Nursing Care Plans | 01/12/2012, 10:49 pm

5 Pneumonia Nursing Care Plans


5 Hyperthermia

Presence of microorganisms stimulates the release of pyrogen from the leukocytes resetting the body’s thermostat to febrile level and then there would be activation of the hypothalamus, which will result in increase in epinephrine and norepinephrine, vasoconstriction of cutaneous vessels. The heat will be produced as peripheral vasodilation results in skin flushing and skin is warm to touch.

ASSESSMENTOBJECTIVESINTERVENTIONSRATIONALEEXPECTED OUTCOME

  • Flushed Skin
  • Skin Warm to Touch
  • Temperature Higher than 37.6C
  • Rales
  • Dehydration
  • Irritability
  Short term: After 4° of NI, the pt’s temperature will drop from 38.4 °C to 37 °C

Long term:

After 2-3 days of NI, the patient will be free from hyperthermia.                                        

  1. Establish Rapport
  2. Monitor VS q 4°.
  3. Provide TSB as a measure.
  4. Instruct SO to provide with loose clothing.
  5. Assess skin temperature and color.
  6. Monitor WBC count.
  7. Encourage fluid intake orally or intravenously as ordered.
  8. Measure intake and output.
  1. To gain trust and have a nurse patient relationship
  2. To establish baseline data of the pt’s
  3. To lower pt’s temperature
  4. To release heat and to provide comfort
  5. Warm, dry, flushed skin may indicate a fever.
  6. eucocytes indicate an inflammatory and infectious process presence.
  7. Replaces fluid lost by insensible loss and perspiration.
  8. Determine fluid balance and need to increase fluid intake.
Short term:After 4° of NI, the pt’s temperature shall drop from 38.4 °C to 37.4 or lower °C.        

Long term:

After 2-3 days of NI, the patient shall be free from hyperthermia.

Other possible nursing care plans can include:

Navigation
  1. Ineffective Airway Clearance
  2. Ineffective Breathing Pattern
  3. Impaired Gas Exchange
  4. Risk for Infection
  5. Hyperthermia & Other Care Plans
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