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Cues Nursing Diagnosis Rationale Planning Nursing Intervention Rationale Evaluation

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NURS

Name: PEDRO DELA CRUZ


Address: ING Age: 70 years old Date: October 25, 2020
Clinical Diagnosis: Hypothermia

Cues CARE
Nursing
Diagnosis
Rationale Planning Nursing
Intervention
Rationale Evaluation

Subjective:
“ Nilalamig ako”
as verbalized by
PLAN
Hypothermia
related to age-
related changes
Older people
are at risk for
hypothermia
After 1hr. of
nursing
 Monitor the
patients vital
signs
 To assess the
severity of
hypothermia.
Goal was met.
The patient
the patient in because their intervention, especially Use oral or temperature
thermoregulatio body's the patient temperature tympanic increased to
Objective: n response to will have a thermometer 36 C.
 Skin cold to cold can be body to get accurate
touch diminished by temperature temperature.
 Pallor certain illnesses within
 Shivering such as normal  Wrapped the  To reduce loss
noted diabetes and range as patient with of heat and
 T- 34.8 some manifested a blanket provide
medicines, by an warmth
including over- increased
the-counter temperature  Increase the  To reverse
cold from 34.8 C room mild
remedies.  With to 35.4 C temperature hypothermia
advancing age, and provide
the body's warmth
ability to
endure long  Encourage  Dehydration
periods of fluid intake can cause
exposure to hypothermia
cold is lowered.
 Administer  Treating
antibiotics as underlying
prescribed by condition will
the physician help the
patient
temperature to
return to
normal range

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