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, 8^th ed. (p. 691-692)