Nursing Care Plan Ige (Cap)
Nursing Care Plan Ige (Cap)
Nursing Care Plan Ige (Cap)
HYPERTHERMIA
Assessment Diagnosis Planning Intervention Evaluation
Objective: Problem: After 1-2 • Elevate head of After 1-2 hours
• Restless • Impaired gas bed/position
• Nasal flaring exchange
hours of client
of nursing
• Weak in Etiology: nursing appropriately, intervention, the
appearance • Community intervention, provide airway patient
• Use of Acquired the patient will adjuncts and demonstrates
accessory Pneumonia suction as
muscle when S/S: demonstrate indicated to improve
breathing • Difficulty of improved maintain airway. ventilation and
• Flushed skin breathing ventilation and • Monitor for adequate
• Warm to touch • Restless carbon dioxide
• Crackles in • Weak in
adequate narcosis (e.g.,
oxygenation
both lung fields appearance oxygenation change in level of and absence of
• BP: • Nasal flaring and absence consciousness, symptoms of
140/90mmHg • Use of of symptoms changes in O2 respiratory
• Temp.: 39 ⁰C accessory and CO2 blood
• PR: 100bpm muscle when of respiratory gas levels, distress.
• RR: 35cpm breathing distress. flushing,
Subjective: • Crackles in both decreased
• Verbalization of lung fields respiratory rate,
“Nahihirapan • RR of 35cpm headaches),
akong • Verbalization of which may occur
huminga”, “Nahihirapan in clients
“Inuubo ako”, akong huminga”, receiving long-
and “napakainit “Inuubo ako”, term oxygen
ng pakiramdam and “napakainit therapy.
ko” ng pakiramdam
ko”