00007 Hyperthermia

Domain 11: security/protection
Class 6: thermoregulation
Diagnostic Code: 00007
Nanda label: hyperthermia
Diagnostic focus: hyperthermia
Approved 1986 • Revised 2013, 2017 • Evidence level 2.2

NANDA Nursing Diagnosis Definition

The Nanda nursing diagnosis « hyperthermia » is defined as: central body temperature higher than the normal daytime range because of the thermoregulation failure.

Definite characteristics

  • Abnormal posture
  • Apnea
  • Coma
  • Ruborized skin
  • Hypotension
  • The infant does not maintain the suction
  • Irritable mood
  • lethargy
  • Seizures
  • Hot skin to touch
  • stupor
  • Tachycardia
  • Tachypnea
  • Vasodilation

Related factors

  • Dehydration
  • Inappropriate clothing
  • Vigorous activity

Risk population

  • People exposed to high ambient temperature

Associated problems

  • Decrease in the sweat response
  • Deterioration of health status
  • Increase in the metabolic rate
  • Ischemia
  • Pharmacological preparations
  • sepsis
  • Trauma

Suggestions of use

Nursing activities, such as taking clothes or bathing with cold sponge, are effective for mild hyperthermia. However, severe hyperthermia is a problem that puts life at risk and requires medical and nursing intervention. It should also be considered that perhaps the high temperature is not a problem but simply the symptom of a disease or infection, in which case it should be treated with medications such as acetaminophen or acetylsalicylic acid. Most hyperthermia cases require a collaboration treatment.

Suggested alternative diagnostics

  • hyperthermia, risk of (no nanda)
  • Body temperature, risk of alteration of
  • ineffective thermoregulation

NOC Results

  • Vital signs: degree in which temperature, pulse, breathing and blood pressure are within normal values ??
  • Thermoregulation: balance between production, gain and heat loss
  • Thermoregulation: Neonate: Balance between production, gain and loss of heat during the first 28 days of life

Evaluation objectives and criteria

  • The patient demonstrates thermoregulation, as manifested by the following indicators (specify from 1 to 5: severe, substantial, moderate, light or none)
    • Increase in cutaneous temperature
    • Hyperthermia
    • Dehydration
    • Somnolence
  • The patient demonstrates thermoregulation, as manifested by the following indicators (specify from 1 to 5: seriously, substantially, moderately, slightly or not compromised):
    • Sweat when it is hot
    • Radial pulse frequency
    • Respiratory rate

Other examples

The patient and family will be able to:

  • Demonstrate the correct method to measure the temperature
  • Describe measures to prevent or reduce the increase in body temperature
  • Communicate the first signs and symptoms of hyperthermia

Babies will be able to:

  • Do not experience dyspnea, restlessness or lethargy
  • Take a posture to dissipate heat

NIC Interventions

  • Newborn control: measure and interpretation of the physiological state of the neonate during the first 24 hours after birth
  • Newborn care: neonate management during transition to extrauterine life and the subsequent stabilization period
  • Monitoring of vital signs: Collection and analysis of cardiovascular, respiratory and body temperature data to determine and prevent complications
  • Prevention of malignant hyperthermia: prevention or reduction of hypermetabolic response to the pharmacological agents used during surgery
  • Temperature regulation: scope or maintenance of body temperature in a normal range
  • Fever treatment: management of a patient with hyperpyexia caused by non -environmental factors

Nursing Activities

  • See also nursing activities for body temperature: Risk of alteration of the.

Valuations

  • Monitor convulsive activity
  • Control hydration (for example, cutaneous turgidity, moisture of mucous membranes)
  • Monitor blood pressure, pulse and breathing
  • Evaluate the use of adequate clothing for the ambient temperature
  • For surgical patients:
    • Obtain the personal and family history of malignant hyperthermia, anesthesia deaths or postoperative fever
    • Monitor the signs of malignant hyperthermia (for example, fever, tachypnea, arrhythmias, changes in ta, mottled skin, stiffness, abundant diaphoresis)
  • (NIC) Temperature regulation:
    • Monitor the temperature at least every two hours, as required
    • Establish a continuous surveillance device of the central temperature, if applicable
    • Monitor the color and temperature of the skin

Patient and family education

  • Teach the patient and family the prevention measures and the soon recognition of hyperthermia (for example, heat stroke and heat exhaustion)
  • (NIC) Temperature regulation: instruct about the heat exhaustion signals and the corresponding emergency treatment, if it proceeds

Collaboration activities

  • (NIC) Temperature regulation:
    • Administer antipyretic medications, as required
    • Use refreshing blankets and temperate bathrooms to adjust body temperature, according to proceed

Others

  • Remove excess clothes and cover the patient only with a sheet
  • Apply cold cloths (or an ice bag covered with a cloth) in armpits, groin, front and neck)
  • Promote the intake of oral fluids, at least 2,000 mi a day and additional liquids during the realization of exhausting activities or moderate activities in hot climate
  • Use a fan in the patient’s room
  • Use a blanket to cool
  • For malignant hyperthermia:
    • Perform emergency care following the protocol
    • Maintain the emergency equipment in the operational areas, according to the protocol

At home

  • Several of the previous interventions can be used at home
  • Teach the patient and the family to use an oral or tympanic thermometer (which does not contain mercury)
  • Evaluate the temperature at home; Help obtain fans or air conditioners, if necessary

Babies and Children

  • Teach parents that they should not administer acetylsalicylic acid for fever to their children under 18 years of age
  • Teach parents that it is not necessary to treat all fevers in children. As a general rule, fevers in children without a history of seizures do not need treatment, unless they exceed 40 ° C (104 ° F).
  • A temperate sponge can be used to treat fever, but increases the child’s discomfort and produces crying and agitation that can counteract the cooling effect of sponge

Older people

  • Teach patients and family that elderly have a higher risk of hyperthermia and dehydration
  • Teach patients and family caregivers the early signs of hyperthermia or a heat stroke
  • Advise that they avoid alcohol and caffeine when it is very hot
  • In the elderly, an oral temperature greater than 37.2 ° C or an increase of between 0.8 ° and 1.1 ° C is considered a fever
  • Do not take the temperature rectally in patients suffering from dementia, since it can be disturbing
  • Instruct the elderly to call the doctor if they present fever