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NURSING CARE PLAN

NURSING GOAL AND


CUES ANALYSIS INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS OBJECTIVES
S: Mr. Lad’s Hyperthermia The classic GOAL:
symptoms of After 8 hour shift, the
primary care related to
UTIs are often patient will maintain
provider infection observed in body temperature
children more within normal range
verbalized,” (UTI) as
than 2 years of (36.5-37.5).
Paggising manifested age. These
includes OBJECTIVES:
nya sinabi by multiple
enuresis or After 10 - 15 minutes
nya sa akin factors daytime of discussion and
incontinence in interaction, the client
na masakit (increase in
the child who as well as his primary
ulo nya.” body has been toilet care giver will be able
trained, fever or to:
temperature Discussion
strong or foul- a. Define Discuss to the client’s a. Was the client
above smelling urine, hyperthermia mother the meaning identifies a problem as well as his
increased accurately. of hyperthermia. primary care
O: normal or establishes
frequency of provider able
• Temperatur range, urination,
strategies to resolve
to define
dysuria or hyperthermia
e: 37.7 °C flushed skin;
urgency. a problem. accurately?
(taken on warm to Yes___ No___
(Fundamentals of Why________
February touch).
Nursing 7th edition by _
11, 2010)
b. Enumerate at Discuss to the client’s Kozier p. 329) b. Was the client
• Warm to least 3 out of mother the signs and as well as his
5 signs and symptoms of Discussion is to primary care
touch
symptoms of hyperthermia give learners an provider able
• Pale in hyperthermia. to enumerate 3
opportunity to apply signs and
color
symptoms of
principles, concepts, hyperthermia?
and theories and in Yes___ No___
Why________
that process, to _
transfer their
learning to new and
different situations.
c. Enumerate 2 Discuss to the client’s Discussions with c. Was the client
ways of how mother the ways to as well as his
to lessen the lessen the severity of nurses or nursing primary care
severity of hyperthermia. provider able
hyperthermia: students about to enumerate 2
professional, ways to lessen
C1. Tepid Discuss & the occurrence
sponge bath demonstrate the societal, or ethical of
ways on how to hyperthermia?
perform tepid sponge
issues can help Yes___ No___
bath participants develop Why_______

C2. Water Discuss the ways on and evaluate their


Therapy how to perform water
beliefs and positions.
therapy
(Teaching Strategies
For Nurse
Educators)

INDEPENDENT
NURSING
FUNCTION:
• To evaluate
After every 4 • Monitor ranges of
hours, the client axillary temperature
will be able to temperature
prevent • Cardiac rate
complications that • Monitor Heart and ECG
may occur. Rate and changes occur
Rhythm due to
electrolyte
imbalance.
• Hyperventilatio
• Monitor n may initially
respiration be present.
• Oliguria or
• Monitor or Renal failure
record all may occur due
sources of to hypotension.
fluid loss such Body attempts
as urine, or to increase
other heat loss.
insensible
losses.

DEPENDENT
NURSING
FUNCTION: • For Fever
After every • Administer Was the client able
administration of Antipyretics to comply with his
medication, the as ordered by the medications?
client will be able to physician and Yes___ No___
comply with his with the Why________
prescribed supervision of the
medications. clinical instructor.
• For Infection
• Administer
Antibiotics as
ordered by
the physician
and with the
supervision of
the clinical
instructor.
• To support
• Administer circulating
replacement volume and
Fluids and tissue
electrolytes perfusion.
as ordered by
the physician
and with the
supervision of
the clinical
instructor. EFFICIENCY:
Were the time,
materials and human
resources used
economically?
___ Yes ___ No
Why _________

ADEQUACY:
Were the numbers of
interventions
sufficient?
___ Yes ___ No
Why _________

ACCEPTABILITY:
Were the interventions
suitable to the client’s
situation?
___ Yes ___ No
Why _________

APPROPRIATENESS
:
Were the
interventions, setting,
and the time realistic
to the client’s
situation?
___ Yes ___ No
Why _________