Nones,Michael Angelo E.

BSN 2-4

Nursing care plan

For fever:

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Hyperthermia Infectious agents After 4 hrs. Independent: Dysrhythmias After 4 hrs.
“Mainit ang related to (Pyrogens) Of nursing Monitor heart and ECG Of nursing
pakiramdam ko” dehydration stimulate interventions, rate and changes are intervention
Monocytes
as verbalized by the patient will rhythm. common due s, the
release
the patient. Pyrogenic cytokines maintain core Record all to electrolyte patient was
Objective: stimulate temperature sources of fluid imbalance able
Flushed skin, Anterior hypothalamus within normal loss such as and maintain
warm to Touch. results in Range. urine, vomiting dehydration core
Restlessness Elevated and diarrhea. and direct temperature
thermoregulatory set effect of within
Promote
point hyperthermia normal
leads to surface cooling
Increased Heat by means of on blood and range.
conservation tepid sponge cardiac
(Vasoconstriction/behavior bath. tissues.
changes) Wrap To monitor or
Increased Heat extremities with potentiates
production cotton blankets. fluid and
(involuntary muscular electrolyte
contractions) Provide
supplemental loses.
result in
FEVER oxygen. To decrease
temperature
by means
through
evaporation
and
conduction.
To minimize
shivering.
To offset
increased
oxygen
demands and
consumption