Cues

Nursing Diagnosis & Scientific Analysis Hyperthermia related to Exposure to environment with increased temperature Scientific Analysis: Hyperthermia is elevated body temperature due to failed thermoregu lation that occurs when a body produces or absorbs more heat than it dissipates. Extreme temperature elevation then becomes a medical emergency requiri ng immediate treatment to

Goal &Objectives

Intervention

Rationale

Evaluation

Subjective: Kanina pa nilalagnat si nanay kaya mayat maya ko siya pinupusan ng bimpo na may yelo kasi mainit din dito sa ospital. As verbalized by the patient Objective: Flushed skin Diaphoresis Skin is warm to touch

Goal: After 2 hours of nursing interventions, the client will manifest a temperature within the normal range. Objective: After 2 hours of nursing intervention: 1. Evaluate the effect/degree of hyperthermia

After 2 hours of nursing interventions, the patient was able to manifest a temperature within the normal range. Independent

1.Monitor core temperature and BP 2. Assess neurological response, level of consciousness and orientation. 3. Monitor respirations. 4. Monitor /record all sources of fluid loss such as urine, vomiting and

Vital Signs: Temp: 39.1C BP: 180/100 PR: 112 bpm RR: 27 cpm

> Cerebral hypertension or peripheral/postU ral hypotension can occur. Hyperventilation may initially be present but ventilatory effort may be impaired by seizures, hypermetabolic state. Oliguria and/or renal

prevent disability or death. The most common causes include heat stroke and adverse reactions to drugs. The former is an acute temperature elevation caused by exposure to excessive heat, or combination of heat and humidity, that overwhelms the heat-regulating mechanisms. The latter is a relatively rare side effect of many drugs, particularly those that affect the central nervous system.

diarrhea.

failure may occur due to hypotension, dehydration, shock. >Heat is loss by evaporation and conduction. > Heat is loss by convection, radiation and conduction.

2. Demonstrate temperature within normal range, from 38.1 C to 36.5C -37.5C

1. Increase oral fluid intake. 2. Promote bed rest, encourage relaxation skills and diversional activities. 3. Provide TSB as Needed 4. Promote surface cooling, loosen clothing and cool environment Collaborative 1. Administer medications as indicated to treat underlying

>To promote wellness

>To prevent dehydration

>To treat underlying causes

cause, such as: -Paracetamol 325mg/tab 1 tab q 6 2. Administer replacement fluids and electrolytes to support circulating volume and tissue perfusion

>To support circulating volume and tissue perfusion. >To prevent dehydration