Page 19 - PNEUMONIA NURSING CARE PLAN

CikguOnline
CikguOnline

HYPERTHERMIA

Hyperthermia in pneumonia is caused by the inflammatory process and is related to dehydration and
infection.

Related Factors

• Dehydration
• Infection
• Increased metabolic rate
• Defining Characteristics
• Body temperature above the normal range
• Hot, flushed skin
• Increased heart rate
• Increased respiratory rate

Desired Outcomes
• Patient maintains body temperature within normal range.
• Patient maintains BP and HR within normal limits.

Nursing Interventions and Rationales

Nursing Interventions Rationales

Assessment

HR and BP increase as hyperthermia progresses.
Monitor the patient’s HR, BP, and especially
the tympanic or rectal temperature. Tympanic or rectal temperature gives a more
accurate indication of core temperature.

Extremes of age or weight increase the risk for
Determine the patient’s age and weight.
the inability to control body temperature.

Monitor fluid intake and urine output. If the Fluid resuscitation may be required to correct
patient is unconscious, central venous pressure dehydration. The patient who is significantly
or pulmonary artery pressure should be dehydrated is no longer able to sweat, which is
measured to monitor fluid status. necessary for evaporative cooling.

Review serum electrolytes, especially serum Sodium losses occur with profuse sweating and
sodium. accidental hyperthermia.

Therapeutic Interventions

Room temperature may be accustomed to near
Adjust and monitor environmental factors like normal body temperature and blankets and
room temperature and bed linens as indicated. linens may be adjusted as indicated to regulate
temperature of the patient.

Exposing skin to room air decreases warmth and
Eliminate excess clothing and covers.
increases evaporative cooling.

19