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Date Identified 01/02/2012 Nursing Diagnosis Hyperthermia Rationale Hyperthermia is an elevated body temperature due to failed thermoregulation. Hyperthermia occurs when the body produces or absorbs more heat than it can dissipate. When the elevated body temperatures are sufficiently high, hyperthermia is a medical emergency and requires immediate treatment to prevent disability or death. The inability to clear secretions or impediment of the respiratory tract to maintain the cleanliness of the airway. This might lead to further complications and in worst cases, can cause death. Once resolved, then the Gas Exchange follows thru. The state in which the individual experiences an actual or potential decreased passage of gases (oxygen and carbon dioxide) between the alveoli of the lungs and the vascular system The state in which an individual experiences or is at risk of experiencing a decrease in nutrition and respiration at the peripheral cellular level because of a decrease in capillary Date Resolved
01/02/2012
01/02/2012
01/02/2012
blood supply. 01/03/2011 Impaired Skin Integrity A state in which the individual experiences or is at risk for damage to the epidermal and dermal tissue.
A state in which an individual experiences pr is at risk of experiencing reduced body weight related to inadequate intake or metabolism of nutrients for metabolic needs
A person who has severe meningitis may need to be treated in the intensive care unit (ICU) of a hospital. Doctors watch the person closely and provide care if needed. See the Other Treatment section of this topic for more information on intensive care in a hospital.
Nursing Management
(1) Administer intravenous fluids and medications, as ordered by the physician. (a) Antibiotics should be started immediately. (b) Corticostertoids may be used for the critically ill patient. (c) Drug therapy may be continued after the acute phase of the illness is over to prevent recurrence. (d) Record intake and output carefully and observe patient closely for signs of dehydration due to insensible fluid loss. (2) Monitor patient's vital signs and neurological status and record. (a) Level of consciousness. Utilize GCS for accuracy and consistency. (b) Monitor rectal temperature at least every 4 hours and, if elevated, provide for cooling measures such as a cooling mattress, cooling sponge baths, and administration of ordered antipyretics. (3) If isolation measures are required, inform family members and ensure staff compliance of isolation procedures in accordance with (IAW) standard operating procedures (SOP). (4) Provide basic patient care needs. (a) The patient's level of consciousness will dictate whether the patient requires only assistance with activities of daily living or total care. If patient is not fully conscious, follow the guidelines for care of the unconscious patient (Part 5). (b) Maintain dim lighting in the patient's room to reduce photophobic discomfort.