Nursing diagnosis – HYPERTHERMIA

HYPERTHERMIA

DEFINITION

Body temperature elevated above normal range

DEFINING CHARACTERISTICS

• Fever

• Flushed, warm skin

• Increased heart and respiratory rate

• Seizures

RELATED FACTORS

• Anesthesia

• Increased metabolic rate

• Decreased perspiration

• Illness

• Dehydration

• Medications

• Exposure to hot environment

• Trauma

• Inappropriate clothing

• Vigorous activity

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Fluid and electrolytes

• Neurocognition

• Pharmacological function

• Respiratory function

• Physical regulation

• Tissue integrity

EXPECTED OUTCOMES

The patient will

• Remain afebrile.

• Maintain balance of intake and output within normal limits.

• Maintain urine specific gravity between 1.005 and 1.015.

• Exhibit moist mucous membranes.

• Exhibit good skin turgor.

• Remain alert and responsive.

SUGGESTED NOC OUTCOMES

Hydration; Infection Severity; Thermoregulation; Vital Signs

INTERVENTIONS AND RATIONALES

Determine: Monitor heart rate and rhythm, blood pressure, respira-

tory rate, LOC and level of responsiveness, and capillary refill time

every 1–4 hr to evaluate effectiveness of interventions and monitor

for complications.

Determine patient’s preferences for oral fluids, and encourage

patient to drink as much as possible, unless contraindicated. Moni-

tor and record intake and output, and administer intravenous fluids,

if indicated. Because insensible fluid loss increases by 10% for every

1.8   F (1   C) increase in temperature, patient must increase fluid

intake to prevent dehydration.

Perform: Take temperature every 1–4 hr to obtain an accurate core

temperature. Identify route and record measurements.

Administer antipyretics as prescribed and record effectiveness.

Antipyretics act on hypothalamus to regulate temperature.

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Use nonpharmacologic measures to reduce excessive fever, such as

removing sheets, blankets, and most clothing; placing ice bags on

axillae and groin; and sponging with tepid water. Explain these

measures to patient. Nonpharmacologic measures lower body tem-

perature and promote comfort. Sponging reduces body temperature

by increasing evaporation from skin. Tepid water is used because

cold water increases shivering, thereby increasing metabolic rate and

causing temperature to rise.

Use a hypothermia blanket if patient’s temperature rises above

103   F (39.4   C), if ordered. Monitor vital signs every 15 min for

1 hr and then as indicated. Prolonged hyperthermia may lead to

complications such as seizures. Turn off blanket if shivering occurs.

Shivering increases metabolic rate, increasing temperature.

Manage: Report lack of responses to interventions to physician to

prevent complications.

SUGGESTED NIC INTERVENTIONS

Environmental Management; Fever Treatment; Fluid Management;

Temperature Regulation

Reference

Kayser-Jones, J. (2006, June). Preventable causes of dehydration: Nursing

home residents are especially vulnerable. American Journal of Nursing,
106(6), 45.

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