Nanda - Hyperthermia - NIC NOC
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
ads
Categories:
Hyperthermia,
NANDA,
Nanda - Hyperthermia - NIC NOC,
NIC NOC
0 komentar:
Post a Comment