Fong, Ingrid Sasha R.

- N2C-10
ASSESSMENT NURSING PLAN NURSING RATIONALE EVALUATION
DIAGNOSIS INTERVENTIONS

Subjective: Hypertermia After 6hours of nursing Identified underlying To obtain factors of After 6 hours on
related to increase intervention the client will factors that may cause increase body effective nursing
“Nilalagnat anak alterations of body
metabolic rate maintain core temperature tempearature interventions the
ko. Mainit po cia” temperature
within normal range of client was able
as verbalized by ( illness) 37.5 fr0m 38.1 Monitored temperature To obtain an accurate core to maintain core
the mother every 30 minutes. temperature and detect for temperature
Monitored pulse rate and further development. within normal
respiratory rate range of 37.5.
To promote core cooling
Provided surface cooling by helping reduce body
such as TSB and removing Goal met
of extra clothing. temperature.
Objective:
Latest temp:
Promoted rest and comfort To detect further existing
Flushed skin 37.2
providing bed rest discomforts and level,
Warm to touch Encouraged increase in whether increased or
fluid intake decreased.
Temperature of
Dependent function:
38.2 To prevent dehydration
Administered paracetamol because increase in body
Respiratory rate of as ordered. temperature causes fluid
27 loss such as sweating
Pulse rate of 125 Paracetamol are classified
as analgesics and
antipyretic which acts on
the hypothalamus to
regulate normal body
temperature.