HYPERTHERMIA

ASSESSMENT NURSING RATIONALE NURSING NURSING RATIONALE EVALUATION

DIAGNOSIS GOALS
INTERVENTIONS
SUBJECTIVE: Hyperthermia Entry of After 30 minutes INDEPENDENT After 30 minutes
r/t pathogens in of effective of effective
inflammatory the systemic nursing *monitor core *temperature of 38.9-41.1 C nursing
“Ang taas ng response circulation intervention, the temperature every suggest acute infectious intervention, the
lagnat niya” as increase in patient’s hour disease process. patient’s
verbalized by body temperature will temperature will
the mother. temperature Regulation of decrease: *Evaporation is decreased decrease:
greater than toxins in the *note presence of by environmental factors of
OBJECTIVE: the normal body *demonstrate sweating as body high humidity and high *demonstrate
range as temperature attempts to increase ambient temperature as temperature
*febrile manifested by within normal heat loss by well as body factors within normal
*T=38 C in both flushed skin; Release of range from 38 C evaporation. producing loss of ability to range from 38 C
axilla warm to pyrogen to 36.5 C- 37.5 sweat. to 36.5 C- 37.5 C
*warm to touch touch. C
with flushing *demonstrate
*to support circulating
skin Stimulation of *demonstrate *increase oral fluid behaviours to
volume and tissue
*PR-46 bpm the behaviours to intake monitor and
perfusion.
*RR-165 bpm hypothalamu monitor and promote
*patient looks s promote normothermia
pale and weak normothermia *to reduce metabolic
in appearance *promote bed rest, demands/oxygen *skin is cool to
*chills Increase or *skin is cool to encourage consumption. touch and less
alteration of touch and less relaxation skills and flushness
thermoregula flushness diversional
REFFERENCE: tion activities. *identify
NURSING *identify *heat is loss by evaporation underlying
CARE PLAN by Increase in underlying *provide TSB as and conduction. cause/contributi
Gulanick 3rd body cause/contributi needed ng factors and
edition temperature ng factors and *heat is loss by convection, importance of
importance of radiation and conduction. treatment, as
Hyperther treatment, as *promote surface well as
mia well as cooling, loosen signs/symptoms
signs/symptoms clothing and cool *to promote wellness requiring
requiring environment interventions.
interventions.
*Review specific risk *verbalized
REFERENCE:
*verbalized factors/causes, signs understanding
Brunner and understanding and symptoms with of specific
Suddharts of specific the interventions interventions to
Textbook of interventions to required *to decrease the body prevent
MS Nursing prevent temperature hyperthermia.
11th edition hyperthermia. DEPENDENT
by Suzanne *Administer
Smeltzer medications as
indicated to treat
underlying cause,
such as:
-Paracetamol
*to treat underlying
325mg/tab 1 tab
condition
every 4 hours

COLLABORATIVE

*administer
replacement fluids
and electrolytes