Nurse's Pocket Guide

HYPERTHERMIA
Decreased perspiration
Medications; anesthesia
Increased metabolic rate; illness; trauma
Defining Characteristics
SUBJECTIVE
[Headache]
OBJECTIVE
Increase in body temperature above normal range
Flushed skin; warm to touch
Tachypnea; tachycardia; [unstable BP]
Seizures; convulsions; [muscle rigidity/fasciculations]
[Confusion]
Desired Outcomes/Evaluation
Criteria—Client Will:
• Maintain core temperature within normal range.
• Be free of complications such as irreversible brain/neurological
damage, acute renal failure.
• Identify underlying cause/contributing factors and importance
of treatment, as well as signs/symptoms requiring further evaluation
or intervention.
• Demonstrate behaviors to monitor and promote normothermia.
• Be free of seizure activity.
Actions/Interventions
NURSING PRIORITY NO.1.To assess causative/contributing factors:
• Identify underlying cause (e.g., excessive heat production,
such as hyperthyroid state; malignant hyperpyrexia; impaired
heat dissipation, such as heatstroke; dehydration; autonomic
dysfunction as occurs with spinal cord transection; hypothalamic
dysfunction, such as CNS infection; brain lesions; drug
overdose; infection).
• Note chronological and developmental age of client. Children
are more susceptible to heatstroke; elderly or impaired individuals
may not be able to recognize and/or act on symptoms
of hyperthermia.
NURSING PRIORITY NO.2.To evaluate effects/degree of hyperthermia:
• Monitor core temperature. Note: Rectal and tympanic temperatures
most closely approximate core temperature; however,
Information in brackets added by the authors to clarify and enhance
the use of nursing diagnoses.
384 Cultural Collaborative Community/Home Care