Nanda - Hyperthermia - NIC NOC

Definition: the body temperature rises above the normal range

Limitation Characteristics:
  • The increase in body temperature above the normal range
  • Offensive or convulsions (seizures)
  • Skin redness
  • Addition of RR
  • Tachycardia
  • Hand feels warm to the touch

Related Factors:
  • disease / trauma
  • increased metabolism
  • excessive activity
  • the influence of medication / anesthesia
  • inability / reduced ability to sweat
  • exposure to hot environment
  • dehydration
  • improper attire

NOC: Thermoregulation

Expected outcomes:
  • Body temperature within normal range
  • Pulse and RR in the normal range
  • No skin discoloration and no dizziness, feeling comfortable

NIC:

Fever Treatment
  • Monitor the temperature as much as possible
  • Monitor IWL
  • Monitor skin color and temperature
  • Monitor blood pressure, pulse and RR
  • Monitor decreased level of consciousness
  • Monitor WBC, Hb, and Hct
  • Monitor intake and output
  • Give anti-pyretic
  • Provide treatment to address the cause of the fever
  • Cover the patient
  • Perform tapid sponge
  • Give intravenous fluids
  • Compress patients in the groin and axilla
  • Increase air circulation
  • Provide treatment to prevent shivering

Temperature regulation
  • Monitor the temperature at least every 2 hours
  • Plan for continuous temperature monitoring
  • Monitor blood pressure, pulse, and RR
  • Monitor skin color and temperature
  • Monitor signs of hyperthermia and hypothermia
  • Increase fluid intake and nutrition
  • Cover the patient to prevent the loss of body warmth
  • Teach the patient how to prevent fatigue due to heat
  • Discuss the importance of temperature regulation and the possible negative effects of the cold
  • Tell about the indications of fatigue and needed emergency treatment
  • Teach indication of hypothermia and handling required
  • Give anti pyretic if necessary

Vital sign monitoring
  • Monitor blood pressure, pulse, temperature, and RR
  • Note the fluctuations in blood pressure
  • Monitor vital signs while the patient is lying down, sitting or standing
  • Auscultation of blood pressure in both arms and compare
  • Monitor blood pressure, pulse, RR, before, during, and after activity
  • Monitor the quality of the pulse
  • Monitor respiratory rate and rhythm
  • Monitor lung sounds
  • Monitor abnormal breathing patterns
  • Monitor temperature, color, and moisture
  • Monitor peripheral cyanosis
  • Monitor the Cushing's triad (widening pulse pressure, bradycardia, increased systolic)
  • Identify the causes of changes in vital sign

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