ASSESSMENT NURSING DIAGNOSIS CLIENT GOAL OUTCOME CRITERIA NURSING RATIONALE ACTUAL

INTERVENTIONS EVALUATION
SUBJECTIVE CUES Hyperthermia related to intrauterine After 4 hours of • Temperature Independent After 4 hours of
• Patient infection manifested by a nursing decreases to at • Washed hands with • Reduces cross nursing
verbalized temperature of 38.2 intervention, least the normal anti-bacterial soap contamination intervention,
feeling weak the patient’s value of 37.5 before and after and prevents the patient’s
and not being temperature degrees Celsius each care the spread of temperature
able to move will decrease at • Patient will infection. decreased at
easily least to the verbalize feeling • Monitored patient • Fever pattern least to the
• Patient also normal warm and able temperature degree aids in normal
verbalized of temperature. to feel her skin and patterns diagnosing temperature
feeling cold • Patient will underlying
and not being verbalize disease
able to feel SCIENTIFIC BASIS: regaining her • Provided sponge • Help reduce
her skin It has been proposed that defects . energy bath using warm fever
following a maternal fever might be • Patient will have water
caused by metabolic changes in the a normal • Provided /
OBJECTIVE CUES mother due to the infection and temperature to encouraged patient • To replace fluids
• T= 38.2 fever, and not due to the associated touch. to drink fluids up to lost due to
• BP= 150/90 elevation of temperature. • Patient will only 1500-2000 cc evaporation
• HR= 79 need minimal • Instructed patient to
• RR= 21 Source: amount of wear clothing that is • To prevent
• Hot to touch Maharaj, D. (n.d). Fever in blankets thin and easy to stimulation of an
Pregnancy. Antimicrobe. Retrieved absorb sweat increase in body
• Grimaced
from: • Provided warm temperature
face
[Link] environment • To keep patient
• Covered in
blankets warm and
prevent
increase of
temperature
Dependent
• Administered • To reduce
acetaminophen as patient’s fever.
prescribed by the
physician.
Collaborative
• Took urine sample • To determine
and submitted for infections that
lab test. caused the
 hypertension.

REFERENCES:
Home Treatment: Fever Intervention. (n.d). HealthNetCafe. Retrieved from: [Link]
Martin, P. (2019). 3 Prenatal Infection Nursing Care Plans. Nurseslabs. Retrieved from: [Link]