Problem List

Cues Problems Priority Justification

Subjective: • Hyperthermia 1st This problem prioritized in the

“Nilalamig ako” as stated highest rank due to progress of the
by the client. dilemma may lead to onset of
other problems/complications.
Objective:
• BP- It is one of the manifestations of
• T- dehydration and if hyperthermia
• RR- continues the client may become
• PR- more dehydrated.
• Warm to touch
• Dry skin
• Dry lips

Subjective: • Acute pain 2nd This is the 2nd highest prioritized

The client’s rate in the problem cause the pain is
pain scale is 6 out of 10 tolerable and manageable by the
where as 10 is the most client.
painful.

Objective:
• BP-
• T-
• RR-
• PR-
• Post-op wound

Objective: • Risk for 3rd This is least prioritized because

• BP- infection the problem is not present. The
• T- client has a tendency to develop
• RR- infection if it was not prevented
• PR- and may trigger other complication
• Post-op wound to arise.

C. Nursing Care Plan

Nursing Analysis Goal and Nursing Rationale Evaluation

Problem Cues Objective Intervention

Nursing Hyperthermia is Goal: Independent After 8 hour

Diagnosis: an elevated With 8 hour of Establish To gain trust and of nursing
body appropriate rapport cooperation. intervention
Hyperthermia
temperature nursing the patient’s
related to due to failed intervention the temperature
dehydration. thermoregulatio patient’s Assess and Vital signs was reduced
n. temperature monitor vital provide more ranges 36.5-
Hyperthermia which is 39.2 signs. accurate 37.5
occurs when will be reduce indication of core
the body ranges 36.5- temperature
produces or 37.5.
absorbs more
heat than it can Provide tepid TSB helps in
dissipate. sponge bath. lowering the body
When the temperature and
elevated body alcohol cools the
temperatures skin too rapidly,
are sufficiently causing
high, shivering.
hyperthermia is Shivering
a medical increases
emergency and metabolic rate
requires and body
immediate temperature
treatment to
prevent Remove excess These decrease
disability and clothing and warmth and
death. The covers. increase
body needs a evaporative
certain cooling.
amount of
Promote a well- To promote clear
fluid in order
ventilated area flow of air in the
to regulate to patient. patient’s area.
body One way of
temperature, promoting heat
carry oxygen loss.
to cells, and
flush waste Increase Additional fluids
from the patient’s oral help prevent
kidneys and fluid intake. elevated
liver. When a temperature
associated with
fever is
dehydration.
present, that
need Maintain bed Reduce
increases and rest. metabolic
makes demands/ oxygen
individuals consumption
with a fever
more Provide high- To meet
susceptible to calorie diet. increased
dehydration metabolic
demands.

Educate and Teaching the

advise support Support system
system (relative) the right way to
to do TSB when do TSB will help
patient feels hot. in knowing what
- Luke warm to do in case the
water only. patient’s
- Make sure that temperature
armpits and increases
groins were
included in
doing TSB.

Dependent ·
Provide
antipyretic ·
medications as
prescribed by
the physician.