DAVAO DOCTORS COLLEGE

Gen. Malvar St., Davao City

NURSING CARE PLAN

Name: ___________________________________ Date of Admission: ______________________________
Age:______ Sex:________ Civil Status:_________ Chief Complain: _________________________________
Religion:_______________ Room No.:__________ Attending Physician: _____________________________

PROBLEM SCIENTIFIC BASIS GOAL NURSING INTERVENTION RATIONALE EVALUATION

OBJECTIVES
S/O Infectious agents Within 2 hours of 1. Promote surface cooling by 1. To decrease temperature by Goal met:
(Pyrogens)
•Temp. of 38.1 C Stimulate nursing intervention means of tepid sponge bath. means through evaporation and
•Warm to touch the patient will conduction. Temperature of
•Lethargic Monocytes
manifest a 2. Encourage increased fluid intake 2. To support circulating volume and 37.1 after 2 hours
•Platelet count of 89 Release decrease in tissue perfusion. Also to prevent and 36.6 after 4
•Decreased temperature, from 3. Maintain bedrest dehydration hours
lecuocyte count Pyrogenic cytokines
38.1 C to 37 to 37.5 3. To reduce metabolic demands/
Stimulate C range 4. Encourage high-calorie diet oxygen consumption
A – hyperthermia r/t 4. To meet increased metabolic
increased body Anterior hypothalamus 5. Promote cool and calm demands.
metabolic rate
results in environment 5. To decrease temp thru
conduction
Elevated thermoregulatory set 6. Monitor heart rate and rhythm 6. Dysrhythmias and ECG changes
point are common due to electrolyte
leads to
7. Monitor respirations Imbalance and dehydration and
direct effect of hyperthermia on
Increased Heat conservation 8. Monitor fluid loss such as urine, blood and cardiac tissues.
(Vasoconstriction/behaviour
changes) vomiting and diarrhea (if any), and 7. Hyperventilation may initially be
insensible losses present
8. May increase fluid & electrolyte
Increased Heat production
(involuntary muscular contractions) Collaborative losses
result in 1. Administer paracetamol as
FEVER
ordered 1. To decrease body temperature

Name: ______________________ Section: _______________ Group: ____________