Hyperthermia or commonly known as fever is present when the body temperature is higher than 37ᴼC which can be measured orally, but 37.7ᴼC if measured per rectum. It occurs when the body is invaded by some bacteria, viruses, or parasites.
Sometimes the occurrence of fever may also be due to non- infectious factors like injury, heat stroke or dehydration.
Some underlying conditions can also cause hyperthermia, like thyrotoxicosis, heart attack and other forms of cancer. If not treated properly, a client may be at risk for its complications involving febrile convulsions, happening mostly to pediatric clients aging from 6 months to 6 years of age, and brain damage; which could be because of prolonged and repeated febrile convulsions.
Nursing Diagnosis: Hyperthemia
Possible Etiologies: (Related to)
- Exposure to environment with increased temperature; inappropriate clothing
- Dehydration; extreme activity
- Inability or decreased ability to perspire
- Illness or trauma
- Intake of medication; post anesthesia effect
- Increased metabolic rate
- Direct effect of circulating endotoxins on hypothalamus resulting to an altered temperature regulation
Defining Characteristics: (Evidenced by)
“I am not feeling well right now. My head is aching and burning as if the steam comes out of my ears periodically.”
- Flushed skin with body temperature of 38.1ᴼC per axilla
- Respiratory rate of : 21 breaths per minute
- Pulse rate of: 89 beats per minute
- Unstable blood pressure
- Muscle rigidity; chills
- Profuse diaphoresis
Short term goal:
Client will be able to resume and maintain normal body temperature after 4 hours.
Long term goal:
Client will be free from complications such as irreversible brain or neurologic damage.
Client will be able to report and show manifestations that fever is relieved or controlled through verbatim, temperature of 36.8ᴼC per axilla, respiratory rate of 12- 18 breaths per minute, pulse rate of 60- 75 beats per minute, stable blood pressure, absence of muscular rigidity/ chills and profuse diaphoresis after 4 hours of nursing care.
Client will be free from febrile convulsions resulting to brain damage after 1 week of nursing care.
|Assess and monitor client’s temperature and note for presence of chills/ profuse diaphoresis; also note for degree and pattern of occurrence.||– Temperature 38.9ᴼC – 41ᴼC may suggest acute infectious disease process. A sustained fever may be due to pneumonia or typhoid fever while a remittent fever may be due to pulmonary infections; and an intermittent fever may be caused by sepsis or tuberculosis.|
|Adjust and monitor environmental factors like room temperature and bed linens as indicated.||-Room temperature may be accustomed to near normal body temperature and blankets and linens may be adjusted as indicated to regulate temperature of client.|
|Apply tepid sponge bath.||– It could help in reducing hyperthermia; avoid using alcohol and iced water which may even produce chills and increase client’s temperature.|
|Administer antipyretics as prescribed by the physician, utilizing the 10 Rs in giving medication.||– Antipyretics acts on the hypothalamus, reducing hyperthermia.|
|Provide cooling blanket as indicated.||– It is helpful in reducing increased body temperature especially with temperatures of 39.5ᴼC – 40ᴼC.|
|Encourage client to increase fluid intake.||– Water regulates body temperature.|
|Raise the side rails at all times.||– To ensure client’s safety even without the presence of seizure activity.|
|Start intravenous normal saline solutions or as indicated.||-To replenish fluid losses during shivering chills.|
|Provide high caloric diet or as indicated by the physician.||-To meet the metabolic demand of client.|
|Educate client of signs and symptoms of hyperthermia and help him identify factors related to occurrence of fever; discuss importance of increased fluid intake to avoid dehydration.||– Providing health teachings to client could help client cope with disease condition and could help prevent further complications of hyperthermia.|