BP:110/70        helps signal                       7. Encourage client to increase fluid intake.
                  helper T cells                        Rationale: Water regulates body temperature.
                  into action                        8. Educate client of signs and symptoms of hyperthermia and help him identify factors
                  (medical                              related to occurrence of fever; discuss importance of increased fluid intake to avoid
                  surgical book,                        dehydration.
                  brunner and                           Ratioanle: Providing health teachings to client could help client cope with disease
                  suddarth 13th                         condition and could help prevent further complications of hyperthermia
                  edition)                              Dependent:
                                                     1. Administer antipyretics as ordered
                                                        Rationale: Antipyretics acts on the hypothalamus, reducing hyperthermia
                                                     2. Start intravenous normal saline solutions or as indicated
                                                        Rationale: To replenish fluid losses during shivering chills.
SUBMITTED TO: Ms. Gremma W.Baratas RN, MN                  SUBMITTED BY: Yasierah K.Agalin , St.N                DATE: february 14, 2017
                Clinical Instructor                                          BSN 3 student
                                             Davao Medical School Foundation. Inc.
                                            Medical School Drive, Bajada, Davao City
                                                      College of Nursing
                                                   Nursing Care Plan
SUBMITTED TO: Ms. Gremma W.Baratas RN, MN        SUBMITTED BY: Yasierah K.Agalin , St.N   DATE: february 14, 2017
                Clinical Instructor                                BSN 3 student