NCP for Swine Flu

ASSESSMENT NURSING OUTCOME PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS IDENTIFICATION
Subjective data: Ineffective 1. Patient will achieve Short Term: Independent: 1. Room temperature may be After short term (2hours)
“ Nilalamig ako thermoregulation and maintain a At the end of 2 hours of 1. Adjust and monitor accustomed to near normal and long term (24-48 hours)
pero minsan ang related to limited environmental factors like body temperature and
normal temperature nursing intervention, of nursing intervention, the
init ng metabolic room temperature and bed blankets and linens may be
pakiramdam ko.” compensatory within normal the patient will have linens as indicated. adjusted as indicated to following goals were met:
As verbalized by regulation range of 36.5 ºC to temperature within regulate temperature of the
the client. secondary to age as patient. 1. Patient had a
37.5 ºC normal range of 36.5 ºC
an older adult.
2. Patient will achieve to 37.5 ºC. temperature 36.5 ºC
Objective data: 2. Monitor VS especially 2. Helps to evaluate the
and maintain a temperature, every 2-4 hours efficacy of treatment and to 37.5 ºC.
 Shivers
and as needed. Utilize the monitors for complications 2. Patient maintained a
 Slow and balanced intake Long Term:
same methods of temperature that may occur.
shallow and output with At the end of 24-48 balanced intake and
reading with each Consistency in methods
breathing measurement. allows for accurate data output with adequate
adequate hydration. hours of nursing
 Mumbled collection and correlation. hydration.
speech 3. Patient verbalize intervention the
understanding of patients will able to: 3. Patient explained
 Weak pulse 3. If the client’s temperature 3. Warm blankets provide a
 Cold to touch individual factors is below normal, give extra passive method for techniques to avoid
skin  Maintain a heat loss at home.
and appropriate covering (passive warming), rewarming.
 Bright Red balanced intake such as clothing and blankets 4. Patient listed
V/S taken as interventions.
and output with situations that
follows: 4. Demonstrate 4. If the client’s temperature 4. Exposing skin to room air
adequate increase heat loss.
techniques to is above normal, Eliminate decreases warmth and
T: 35.7ºC
hydration. excess clothing and covers. increases evaporative
PR: 65 bpm correct underlying
RR: 10 cpm  Explain cooling.
BP: 90/60 mmHg condition.
techniques to
avoid heat loss at 5. Encourage an increase in 5. Increase in body
home. fluid intake to 3-4 L/day, temperature multiplies
unless contraindicated. insensible fluid losses by
 List situations that 10% for every 1 ºC of
increase heat loss. increase in body
temperature, which may
NCP for Swine Flu

result in dehydration.
6. Monitor intake and output 6. Helps to identify fluid
every 2-4 hours. status changes and
imbalances, and allows for
prompt treatment.
7. Notify physician of
temperature increases/ 7. May indicate other sources
decrease within the normal of temperature aberration
range that do not respond to and may cause permanent
any measure used. organ damage.

8. Monitor patient for seizures.

8. Seizure may occur with
high temperatures because
of hyperactivity within the
brain, which can cause
further impair tissue
perfusion.
9. Explained age-related
changes that interfere with 9. Provides knowledge and
thermoregulation to patient/ helps to involve the patient
family such as inefficient and the family in care.
vasoconstriction, decreased
cardiac output, decreased
subcutaneous tissue, delayed
and diminished shivering.

Dependent
1. Administer medication as
prescribed by the physician: 1. Benefits are effective
antipyretics. management of the
illness/disease, slowed
progression of the disease,
and improved patient
NCP for Swine Flu

outcomes.

2. Provide supplemental IV 2. To restore or maintain body

fluids as necessary. function.

Collaborative:
1. Helps to evaluate the
1. Monitor laboratory studies efficacy of treatment and
such as test indicative of monitors for complications
infection, thyroid/ other that may occur.
endocrine test, organ damage,
drug screen.