Definition of the Case + Hyperthermia NCP PDF

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Assessment Subjective Data: “Kanina pa po ako nanginginig at nilalamig,” as verbalized by the client Objective Data: Flushed skin Warm to touch VS taken as follows: Temperature: 83.3C PR: 18 cpm HR: 110bpm BP: 113/80 mm Hg Pain: No pain

Diagnosis Hyperthermia related to increased metabolic rate as evidenced by flushed skin, warm to touch, tachycardia and body temperature higher than the normal range.

Planning Short Term Goal: After 4 hours of nursing intervention the client will demonstrate temperature within normal range and be free of chills. Long Term Goal: After 2-3 days of nursing intervention the client will be free from hyperthermia and experience no associated complications.

Intervention 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.

Collaboration: - Provide cooling blanket, or hypothermia therapy as indicated.

- Administer antipyretics, such as acetylsalicylic acid (ASA) (aspirin) or acetaminophen (Tylenol) as ordered.

Rationale - Fever pattern may help in the diagnosis. Chills often precede temperature spikes. - Room temperature and linens should be altered to maintain near-normal body temperature. - Tepid sponge baths may help reduce fever. The use of alcohol may cause chills, elevating temperature, and skin dehydration. - Used to reduce fever, especially when higher than 104°F to 105°F (39.9°C– 40°C), and when seizures or brain damage are likely to occur. - 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 the growth of organisms and enhancing auto destruction of infected cells.

Evaluation Goals are met: After 4 hours of nursing intervention the client demonstrated a temperature of 37C and is free of chills.

After 3 days of nursing intervention the client experienced no associated complications and is free of hyperthermia as manifested by: No signs of discomfort, temperature (36.8C) and other vital signs are within normal range.

Sepsis Sepsis is a syndromic response to infection and is frequently a final common pathway to death from many infectious diseases worldwide. Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection and if not recognized early and managed promptly, it can lead to septic shock, multiple organ failure and death. (WHO, 2017)....