Hyperthermia related ro the disease process.
Defining characteristics:
- The increase in body temperature above the normal range.
- Attacks or convulsions (seizures).
- Skin redness.
- Increased RR.
- Tachycardia.
- Feels warm to the touch.
Goals and Outcomes (NOC)
Goal : The patient experienced a balance of thermoregulation.
Outcomes :
- Body temperature within the normal range of 35.9 C - 37.5 C
- Pulse and RR in the normal range.
- There is no change in skin color.
- There is no dizziness.
Interventions (NIC)
Controlling body heat
- Monitor temperature at least every 2 hours.
- Continuously monitor basal temperature according to need.
- Monitor BP, pulse, and RR.
- Monitor skin color and temperature.
- Monitor decreased level of consciousness.
- Monitor WBC, Hb, Hct.
- Monitor intake and output.
- Give anti-pyretic.
- Give treatment to address the cause of the fever.
- Give the patient a blanket.
- Do Tapid sponge.
- Give intravenous fluids.
- Compress patients in the groin, axilla and neck.
- Increase air circulation.
- Give treatment to prevent shivering.
- Monitor for signs of hyperthermia.
- Increase fluid intake and nutrition.
- Teach the patient how to prevent fatigue due to heat.
- Discuss the importance of setting neighbor temperatures and possible negative effects of the cold.
- Give antipyretics as needed.
- Use mattress cold and warm water bath to overcome the interference temperature according to need.
- Remove excess clothing.
Vital Sign Monitoring
- Monitor BP, pulse, temperature, and RR.
- Note the fluctuations in blood pressure.
- Monitor vital signs while the patient is standing, sitting and lying down.
- Auscultation of blood pressure in both arms and compare.
- Monitor BP, pulse, and respiratory rate before, during, and after activity.
- Monitor the quality of the pulse.
- Monitor respiratory rate and rhythm.
- Monitor lung sounds.
- Monitor abnormal breathing pattern.
- Monitor temperature, color and moisture.
- Monitor peripheral cyanosis.
- Monitor widened pulse pressure, bradycardia, increase in systolic (the Triad Chusing).
- Identify the cause of vital sign changes.