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Pneumonia Nursing Care Plans

ASSESSMENT OBJECTIVES Short term: After 4 of NI, the pts 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. NURSING INTERVENTIONS 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. RATIONALE 1. To gain trust and have a nurse patient relationship 2. To establish baseline data of the pts 3. To lower pts 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. EXPECTED OUTCOMES Short term: After 4 of NI, the pts 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.

Flushed Skin Skin Warm to Touch Temperature Higher


than 37.6C Rales Dehydration Irritability

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