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Nursing Care Plan: Subjective: Short Term Independent

The nursing care plan is for an 87-year-old male patient admitted with CAP, hypertension, heart disease, and COPD. The patient has a fever of 38.2°C. The nursing diagnosis is hyperthermia related to bacterial infection. Short term goals include decreasing the patient's temperature to 37.5°C within 1 hour with tepid sponge baths and monitoring. Long term goals are for vital signs to return to normal range within 4 hours and provide antipyretic medications as needed.

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Kristine Young
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4K views

Nursing Care Plan: Subjective: Short Term Independent

The nursing care plan is for an 87-year-old male patient admitted with CAP, hypertension, heart disease, and COPD. The patient has a fever of 38.2°C. The nursing diagnosis is hyperthermia related to bacterial infection. Short term goals include decreasing the patient's temperature to 37.5°C within 1 hour with tepid sponge baths and monitoring. Long term goals are for vital signs to return to normal range within 4 hours and provide antipyretic medications as needed.

Uploaded by

Kristine Young
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOC, PDF, TXT or read online on Scribd
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ST.

ANTHONY’S COLLEGE
Nursing Department

NURSING CARE PLAN

Name of patient: D.C.O. Attending Physician: Dr.B.


Age: 87 yrs. old Ward/Bed #: Medical Ward 3007-2 Impression Diagnosis:CAP,
Hypertensive urgency, HCVD, COPD

Clustered Cues: Nursing Diagnosis Rationale Outcome Criteria Nursing Rationale Evaluation
Interventions
Subjective: Hyperthermia Hyperthermia is Short Term Independent Vital signs provide
“Daw init lawas ni related to bacterial elevated body After 1 hour of 1. Monitor vital more accurate Latest body
tatay au” as infection temperature due to a appropriate signs. indication of core temperature:
verbalized by the break in nursing temperature. 36.8oC
patient’s relative. thermoregulation that intervention the
arises when a body patient’s RR:18
Objective: produces or absorbs temperature will 2. Provide tepid TSB helps in
 Temperature: more heat than it decrease to sponge bath. lowering the body PR: 89bpm
38.2oC dissipates. It is a 37.5oC. Do not use temperature and
 Warm to sustained core alcohol. alcohol cools the
touch temperature beyond Long Term skin too rapidly,
 RR: 26cpm normal variance. After 4 hours of causing shivering.
 PR: 112bpm Hyperthermia differs appropriate Shivering
from fever in that it is nursing increases
characterized by an intervention the metabolic rate and
uncontrolled increase patient’s vital body temperature
in body temperature signs will return
that exceeds the to normal range;
body’s ability to lose with a 3. Remove excess
heat. The setting of temperature of clothing and
hypothalamic 36.5-37.5oC,pulse covers. These decrease
thermoregulatory rate of 60- warmth and
center is unchanged. 100bpm and increase
In contrast to fever in respiratory rate of evaporative
infections, 12-20 cycles per 4. Promote a well- cooling.
hypethermia does not min. ventilated area
involve pyrogenic to patient.
molecules. To promote clear
flow of air in the
patient’s area. One
way of promoting
5. Advise patient heat loss.
to increase oral
fluid intake.

Additional fluids
help prevent
elevated
6. Maintain bed temperature
rest. associated with
dehydration.

Dependent  Reduce metabolic


10. Provide demands/ oxygen
antipyretic consumption
medications as
indicated.
 These drugs
inhibit the
prostaglandin
that serve as
mediators of
pain and fever.

Student’s Name: Cen Janber A. Cabrillos


Clinical Instructor: Jerry V. Able, RN, MAN

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