Hyperthermia Nursing Diagnosis & Care Plans

Hyperthermia is a body temperature above 104°F (40°C). Hyperthermia occurs when the body’s thermoregulatory system fails, after being exposed to too much heat or when the body generates more heat than it can release. Heat-related illnesses such as heat exhaustion and heat stroke from long periods in high temperatures are preventable. Other causes such as sepsis, the body’s inability to perspire and cool itself down such as with spinal cord injuries, or hyperthyroidism are more complex underlying causes.

Hyperthermia requires quick diagnosis and intervention to prevent irreversible harm to organs and even death. Nurses play a crucial role in both assessing and monitoring the patient’s condition, providing simple as well as critical cooling methods, and educating patients about their increased risk of experiencing hyperthermia.

Causes (Related to)

The following are common causes of hyperthermia:

• Hot environment 
• Dehydration 
• Strenuous physical activity 
• Inability to sweat 
• Anesthesia 
• Increased metabolic rate 
• Sepsis

Signs and Symptoms (As evidenced by)

The following are common signs and symptoms of hyperthermia:

• Body temperature above normal range 
• Flushed skin warm to touch
• Blurred vision
• Headache
• Nausea and vomiting
• Muscle cramps and aches
• Tachycardia
• Tachypnea 
• Seizures 
• Confusion

Expected Outcomes

The following are common nursing care planning goals and expected outcomes for hyperthermia:

• Patient will maintain core body temperature within normal limits.
• Patient will verbalize underlying factors that contribute to hyperthermia.
• Patient will remain free of life-threatening complications such as brain damage or organ failure from hyperthermia.

Nursing Assessment

The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In the following section, we will cover subjective and objective data related to hyperthermia.

1. Assess for signs of hyperthermia.
Flushed face with skin that is hot to touch, weakness, fatigue, headache, and abnormal vital signs are possible indicators of hyperthermia.

2. Assess for underlying conditions.
Thyroid conditions, autonomic dysfunction from spinal cord injuries, infections, and brain lesions are a few disorders that can cause hyperthermia.

3. Monitor vital signs.
Hyperthermia results in a core temperature of 104°F or higher. This will cause a rapid heart rate and breathing. Rectal or tympanic thermometers are most accurate for core temperature assessment.

4. Monitor neurological status.
Note the level of consciousness, orientation, pupil reaction, and any posturing. Confusion and delirium may occur as the condition worsens.

5. Monitor for dehydration.
Signs of dehydration are expected. Monitor for diaphoresis or a lack of sweating which indicates a loss of fluids (or a disorder that prevents the patient from sweating such as a spinal cord injury). Assess for poor skin turgor, dry mucous membranes, decreased or dark urine, and tachycardia.

6. Review lab work.
Monitor lab work closely for dehydration and subsequent electrolyte imbalances. Organ failure is a severe complication; monitor kidney function, cardiac and liver enzymes, and the presence of proteins in the urine which signal muscle breakdown.

7. Assess for malignant hyperthermia.
Malignant hyperthermia is a medical emergency that occurs from a severe reaction to anesthesia drugs. It can occur during surgery or hours after and must be treated promptly with rapid cooling. Signs include a dangerously high body temperature, muscle rigidity, rapid, shallow breathing, rapid heart rate, and abnormal heart rhythms.

Nursing Interventions

Nursing interventions and care are essential for the patients recovery. In the following section, you will learn more about possible nursing interventions for a patient with hyperthermia.

1. Implement surface cooling measures.
Cooling blankets can be applied to decrease body temperature. Place ice packs to the groin, neck, and axillae. A sheet can be soaked in cool water, wrung out, and wrapped around the patient or a tepid sponge bath can be given. Water placed on the body in conjunction with a fan will increase evaporation, rapidly decreasing body temperature.

2. Administer antipyretics.
Administer acetaminophen orally if the patient is awake, or IV if not able to tolerate PO medications. *Antipyretics will not be useful in certain situations such as heat-related illnesses (heat stroke, heat exhaustion).

3. Cool the environment.
Remove blankets and heavy clothing. Provide fans for ventilation.

4. Implement seizure precautions.
Very high body temperatures can increase the risk of seizures. Keep the patient safe by padding bed rails, keeping the bed in a low position, and keeping movement unrestricted. Turn them onto their left side to keep the airway free from saliva or vomitus.

5. Rehydrate.
Administer IV fluids to treat dehydration. Cooled IV fluids can further help in decreasing the body temperature.

6. Teach about preventing heat exhaustion & heat stroke.
Heat-related illnesses are often preventable. Heat exhaustion symptoms include heavy sweating, nausea, muscle cramps, dizziness, and headache. It can be treated simply by moving to a cool place, cooling the body, and drinking water. Heat stroke is when heat exhaustion progresses. The body temperature is high, the patient’s skin is likely hot and dry, and they may become confused or lose consciousness. This is an emergency.

7. Promptly treat malignant hyperthermia.
Dantrolene is the drug of choice in reversing the effects of MH. Rapid cooling measures should also be implemented such as surface cooling methods and infusing cooled IV fluids. Peritoneal lavage is also effective due to the large surface area and high perfusion, though it is invasive and requires special equipment.

8. Treat shivering.
Shivering can result from rapid cooling but will hinder the goal of decreasing the body temperature. Chlorpromazine and diazepam can be administered to control shivering. These medications can also treat seizures.

9. Assess the skin from cooling measures.
If ice packs or cool rags/sheets are used to cool the body, monitor frequently for damage to the skin from prolonged exposure to ice and moisture.

10. Lifestyle modifications.
Many instances of hyperthermia are preventable. Parents should never leave children in a hot car for any length of time. Certain individuals should be instructed not to use hot tubs or saunas such as those with multiple sclerosis or heart conditions. Those without air conditioning in their homes can be directed to community resources for assistance. Athletes should not practice outside in extreme temperatures and should take regular breaks to cool down and rehydrate.

Care Plan #1

Diagnostics statement:

Hyperthermia related to heat stroke as evidenced by hot, dry skin and loss of consciousness.

Expected putcomes:

• Patient will maintain a core temperature between 97.0 F (36.1 C) and 99.0 F (37.2 C).
• Patient will maintain heart rate and blood pressure within acceptable limits.
• Patient will be free of seizures.

Assessment:

1. Assess neurological status, noting the level of consciousness and orientation, reaction to stimuli, pupils’ reaction, and posturing or seizures.
Hyperthermia accompanied by alterations in the sensorium is life-threatening.

2. Monitor heart rate and rhythm, blood pressure, and temperature.
Dysrhythmias and ECG changes may occur due to electrolyte imbalances, dehydration, and catecholamine actions brought by the direct effects of hyperthermia on the blood and heart. Continuous temperature measurement is warranted for a life-threatening condition like heat stroke.

3. Monitor and record all sources of fluid loss.
Increased metabolic rate, diuresis, and diaphoresis cause excessive fluid loss.

Interventions:

1. Administer replacement fluids and electrolytes.
Rehydration is needed to replace circulating volume and support tissue perfusion. If the oral route is not tolerated, initiate the administration of IV fluids.

2. Move into shade/cool environment.
If the patient experienced heat stroke outdoors, transfer the patient immediately to a shaded, or preferably, an air-conditioned room. Moving to a cooler place facilitates convection heat transfer.

3. Use external cooling measures.
Use external cooling measures such as:

• Loosen or remove excessive clothing
• Immerse in the cold water
• Apply cold packs
• Use a fan

Hyperthermia must be treated aggressively to lower the body temperature, but not to an extent to induce shivering. Shivering increases heat production, oxygen consumption, and cardiorespiratory effort.

4. Instruct the family on the dangers of heat exhaustion and heat stroke and ways to manage hot environments.

• Early morning or late afternoon are the recommended times to work outside to avoid the hottest part of the day
• Wear hats or cooling scarves
• Take frequent breaks
• Rehydrate

Heat stroke can be fatal. These measures will help to prevent heat stroke while in hot environments.

5. Discuss the symptoms of heat stroke/exhaustion (e.g., sweating, dry skin, headache, and changes in mentation.
Informing the family about these signs will help them to recognize heat stroke/exhaustion and to conduct prompt management.

Care Plan #2

Diagnostic Statement:

Hyperthermia related to infectious processes secondary to influenza as evidenced by flushed skin and body temperature of 103.0 F (39.4 C).

Expected outcomes:

• Patient will maintain a normal body temperature within 97.0 F (36.1 C) and 99.0 F (37.2 C).
• Patient will manifest unremarkable pulmonary findings:
  • Normal respiratory rate
  • Clear breath sounds
  • Absence of dyspnea
  • Absence of retractions
  • Absence of cough and colds

Assessment:

1. Determine the precipitating factors.
Influenza is transmitted through airborne droplets or direct contact with an infected person. People with immunocompromised health are at increased risk of acquiring influenza. Knowing the exposure history and the patient’s immune function helps source control and manage the underlying cause.

2. Monitor intake and output.
Maintaining fluid balance is vital to maintain optimal metabolic function during fever.

3. Monitor respiratory findings.
Influenza affects the upper and lower respiratory tracts. Symptoms may include cough, sore throat, muscle pain, headache, runny nose, and coryza.

Interventions:

1. Administer antipyretics (e.g., ibuprofen, acetaminophen) as ordered.
Antipyretic medications block the synthesis of prostaglandins in the hypothalamus which cause a temperature rise.

2. Administer replacement fluids and electrolytes.
Rehydrate via the oral route if tolerated. Aside from preventing dehydration, adequate hydration mobilises mucus discharges for decongestion and improves the circulation of immune cells in the blood to fight against the virus.

3. Promote surface cooling.
Promote surface cooling such as:

• Undressing
• Cool environment and fans
• Cool, tepid sponge baths or immersion
• Local ice packs, especially in the groin and axillae

These measures promote cooling and lower core temperature.

4. Encourage the patient and family to have an annual flu vaccination.
Flu vaccination is highly recommended to prevent, especially at the start of the winter season.

References

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