Nursing Care Plan for Diarrhea
Nursing Diagnosis : Hyperthermia
Hyperthermia is a condition where an individual's body temperature is elevated beyond normal due to failed thermoregulation.
Hyperthermia r/t dehydration, metabolic increase, intestinal inflammation
Defining Characteristics:
- Body temperature is more than normal
- Seizures
- Tachycardia
- Respiration increases
- Feeling warm
- Reddened skin
Goal:
After implementation, the client's body temperature is normal, with the criteria:
Thermoregulation:
- Normal skin temperature
- Body temperature 35,9˚C- 37,3˚C
- There is no headache
- There is no muscle pain
- There is no change in skin color
- Pulse, respiration is within normal limits
- Adequate hydration
- The patient is comfortable
- Not shivering
- Not irritable / seizure
Interventions
Heat Management
- Monitor temperature as needed.
- Monitor blood pressure, pulse and respiration.
- Monitor skin temperature and color.
- Monitor and report signs and symptoms of hyperthermia.
- Advise adequate fluid and nutritional intake.
- Teach clients how to prevent high body temperature.
- Give antipyretic drugs.
- Give medication to prevent or control shivering.
Heat Treatment
- Monitor temperature as needed.
- IWL Monitor.
- Monitor skin temperature and color.
- Monitor blood pressure, pulse and respiration.
- Monitor the degree of decreased consciousness.
- Monitor activity capabilities.
- Monitor leukocytes, hematocrit.
- Monitor intake and output.
- Monitor for cardiac arrhythmias.
- Encourage increased fluid intake.
- Give intravenous fluids.
- Increase air circulation with the fan.
- Encourage doing oral hygiene.
- Give oxygenation.
- Cold compresses in the groin, forehead and axilla if the body temperature is 39˚C or more.
- Warm compresses in the groin, forehead and axilla if the body temperature is less than 39˚C.
- Encourage clients not to wear blankets.
- Encourage clients to wear clothes made from cold, thin and absorb sweat.
Environmental Management
- Give the client a separate room as indicated.
- Give a clean and comfortable bed.
- Limit visitors.
Infections Control
- Encourage the client to wash hands before eating.
- Use soap for washing
- Wash hands before and after carrying out maintenance activities.
- Change the place of infusion and clean it according to standard operating procedures.
- Give skin care in areas of edema.
- Encourage the client to get enough rest.
Source :
Johnson, M., et all. 2000. Nursing Outcomes Classification (NOC) Second Edition. New Jersey: Upper Saddle River
Mc Closkey, C.J., et all. 1996. Nursing Interventions Classification (NIC) Second Edition. New Jersey: Upper Saddle River
