Nursing Care Plan Fever by chandrapro

VIEWS: 3,136 PAGES: 3

									NURSING CARE PLAN
ASSESSMENT              DIAGNOSIS               INFERENCE                          PLANNING           INTERVENTION               RATIONALE         EVALUATION
                                                                                                      Independent:
Subjective:         •    Hyperthermia            Infectious agents             •   After 4 hrs. Of    • Monitor heart        •    Dysrhythmias     •   After 4 hrs.
                         related to                 (Pyrogens)                     nursing               rate and                 and ECG              Of nursing
“Mainit ang              dehydration.                        stimulate             interventions,        rhythm.                  changes are          intervention
pakiramdam ko”                                      Monocytes                      the patient will                               common due           s, the
as verbalized by                                                                   maintain core                                  to electrolyte       patient was
                                                               release
the patient.                                                                       temperature                                    imbalance            able
                                               Pyrogenic cytokines
                                                                                   within normal                                  and                  maintain
Objective:                                                    stimulate            range.                                         dehydration          core
                                              Anterior hypothalamus                                                               and direct           temperature
•   Flushed skin,                                                                                                                 effect of            within
                                                              results in
    warm to                             Elevated thermoregulatory set point
                                                                                                                                  hyperthermia         normal
    touch.                                                                                                                        on blood and         range.
                                                               leads to                                                           cardiac
•   Restlessness                            Increased Heat conservation
                                                                                                                                  tissues.
    .                                   (Vasoconstriction/behaviour changes)                          •   Record all         •    To monitor or
                                             Increased Heat production                                    sources of fluid        potentiates
                                         (involuntary muscular contractions)
•   V/S taken as                                                                                          loss such as            fluid and
                                                               result in                                  urine, vomiting         electrolyte
    follows:
                                                     FEVER                                                and diarrhea.           loses.
    T: 38.1                                                                                           •   Promote            •    To decrease
    P: 70                                                                                                 surface cooling         temperature
    R: 19                                                                                                 by means of             by means
    BP: 110/90                                                                                            tepid sponge            through
                                                                                                          bath.                   evaporation
                                                                                                                                  and
                                                                                                                                  conduction.
                                                                                                      •   Wrap               •    To minimize
                                                                                                          extremities with        shivering.
                                                                                                          cotton blankets.
                                                                                                      •   Provide            •    To offset
                                                                                                          supplemental            increased
                                                                                                          oxygen.                 oxygen
                                                                                                                                  demands and
                                                                                                                                  consumption.
•   Administer           •   To support
    replacement              circulating
    fluids and               volume and
    electrolytes.            tissue
                             perfusion.
•   Maintain bed         •   To reduce
    rest.                    metabolic
                             demands and
                             oxygen
                             consumption
•   Provide high         •   To increased
    calorie diet,            metabolic
    tube feedings,           demands.
    or parenteral
    nutrition.
•   Administer           •   To facilitate
    antipyretics             fast recovery.
    orally or rectally
    as prescribed
    by the
    physician.

								
To top