Nursing care plan for hyperthermia (fever)

<Definition>
“Human beings are homeothermic animals and can maintain internal temperatures regardless of the temperature of the external environment. Body tissues and cells can function best in a relatively narrow body temperature range. Body surface and skin body temperature are It changes greatly depending on the external environment and physical exercise. Despite these changes, the temperature inside the body is kept relatively constant unless it is employed by a febrile disease. Must maintain a normal range of body temperature. ” Hyperthermia is a condition in which the balance between heat dissipation and production is lost and body temperature becomes abnormally high. It also refers to a state in which the risk is high.

<Nursing care plan>

Target
Antipyretic and normal body temperature
It is possible to minimize the exhaustion of physical strength due to fever.

Observation plan
1. Vital signs, awareness level
2. Fluctuations in body temperature and peripheral circulation
3. The degree of warmth and moistness of the skin
4. Presence or absence of accompanying symptoms associated with fever
-Presence of pallor of the skin and cold limbs during chills
-At fever: Red tide, sweating, decreased blood pressure, increased heart rate and pulse rate, increased respiratory rate, loss of appetite, malaise, pain such as headache and open nodal pain, mouthache, decreased urine volume (concentrated urine) , Motivation and shortness of breath
5. Presence or absence of septic symptoms
6. Degree of vitality and mood, appetite and amount of food, (children) feeding ability
7. Test data (WBC, CRP, Hb, amylase, electrolyte, liver function, various bacterial tests, chest X-ray, urine ketone, urine specific gravity)
8. Moisture balance
9. (Children) Presence or absence of depression of Oizumimon.
10. Changes in hemodynamics after administration of antipyretics, presence or absence of effects
11. Presence or absence of respiratory symptoms (cough, sputum, sore throat, chest pain)
12. Presence or absence of cranial nerve symptoms (headache, impaired consciousness, meningeal irritation)
13. Presence or absence of tumor fever
14. Infection: The condition of the insertion part of each tube (redness, exudate, bleeding, pain, odor), drainage volume and properties
15. Treatment details and presence or absence of side effects
16. Environment (room temperature, humidity, ventilation, cleaning, source of infection, unpleasant stimuli such as direct sunlight)

Care plan
1. Maintain rest and adjust your posture to a comfortable position
2. Adjust the room temperature and clothes / hangings
3. Wear an electric blanket or futon according to your senses during chills.
4. Immediately cool when fever occurs
5. Follow the doctor’s instructions and give antipyretic medicine
6. When the skin is moist or sweaty, clean it and change the sleeping clothes to keep the skin clean and dry.
7. Wipe with gauze or moisturizing gauze, and apply moisturizing gel to moisturize the oral cavity (be careful of aspiration depending on the level of consciousness).
8. Encourage fluid intake. If you are infusing, manage the infusion
9. Perform a whole body cold treatment

Education plan
1. Explain the appropriate thermoregulation for patients and their families
2. Explain the need for hydration as it is easy to dehydrate when fever persists
3. Explain the need to maintain cleanliness when sweating a lot


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