Javier, Jomar A.

BSN121 GROUP 83

Nursing Care Plan

NURSING ANALYSIS GOAL AND INTERVENTION RATIONALE EVALUATION
DIAGNOSIS/CUE OBJECTIVES
S
Hypothermia r/t Goal: Independent: GOAL MET
diseases process A fever occurs Within 8 hours of • Promote To promote heat Within 8 hours of
secondary to when the body nursing surface loss by radiation, nursing
gastroenteritis interventions, the cooling by conduction, intervention the
sets the core patient will convection, patient
means of
Subjective: temperature to a maintain body undressing, evaporation, and maintained body
S>: The mother higher temperature cool to decrease temp temperature
said “kanina pa within the normal environment, of areas with high within the normal
siya mainit” temperature, range. and or fans, blood flow. range as
S>: “irritable through the cool/ tepid manifested by:
siya, kanina Objectives: sponge baths • Body temp of
mataas daw action of the pre-
• Demonstrate or immersion; 36.7° C
temperature niya optic region of behaviors to local ice • Upon
mga 38° C daw.” monitor and packs, To reduce palpation
the anterior
promote especially in metabolic normal skin
Objective: hypothalamus. normothermia the groin or demands/ oxygen temperature
• Flushed skin For example, in • Be able to axillae. consumption. was noted.
noted and avoid seizure • Maintain bed • No incidence
response to
warm to activity. rest. of convulsions
touch. a bacterial or vira and shivering.
• The patient l infection, the • Promote
was irritable client’s safety
and crying. body will raise its (e.g., maintain
temperature, airway; raise
Measurement: side rails,
much like raising
• Body temp. of never leave
38° C . the temperature the child
setting on unattended,
skin
thermostat. protection
 from cold, To prevent
In contrast, observation of dehydration
hyperthermia equipment
safety
occurs when the measures.)
body
temperature rises Indicates need
• Discuss the for prompt
without a change importance of intervention.
in the heat adequate fluid
intake.
control centers.

Some of the
• Review sing
gastrointestinal and
symptoms of symptoms of
hyperthermia
acute exertional (e.g., flushed
heat stroke, such skin,
increased
as vomiting,
body temp,
diarrhea, and increased Aspirin in
gastrointestinal respiratory children may
rate/ heart cause Reye’s
bleeding, may be rate, fainting, syndrome
caused by barrier loss of
consciousness
dysfunction and
and seizures)
subsequent
endotoxemia.
Dependent:
Ultraendurance • Administer
athletes have antipyretic,
orally/rectally
been found to
(e.g., aspirin,
have significantly acetaminophe
increased plasma n as ordered.
Refrain from
 use of aspirin To control
endotoxin levels. products in shivering or
Endotoxin children or seizures.
individual with
stimulates many clotting
inflammatory disorder or To offset
cytokines, which receiving increased oxygen
anticoagulant demand and
in turn may therapy. consumption
cause multiorgan • Administer
medications
dysfunction. To treat
(e.g.,
chlorpromazin underlying cause
Situational:
e or such as infection.
As for the diazepam) as
ordered.
patient, the • Provide To support
cause of the supplemental circulating
oxygen. volume and
fever may be tissue perfusion.
dehydration or • Administer
the disease medication as
indicated,
process itself.
such as
antibiotics.

• Administer
replacement
fluids and
electrolytes.