NURSING CARE PLAN FOR HYPERTHERMIA CUES Subjective: The client verbalized, Mainit ang pakiramdam ko.

Objective: Warm to touch Flushed skin NURSING DIAGNOSIS Hyperthermia r/t Trauma SCIENTIFIC EXPLANATION In a fever, the set point of the hypothalamic thermostat changes suddenly from the normal level to a higher value as a result of the effects of tissue destruction, pyrogenic substances, or dehydration on the hypothalamus. (Source: Fundamentals of Nursing 7th Edition, by Kozier, page 488) OBJECTIVES LONG TERM: After the nursing intervention the client will be able to maintain core temperature within normal range. SHORT TERM: After the nursing intervention the client will be able to apply the interventions intended to improve condition. INTERVENTIONS INDEPENDENT: 1. Monitor the clients temperature. Note shaking chills/profuse diaphoresis. RATIONALE EVALUATION The client was able to maintain core temperature within normal range after the nursing interventions.

Measurement: T 38 C

1. The temperature of 102F-106F (38.9C-41.1C) suggests acute infectious disease process. Fever pattern may aid in diagnosis; eg. sustained or continuous fever curves lasting more than 24 hours suggest pneumoccocal pneumonia, scarlet of typhoid fever; remittent fever (varying only a few degress in either direction) reflects pulmonary infections; 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. 2. Room

2. Monitor environmental

temperature, limit/add bed lines as indicated.

temperature/number of blankets should be altered to maintain nearnormal body temperature. 3. May help reduce fever.

3. Provide tepid sponge baths, avoid use of alcohol. DEPENDENT: 4. Administer antipyretics.

4. Used to reduce fever by its central axon on the hypothalamus; fever should be controlled in clients who are nuerotropenic or asplenic. However, fever may be beneficial in limiting growth of organisms or enhancing autodestruction of infected cells.