• Author / Uploaded
• sandie_best

Citation preview

NURSING CARE PLAN Assessment S: “Miss pwede po ba pakitingin ung temperature niya medyo mainit siya eh” as verbalized by the patient’s father O: T: 38.8 C PR: 102bpm RR: 70cpm Very Warm Skin Little weak Always sleeping

Nursing Diagnosis Hyperthermia related to inflammatory process secondary to pericardial infection

Scientific Explanation 1 Idiopathic or suspected viral infection. Inflammation process of pericarditis - lead to Accumulation of fluid in the pericardial sac(pericardial effusion) and increased pressure on the heart -leading to

Cardiac tamponade *Frequent or prolonged episodes of pericarditis -may lead to Thickening and decreased and decreased elasticity of the pericardium/ scarring may fuse the visceral and parietal pericardium 1

Planning

Intervention

Rationale

Goal: Client will be able to maintain normal body temperature with out complications.

Independent: 1. Monitor vital signs Regular temperature monitoring will identify adequate thermoregulation

Objectives: After the nursing intervention:

2.Provide tepid sponge bath(if not contraindicated)

To promote cooling of body surface

3. Promote ventilation of skin by means of undressing (heat loss by radiation and conduction)

To maintain stable body temperature of newborn and decrease the possibility of complication (dehydration)

4.Promote client safety

Besides treating the sickness safety of the client is imporant

Short term -The patient will be able to be free from any complications Long term - Maintain body temperature at a normal range

Depdendent 1. Administer antipyretics w/ correct pediatric

Treatment of mild to moderate pain; fever; various inflammatory

Brunner & Suddarth’s Textbook of Medical-Surgical Nursing 12th edition, Smeltzer, Bare, Hinkle, Cheever, page 818

Evaluation Client was able to maintain normal body temperature with out complications. Objectives After the nursing intervention: Short term The patient was able to be free from complications The patient was able to maintain body temperature at a normal range

dose (as ordered) 2. Administer antibiotics w/ correct pediatric dose (as ordered)

conditions To treat the underlying cause

Collaborative 1. Instruct the mother To dehydrate the to patient increase adequate fluid intake( if not contraindicated