Name of Patient: Diagnosis/Impression: NURSING CARE PLAN CUES NURSING DIAGNOSIS Hyperthermia

Age:

Room Number: Attending Physician:

Hospital Number:

OBJECTIVES Short term

INTERVENTIONS Independent Identify underlying cause (e.g excessive heat production such as hyperthyroid state, malignant hyperperexia, dehydration, infection, pelvic laparotomy surgery.) Monitor core temperature.

RATIONALE

EVALUATION

Subjective

After 4 hours of nursing intervention, the patient will be able to: To determine ways how to increase heat loss Identify underlying cause/contribu ting factors and importance of treatment, as well as signs and symptoms requiring further evaluation and intervention. Demonstrate behaviours to

To assess causative and contributing factors.

Objective

To evaluate effects and degree of hyperthermia. Evaporation is decreased by environmental fdactors of high humidity and high ambient temperature as

Note presence and absence of sweating as body attempts to increase heat loss by evaporation,

monitor or promote normothermia or or temperature within normal range. Long term After 8 hours of nursing intervention, the patient will be able to: Maintain core temperature within normal range Be free of complications such as irreversible brain/ neurologic damage and acute renal failure. Be free of seizure activity.

conduction, and diffusion.

well as body factors producing loss of ability to sweat or sweat gland dysfunction (e.g dehydration, vasoconstriction) To assist with measures or reduce body temperature and restore normal body and organ function.

Promote surface cooling by means of undressing (heat loss by radiation and conduction);cool environment and or fans (heat loss by convection); cool tepid sponge bath or immersion (heat loss by evaporation and conduction); local ice packs, especially in groinand axillae (areas og high blood flow); and or use of hypothermia blanket. Wrap extremities with bath towel

To minimize shivering.

when hypothermia blanket is used.

Maintain bed rest

To reduce metabolic demands/oxygen consumption. To prevent dehydration.

Discuss importance of adequate fluid intake.

Dependent: Administer replacement fluids and electrolytes. Administer medications (e.g diazepam and chlorpromazine) as ordered Administer antipyretics (e.g paractemol)

To support circulating volume and tissue perfusion. To control shivering and seizures

To assist with measures or reduce body temperature and restore normal body and organ function