Ncp On Hyperthermia
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ASSESMENT
NURSING DIAGNOSIS
SCIENTIFIC EXPLANATION
HYPERTHERM IA R/T INFLAMMATO RY RESPONSE AEB INCREASE IN BODY TEMPERATUR E GREATER THAN THE NORMAL RANGE, FLUSHED SKIN; WARM TO TOUCH
ENTRY OF PATHOGENS IN THE SYSTEMIC CIRCULATION
NURSING GOAL
Subjective Data: •
“Tatlong araw ng pabalikbalik ang lagnat ng apo ko, hindi maganda ang pakiramdam nya kaya pinunta ko na siya dito” AVB the grandmother.
Objective Data: •
Febrile, T= 38.1 °C in both axilla; warm to touch with flushing
•
PR=65 bpm
•
RR=28cpm
•
Patient looks pale and weak in appearance
After 2 hours of effective nursing intervention, the patient’s temperature will decrease AEB: •
REGULATION OF TOXINS IN THE BODY • RELEASE OF PYROGEN • STIMULATION OF THE HYPOTHALAMUS
•
INCREASE OR ALTERATION OF THERMOREGULATIO N
INCREASE IN BODY TEMPERATURE
Demonstrate temperature within normal range, from 38.1 °C to 36.5°C -37.5°C Demonstrate behaviors to monitor and promote normothermia.
NURSING INTERVENTION Independent: •
Monitor core temperature q 1 °.
•
Note presence or absence of sweating as body attempts to increase heat loss by evaporation.
•
Skin is cool to touch and less flushness Identify underlying cause/contributing factors and importance of treatment, as well as signs/symptoms requiring further interventions.
•
Verbalized
•
understanding of specific interventions to prevent hyperthermia
RATIONALE OF THE NURSING ACTION •
•
Increase oral fluid intake. •
•
•
Promote bed rest, encourage relaxation skills and diversional activities.
•
Temperature of 38.9-41.1°C suggest acute infectious disease process. Evaporation is decreased by environmental factors of high humidity and high ambient temperature as well as body factors producing loss of ability to sweat. To support circulating volume and tissue perfusion. To reduce metabolic demands/oxygen consumption.
Provide TSB as needed •
Promote surface cooling, loosen clothing and cool environment
•
Review specific
•
Heat is loss by evaporation and conduction.
•
Heat is loss by convection,
EVALUATION
After 2 hours of effective nursing intervention, goal is met. •
Patient’s temperature is already in the normal range; T=37.1 °C
•
Demonstrated behaviors to monitor and promote normothermia.
•
Skin is cool, absence of flushing.
•
The patient, together with his significant others understands causes of the disease and is ready to practice specific interventions to prevent hyperthermia.
risk factors/causes, signs and symptoms with the interventions required
HYPERTHERMIA
•
Discuss importance of adequate fluid intake and protein diet
Collaborative: • Administer medications as indicated to treat underlying cause, such as:
radiation and conduction.
•
To promote wellness
•
To prevent dehydration
•
To treat underlying causes
•
To support circulating volume and tissue perfusion.
-Paracetamol 325mg/tab 1 tab q 6° •
Administer replacement fluids and electrolytes to support circulating volume and tissue perfusion
NURSING DIAGNOSIS
SCIENTIFIC EXPLANATION
HYPERTHERM IA R/T INFLAMMATO RY RESPONSE AEB INCREASE IN BODY TEMPERATUR E GREATER THAN THE NORMAL RANGE, FLUSHED SKIN; WARM TO TOUCH
ENTRY OF PATHOGENS IN THE SYSTEMIC CIRCULATION
NURSING GOAL
Subjective Data: •
“Tatlong araw ng pabalikbalik ang lagnat ng apo ko, hindi maganda ang pakiramdam nya kaya pinunta ko na siya dito” AVB the grandmother.
Objective Data: •
Febrile, T= 38.1 °C in both axilla; warm to touch with flushing
•
PR=65 bpm
•
RR=28cpm
•
Patient looks pale and weak in appearance
After 2 hours of effective nursing intervention, the patient’s temperature will decrease AEB: •
REGULATION OF TOXINS IN THE BODY • RELEASE OF PYROGEN • STIMULATION OF THE HYPOTHALAMUS
•
INCREASE OR ALTERATION OF THERMOREGULATIO N
INCREASE IN BODY TEMPERATURE
Demonstrate temperature within normal range, from 38.1 °C to 36.5°C -37.5°C Demonstrate behaviors to monitor and promote normothermia.
NURSING INTERVENTION Independent: •
Monitor core temperature q 1 °.
•
Note presence or absence of sweating as body attempts to increase heat loss by evaporation.
•
Skin is cool to touch and less flushness Identify underlying cause/contributing factors and importance of treatment, as well as signs/symptoms requiring further interventions.
•
Verbalized
•
understanding of specific interventions to prevent hyperthermia
RATIONALE OF THE NURSING ACTION •
•
Increase oral fluid intake. •
•
•
Promote bed rest, encourage relaxation skills and diversional activities.
•
Temperature of 38.9-41.1°C suggest acute infectious disease process. Evaporation is decreased by environmental factors of high humidity and high ambient temperature as well as body factors producing loss of ability to sweat. To support circulating volume and tissue perfusion. To reduce metabolic demands/oxygen consumption.
Provide TSB as needed •
Promote surface cooling, loosen clothing and cool environment
•
Review specific
•
Heat is loss by evaporation and conduction.
•
Heat is loss by convection,
EVALUATION
After 2 hours of effective nursing intervention, goal is met. •
Patient’s temperature is already in the normal range; T=37.1 °C
•
Demonstrated behaviors to monitor and promote normothermia.
•
Skin is cool, absence of flushing.
•
The patient, together with his significant others understands causes of the disease and is ready to practice specific interventions to prevent hyperthermia.
risk factors/causes, signs and symptoms with the interventions required
HYPERTHERMIA
•
Discuss importance of adequate fluid intake and protein diet
Collaborative: • Administer medications as indicated to treat underlying cause, such as:
radiation and conduction.
•
To promote wellness
•
To prevent dehydration
•
To treat underlying causes
•
To support circulating volume and tissue perfusion.
-Paracetamol 325mg/tab 1 tab q 6° •
Administer replacement fluids and electrolytes to support circulating volume and tissue perfusion
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