Hyperthermia

A Nursing Care Plan Presented

to Maria Catherine Belarma, RN, MN

In Partial Fulfillment
of the Requirements for the Degree of
Bachelor of Science in Nursing

By:
Janelle Faith E. Narciso, St. N

BSN2D, Group 2

March 25, 2020

 A.B.C
Name of Patient: ________________________________ 10 yo / F
Age/Gender: ____________ Ward:_________ Room no._______
fever
Chief Complaint: _______________________________________________________ Physician:_ __________________
Dr. Aling
Diagnosis:____ _____________________________________________________________________________________
Urinary Tract Infection

Date/ Cues Need Nursing Diagnosis Objectives of Care / Nursing Implementations Evaluation
Time Patient Outcome Interventions
Objective: N Hyperthermia related to After 8 hours of Independent Goal Met
M U the infectious process appropriate nursing 1. Monitor vital 1 @4 pm
A -VS T as evidenced by intervention, the signs
R Temp: 38 °C R increased body client will: especially After 8 hours of
C PR: 83 bpm I temperature above temperature, as nursing
H RR: 18 cpm T normal range - Maintain core indicated intervention, the
CR: 85 bpm I temperature patient was able to
25, BP: 110/70 mmHg O Rationale: within normal R: to determine maintain normal
N Fever may be the only range appropriate body temperature
2 - skin warm to touch A apparent symptom of interventions and showed no
0 - flushed skin L UTI. Older children may - Be free of signs and
2 - weakness observed experience fever and dehydration 2. Provide tepid symptoms of
4
0 - body malaise complain of pain or sponge bath dehydration as
- dry mucous M stinging while urinating - Be alert and evidenced by:
@8a membrane E or have abdominal or responsive R: a tepid sponge
m T back pain bath is done to - @8am
A reduce fever (38 °C);
-Medicines B Reference:
Paracetamol 10mL O Herdman, T.H., & 3. Encourage @10am
7
4x a day L Kamitsuru, S. (2018). adequate oral (37.5 °C);
I Nanda nursing fluid intake
Augmentin 200 mg/ C diagnoses: definitions @12nn
5mL every 12 hours & classification 2018 R: to prevent (37.2 °C);
– 2020. New York: occurrence of
Thieme. dehydration @2pm
(37 °C);
Urinary Tract Infection 4. Promote bed 5
 (UTI): Children’s rest
Hospital Pittsburgh. @4pm
P (n.d). Retrieved from R: to reduce (37.2 °C)
A https://www.chp. metabolic
T edu/our- demands or - “naga inom
T services/uti/ oxygen ako tubig.
E conditions/uti consumption Mga ka 4
R times ako
N 5. Provide oral 10 nagpa refill
hygiene kay mama”

R: prevents - Patient was

herpetic lesions of alert and
the mouth responded to
questions
6. Monitor intake 6 during the
and output assessment

R: to assess for
urinary and
bladder distention

7. Encourage
9
client intake of
vitamin C
supplement
and
other vitamin c
–
rich foods such Janelle Faith E.
as citrus fruits Narciso, St. N

R: to boost the
immune system

Dependent

8. Administer
2
antipyretic
drugs as
indicated

R: to reduce body
temperature

9. Administer 3
antibiotic as
ordered

R: treats
underlying causes

Collaborative:

10. Discuss 8
condition of
the client with
other
members of
the health
care team

R: ensures
continuous
intervention
References:
Gulanick, M., &
myers, J.L.,
(2017).
Nursing care
plans:
diagnoses
interventions, &
outcomes. St.
Louis, MO:
Mosby, an
imprint of
Elsevier Inc.

BAKER, W. A. N.
D. A. (2018).
Nursing Care
Plans. Place of
publication not
identified:
PEARSON.
Clustering

-VS
-Medicines -------------------- 1
Temp: 38 °C -------------------- 2
Paracetamol 10mL Gordon’s Functional Pattern
PR: 83 bpm -------------------- 4
4x a day 1 – Health Perception and Health Management
RR: 18 cpm -------------------- 4
Pattern
CR: 85 bpm -------------------- 4
Augmentin 200 mg/ 2 - Nutritional and Metabolic Pattern
BP: 110/70 mmHg -------------------- 4
5mL every 12 hours 3 – Elimination Pattern
4 – Activity and Exercise Pattern
- skin warm to touch -------------------- 2
5 – Sleep and Rest Pattern
- flushed skin -------------------- 2
6 – Sexuality and Reproduction Pattern
- weakness observed -------------------- 4
7 – Cognitive and Perception Pattern
- dry mucous membrane -------------------- 2
8 – Role and Relationship Pattern
9 – Self-perception and Self- concept Pattern
10 – Coping and Stress Tolerance Pattern
11 – Values and Belief Pattern