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Friday, January 27, 2012

Hyperthermia NCP


SYSTEMIC INFECTION 

Nursing Diagnosis: 
  • Hyperthermia related to increased metabolic rate, illness.
  • Hyperthermia related to dehydration.
  • Hyperthermia related to direct effect of circulating endotoxins on the hypothalamus, altering temperature regulation. 

Cause Analysis:

ASSESSMENT
OBJECTIVE
INTERVENTION
RATIONALE
Subjective:
 "I feel warm" as verbalized by the patient

Objective:
  •   Increase in body temperature higher than normal range
  •   Flushed skin, warm to touch
  •  Increased respiratory rate
  •  Tachycardia
  •  Increased Neutrophil level
  •  Increased platelet level
Short Term Objective:
     After 4 hours of giving nursing interventions, the client will be able to demonstrate temperature within normal range and be free of chills.

Long Term Objective:
     After 3 days of giving nursing interventions, the client will experience no associated complications.
Independent
  • Monitor client temperature—degree and pattern. Note shaking, chills or profuse diaphoresis.












  •    Monitor environmental temperature. Limit or add bed linens, as indicated.

  • Provide tepid sponge baths. Avoid use of alcohol.





Collaborative
  • Administer antipyretics, such   as acetylsalicylic acid (ASA) (aspirin) or acetaminophen (Tylenol).

  • Provide cooling blanket, or hypothermia therapy, as indicated.



  • Temperature of 102_F to106_F (38.9_C–41.1_C) suggests acute infectious disease process. Fever pattern may aid in diagnosis: sustained or continuous fever curves lasting more than 24 hours suggest pneumococcal pneumonia, scarlet or typhoid fever; remittent fever varying only a few degrees in either direction reflects pulmonary infections; and intermittent curves or fever that returns to normal once in 24-hour period suggests septic episode, septic endocarditis, or tuberculosis (TB). Chills often precede temperature spikes. Note: Use of antipyretics alters fever patterns and may be restricted until diagnosis is made or if fever remains higher than 102_F (38.9_C).

  •    Room temperature and linens should be altered to maintain near-normal body temperature.

  • Tepid sponge baths may help reduce fever. Note: Use of ice water or alcohol may cause chills, actually elevating temperature. Alcohol can also cause skin dehydration.




  • Antipyretics reduce fever by its central action on the hypothalamus; fever should be controlled in clients who are neutropenic or asplenic. However, fever may be beneficial in limiting growth of organisms and enhancing autodestruction of infected cells.
  • Used to reduce fever, especially when higher than 104_F to 105_F (39.5_C–40_C), and when seizures or brain damage are likely to occur.


Reference: Doenges, M. E., Moorehouse, M. F., Murr, A. C. (2009). Nursing Care Plans: Guidelines for Individualizing Client Care Across the Life Span, 8th ed. (p. 691-692)

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