The words you are searching are inside this book. To get more targeted content, please make full-text search by clicking here.
Discover the best professional documents and content resources in AnyFlip Document Base.
Search
Published by cikgu online, 2021-07-15 02:51:30

PNEUMONIA NURSING CARE PLAN

CikguOnline
CikguOnline






PNEUMONIA





NURSING




CARE PLANS





















































JULIE JAMES




ABDULLAH

CikguOnline
CikguOnline



CONTENTS

INEFFECTIVE AIRWAY CLEARANCE .................................................................................................................. 3

IMPAIRED GAS EXCHANGE .................................................................................................................................7
INEFFECTIVE BREATHING PATTERN ..............................................................................................................10
ACUTE PAIN ......................................................................................................................................................... 13

ACTIVITY INTOLERANCE ................................................................................................................................... 15
DEFICIENT KNOWLEDGE ................................................................................................................................... 17
HYPERTHERMIA .................................................................................................................................................. 19









































2

CikguOnline
CikguOnline
INEFFECTIVE AIRWAY CLEARANCE




This diagnosis is related to excessive secretions and ineffective cough or non-productive coughing.
Inflammation and increased secretions in pneumonia make it difficult to maintain a patent airway.

Related Factors
• Tracheal bronchial inflammation, oedema formation, increased sputum production
• Pleuritic pain
• Decreased energy, fatigue
• Aspiration
Assessment

• Changes in rate, depth of respirations
• Abnormal breath sounds (rhonchi, bronchial lung sounds, egophony)
• Use of accessory muscles
• Dyspnea, tachypnea
• Cough, effective or ineffective; with/without sputum production
• Cyanosis
• Decreased breath sounds over affected lung areas
• Ineffective cough
• Purulent sputum
• Hypoxemia
• Infiltrates seen on chest x-ray film

Goals and outcomes

• Patient will identify / demonstrate behaviors to achieve airway clearance.
• Patient will display/maintain patent airway with breath sounds clearing; absence of dyspnea, cyanosis, as
evidenced by keeping a patent airway and effectively clearing secretions.


Nursing Interventions and Rationale


Nursing Interventions Rationale


Assessment

Tachypnea, shallow respirations and asymmetric
chest movement are frequently present because of
Assess the rate, rhythm, and depth of discomfort of moving chest wall and/or fluid in
respiration, chest movement, and use of lung due to a compensatory response to airway
accessory muscles. obstruction. Altered breathing pattern may occur
together with use of accessory muscles to increase
chest excursion to facilitate effective breathing.


Coughing is the most effective way to remove
Assess cough effectiveness and
productivity secretions. Pneumonia may cause thick and
tenacious secretions to patients.



3

CikguOnline
CikguOnline

Nursing Interventions Rationale

Decreased airflow occurs in areas with
consolidated fluid. Bronchial breath sounds can
Auscultate lung fields, noting areas of also occur in these consolidated areas. Crackles,
decreased or absent airflow and
adventitious breath sounds: crackles, rhonchi, and wheezes are heard on inspiration
and/or expiration in response to fluid
wheezes.
accumulation, thick secretions, and airway spasms
and obstruction.


Changes in sputum characteristics may indicate
Observe the sputum color, viscosity, infection. Sputum that is discolored, tenacious, or
and odor. Report changes. has an odor may increase airway resistance and
may warrant further intervention.


Airway clearance is hindered with inadequate
Assess the patient’s hydration status.
hydration and thickening of secretions.

Therapeutic Interventions

Doing so would lower the diaphragm and promote
Elevate head of bed, change position chest expansion, aeration of lung segments,
frequently.
mobilization and expectoration of secretions.


• Deep breathing exercises facilitates
maximum expansion of the lungs and smaller
airways, and improves the productivity of
Teach and assist patient with proper cough.
deep-breathing exercises. Demonstrate • Coughing is a reflex and a natural self-
proper splinting of chest and effective cleaning mechanism that assists the cilia to
coughing while in upright position. maintain patent airways. It is the most helpful
Encourage him to do so often. way to remove most secretions.

• Splinting reduces chest discomfort and an
upright position favors deeper and more
forceful cough effort making it more effective.


Stimulates cough or mechanically clears airway in
Suction as indicated: frequent patient who is unable to do so because of
coughing, adventitious breath sounds, ineffective cough or decreased level of
desaturation related to airway consciousness. Note: Suctioning can cause
secretions. increased hypoxemia; hyper oxygenate before,
during, and after suctioning.


Maintain adequate hydration by forcing Fluids, especially warm liquids, aid in
fluids to at least 3000 mL/day unless mobilization and expectoration of secretions.
contraindicated (e.g., heart failure). Fluids help maintain hydration and increases
Offer warm, rather than cold, fluids. ciliary action to remove secretions and reduces the




4

CikguOnline
CikguOnline

Nursing Interventions Rationale

viscosity of secretions. Thinner secretions are
easier to cough out.


• Nebulizers humidify the airway to thin
secretions and facilitates liquefaction and
expectoration of secretions.

• Postural drainage may not be as effective in
Assist and monitor effects of nebulizer interstitial pneumonias or those causing
treatment and other respiratory alveolar exudate or destruction.
physiotherapy: spirometer, percussion,
postural drainage, Peek Flow Meter • Incentive spirometry serves to improve
deep breathing and helps prevent atelectasis.
Perform treatments between meals and • Chest percussion helps loosen and mobilize
limit fluids when appropriate. secretions in smaller airways that cannot be
removed by coughing or suctioning.
• Coordination of treatments and oral intake
reduces likelihood of vomiting with coughing,
expectorations.

Encourage ambulation. Helps mobilize secretions and reduces atelectasis.


• Mucolytics increase or liquefy respiratory
secretions.
• Expectorants increase productive cough
Administer medications as to clear the airways. They liquefy lower
indicated: respiratory tract secretions by reducing its
viscosity.
• mucolytics • Bronchodilators are medications used to

• expectorants facilitate respiration by dilating the
airways.
• bronchodilators
• Analgesics are given to improve cough
• analgesics
effort by reducing discomfort, but should
be used cautiously because they can
decrease cough effort and depress
respirations.


Increasing the humidity will decrease the viscosity
Use humidified oxygen or humidifier at of secretions. Clean the humidifier before use
bedside.
to avoid bacterial growth.

Follows progress and effects and extent of
Monitor serial chest x-rays, ABGs, pulse pneumonia. Therapeutic regimen, and may
oximetry readings. facilitate necessary alterations in therapy. Oxygen
saturation should be maintain at 90% or greater.




5

CikguOnline
CikguOnline

Nursing Interventions Rationale

Imbalances in PaCO2 and PaO2 may indicate
respiratory fatigue.

Bronchoscopy is occasionally needed to remove
mucous plugs, drain purulent secretions, obtain
Assist with bronchoscopy and/or lavage samples for culture and sensitivity.
thoracentesis, if indicated.
Thoracentesis is done to drain associated
pleural effusions and prevent atelectasis.

Anticipate the need for supplemental These measures are needed to correct hypoxemia.
oxygen or intubation if patient’s Intubation is needed for deep suctioning efforts
condition deteriorates. and provide a source for augmenting oxygenation.

Urge all bedridden and postoperative To promote full aeration and drainage of
patients to perform deep breathing and secretions.
coughing exercises frequently.



































6

CikguOnline
CikguOnline
IMPAIRED GAS EXCHANGE



Impaired Gas Exchange related to retained secretions and inflammatory pulmonary.

Related Factors

• Alveolar-capillary membrane changes (inflammatory effects)
• Altered oxygen-carrying capacity of blood/release at cellular level (fever, shifting oxyhemoglobin curve)
• Altered delivery of oxygen (hypoventilation)
• Collection of mucus in airways
• Inflammation of airways and alveoli
• Fluid-filled alveoli
Assessment

• Dyspnea, Tachypnea
• Pale, dusky, skin color
• Cyanosis
• Tachycardia
• Restlessness, irritability, changes in mentation
• Hypoxemia
• Hypotension
• Disorientation

Goals and outcomes
• Patient will demonstrate improved ventilation and oxygenation of tissues by ABGs within patient’s acceptable
range and absence of symptoms of respiratory distress.
• Patient will maintain optimal gas exchange.
• Patient will participate in actions to maximize oxygenation.

Nursing Interventions and Rationales


Nursing Interventions Rationale

Assessment


Manifestations of respiratory distress are
dependent on/and indicative of the degree of lung
involvement and underlying general health status
as patients will adapt their breathing patterns to
Assess respirations: note quality, rate,
rhythm, depth, use of accessory muscles, facilitate effective gas exchange.

ease, and position assumed for easy
breathing. Rapid, shallow breathing patterns and
hypoventilation directly affects gas exchange.
Hypoxia is associated with signs of increased
breathing effort. Tripod positioning is an evidence
of significant dyspnea.

As oxygenation and perfusion become impaired,
Observe color of skin, mucous membranes, peripheral tissues become cyanotic. Cyanosis of
and nail beds, noting presence of peripheral
nail beds may represent vasoconstriction or the

7

CikguOnline
CikguOnline

Nursing Interventions Rationale

cyanosis (nail beds) or central cyanosis body’s response to fever/chills; however, cyanosis
(circumoral). of earlobes, mucous membranes, and skin around
the mouth (“warm membranes”) is indicative of
systemic hypoxemia.

Restlessness, irritation, confusion, and
somnolence may reflect hypoxemia and decreased
Assess mental status, restlessness, and cerebral oxygenation and may require further
changes in level of consciousness.
intervention. Check pulse oximetry results with
any mental status changes in older adults.


Anxiety is a manifestation of psychological
concerns and physiological responses to hypoxia.
Assess anxiety level and encourage Providing reassurance and enhancing sense of
verbalization of feelings and concerns. security can reduce the psychological component,
thereby decreasing oxygen demand and adverse
physiological responses.


Tachycardia is usually present as a result of fever
and/or dehydration but may represent a response
Monitor heart rate and rhythm and blood to hypoxemia. Initial hypoxia and hypercapnia
pressure. increases BP and HR. As hypoxia becomes more
severe, BP may drop while HR tends to continue to
be rapid with dysrhythmias.

Monitor body temperature, as indicated. High fever (common in bacterial pneumonia and
Assist with comfort measures to reduce fever
and chills: addition or removal of bedcovers, influenza) greatly increases metabolic demands
and oxygen consumption and alters cellular
comfortable room temperature, tepid or cool
water sponge bath. oxygenation.


Observe for deterioration in condition, Shock and pulmonary edema are the most
noting hypotension, copious amounts of
bloody sputum, pallor, cyanosis, change in common causes of death in pneumonia and
require immediate medical intervention.
LOC, severe dyspnea, and restlessness.

Follows progress of disease process and facilitates
alterations in pulmonary therapy. Pulse oximetry
Monitor ABGs, pulse oximetry.
detects changes in oxygenation. O2 sats should be
at 90% or greater.

Therapeutic Interventions

Prevents over exhaustion and reduces oxygen
Maintain bedrest by planning activity and demands to facilitate resolution of infection.
rest periods to minimize energy use. Relaxation techniques helps conserve energy that
Encourage use of relaxation techniques and can be used for effective breathing and coughing
diversional activities.
efforts.






8

CikguOnline
CikguOnline

Nursing Interventions Rationale

Elevate head and encourage frequent These measures promote maximum chest
position changes, deep breathing, and expansion, mobilize secretions and improve
effective coughing. ventilation.

The purpose of oxygen therapy is to maintain
PaO2 above 60 mmHg. Oxygen is administered by
Administer oxygen therapy by appropriate the method that provides appropriate delivery
means: nasal prongs, mask, Venturi mask. within the patient’s tolerance. Note: Patients with
underlying chronic lung diseases should be given
oxygen cautiously.










































9

CikguOnline
CikguOnline
INEFFECTIVE BREATHING PATTERN




Ineffective Breathing Pattern is related to compensatory tachypnoea due to an inability to meet
metabolic demands. Changes in breathing pattern occur because affected alveoli cannot effectively
exchange oxygen and carbon dioxide, as a result of chest pain, and increased body temperature.

Related Factors
• Alteration of patient’s O2/CO2 ratio
• Anxiety
• Hypoxia
• Decreased lung expansion
• Inflammatory process
• Pain

Assessment
• Changes in rate, depth of respirations
• Abnormal breath sounds (rhonchi, bronchial lung sounds, egophony)
• Use of accessory muscles
• Dyspnea, tachypnea
• Cough, effective or ineffective; with/without sputum production
• Cyanosis
• Decreased breath sounds over affected lung areas
• Ineffective cough
• Purulent sputum
• Hypoxemia
• Infiltrates seen on chest x-ray film
• Reduced vital capacity

Goals and outcomes
• Patient maintains an effective breathing pattern, as evidenced by relaxed breathing at normal rate and depth and
absence of dyspnoea.
• Patient’s respiratory rate remains within established limits.


Nursing Interventions and Rationales

Nursing Interventions Rationales

Assessment

The average rate of respiration for adults is 10 to 20
breaths per minute. It is important to take action
Assess and record respiratory rate and depth when there is an alteration in the pattern of
at least every 4 hours.
breathing to detect early signs of respiratory
compromise.


Assess ABG levels, according to facility This monitors oxygenation and ventilation status.
policy.






10

CikguOnline
CikguOnline

Unusual breathing patterns may imply an
underlying disease process or dysfunction. Cheyne-
Stokes respiration signifies bilateral dysfunction in
Observe for breathing patterns. the deep cerebral or diencephalon related with
brain injury or metabolic abnormalities. Apneusis
and ataxic breathing are related with failure of the
respiratory centers in the pons and medulla.

Auscultate breath sounds at least every four This is to detect decreased or adventitious breath
(4) hours. sounds.

Work of breathing increases greatly as lung
Assess for use of accessory muscle.
compliance decreases.

Paradoxical movement of the abdomen (an inward
Monitor for diaphragmatic muscle fatigue or versus outward movement during inspiration) is
weakness (paradoxical motion). indicative of respiratory muscle fatigue and
weakness.

Observe for retractions or flaring of nostrils. These signs signify an increase in respiratory effort.


Therapeutic Interventions

Place patient with proper body alignment for
maximum breathing pattern.
Positioning the client to facilitate A sitting position permits maximum lung excursion
effective breathing (raising head of bed and chest expansion.
to 45 degrees), teaching how to splint
chest wall with a pillow.


Encourage sustained deep breaths by:
These techniques promotes deep inspiration, which
• Using demonstration: highlighting
slow inhalation, holding end increases oxygenation and prevents atelectasis.
Controlled breathing methods may also aid slow
inspiration for a few seconds, and
passive exhalation respirations in patients who are tachypneic.
• Utilizing incentive spirometer Prolonged expiration prevents air trapping.
• Requiring the patient to yawn

Encourage diaphragmatic breathing for This method relaxes muscles and increases the
patients with chronic disease. patient’s oxygen level.


Maintain a clear airway by
encouraging patient to mobilize own This facilitates adequate clearance of secretions.
secretions with successful coughing.

Suction secretions, as necessary. This is to clear blockage in airway.


Stay with the patient during acute episodes This will reduce the patient’s anxiety, thereby
of respiratory distress. reducing oxygen demand.






11

CikguOnline
CikguOnline

Ambulate patient as tolerated with doctor’s Ambulation can further break up and move
order three times daily. secretions that block the airways.

Extra activity can worsen shortness of breath.
Encourage frequent rest periods and teach Ensure the patient rests between strenuous
patient to pace activity.
activities.

Encourage small frequent meals. This prevents crowding of the diaphragm.

This conserves energy and avoids overexertion and
Help patient with ADLs, as necessary.
fatigue.

Avail a fan in the room. Moving air can decrease feelings of air hunger.


Educate patient or significant other proper These allow sufficient mobilization of secretions.
breathing, coughing, and splinting methods.


Teach patient about:

• pursed-lip breathing

• abdominal breathing
• performing relaxation techniques
• performing relaxation techniques These measures allow patient to participate in
maintaining health status and improve ventilation.
• taking prescribed medications
(ensuring accuracy of dose and
frequency and monitoring adverse
effects)
• scheduling activities to avoid fatigue
and provide for rest periods



























12

CikguOnline
CikguOnline
ACUTE PAIN




Increased sputum production in pneumonia comes with frequent coughing. Persistent coughing can
be painful therefore the need for Acute Pain nursing diagnosis.

Related Factors
• Inflammation of lung parenchyma
• Cellular reactions to circulating toxins
• Persistent coughing

Assessment
• Reports of discomfort: pleuritic chest pain, headache, muscle/joint pain
• Guarding of affected area
• Self-focused
• Moaning, restlessness
• Facial mask, distraction behaviors
• Irritability
• Tachycardia
• Increased BP
• Tachypnea

Goals and expected outcomes
• Patient will verbalize relief/control of pain at level less than 3 to 4 using a rating scale of 0 to 10.
• Patient will demonstrate relaxed manner, resting/sleeping and engaging in activity appropriately.
• Patient will verbalize understanding of nonpharmacological interventions for pain relief.

Nursing Interventions and Rationales
These nursing interventions and actions are for pain relief to facilitate effective mobilization of
secretions through coughing and deep breathing exercises.


Nursing Interventions Rationale

Assessment

Assess pain characteristics: sharp, constant, Chest pain, usually present to some degree with
stabbing. Investigate changes in character, pneumonia, may also herald the onset of
location, or intensity of pain. Assess reports of complications of pneumonia, such as
pain with breathing or coughing. pericarditis and endocarditis.


Changes in heart rate or BP may indicate that
patient is experiencing pain, especially when
Monitor vital signs.
other reasons for changes in vital signs have
been ruled out.


Therapeutic Interventions

Provide comfort measures: back rubs, Non-analgesic measures administered with a
position changes, quite music, massage. gentle touch can lessen discomfort and



13

CikguOnline
CikguOnline

Nursing Interventions Rationale

Encourage use of relaxation and/or breathing augment therapeutic effects of analgesics.
exercises. Patient involvement in pain control measures
promotes independence and enhances sense of
well-being.

Mouth breathing and oxygen therapy can
Offer frequent oral hygiene. irritate and dry out mucous membranes,
potentiating general discomfort.


Instruct and assist patient in chest splinting Aids in control of chest discomfort while
techniques during coughing episodes. enhancing the effectiveness of cough effort.

These medications may be used to suppress
non-productive cough or reduce excess mucus,
Administer antitussives as indicated. Do not thereby enhancing general comfort.
suppress a productive cough; moderate
amounts of analgesics are used to relieve Coughing is necessary to mobilize secretions
pleuritic pain.
and suppressing cough will cause retained
secretions and delay resolution of pneumonia.

Administer analgesics as prescribed. Medications allow for pain relief and the ability
Encourage patient to take analgesics before to deep breathe and cough. Analgesics help
discomfort becomes severe. prevent peak periods of pain.































14

CikguOnline
CikguOnline
ACTIVITY INTOLERANCE




The nursing diagnosis Activity Intolerance is related to decreased oxygen levels for metabolic
demands. For these pneumonia nursing care plans, energy reserves are also depleted due to
insufficient intake of food during periods of dyspnea.
Related Factors
• Imbalance between oxygen supply and demand
• General weakness
• Exhaustion associated with interruption in usual sleep pattern because of discomfort, excessive coughing, and
dyspnea
Assessment

• Verbal reports of weakness, fatigue, exhaustion
• Exertional dyspnea, tachypnea
• Tachycardia in response to activity
• Development/worsening of pallor/cyanosis

Goals and expected outcomes
• Report/demonstrate a measurable increase in tolerance to activity with absence of dyspnea and excessive fatigue,
and vital signs within patient’s acceptable range.


Nursing Interventions and Rationales
Nursing interventions for activity intolerance in this pneumonia nursing care plan should include
assessment of the client’s baseline activity level and response to activity and noting how well the client
tolerates activity. Next is to schedule activities after treatment or medications and providing
emotional support and a quiet environment to reduce anxiety and promote rest.


Nursing Interventions Rationale

Assessment


Determine patient’s response to activity. Note Establishes patient’s capabilities and needs
reports of dyspnea, increased weakness and fatigue,
changes in vital signs during and after activities. and facilitates choice of interventions.

Therapeutic Interventions


Provide a quiet environment and limit visitors
during acute phase as indicated. Encourage use of Reduces stress and excess stimulation,
stress management and diversional activities as promoting rest
appropriate.


Bedrest is maintained during acute phase
to decrease metabolic demands, thus
Explain importance of rest in treatment plan and conserving energy for healing. Activity
necessity for balancing activities with rest. restrictions thereafter are determined by
individual patient response to activity and
resolution of respiratory insufficiency.


15

CikguOnline
CikguOnline

Nursing Interventions Rationale

Effective coughing may exhaust an already
Pace activity for patients with reduced activity. compromised patient. Fatigue may be a
contributing factor to ineffective coughing.

Patient may be comfortable with head of
Assist patient to assume comfortable position bed elevated, sleeping in a chair, or leaning
for rest and sleep. forward on overbed table with pillow
support.


Assist with self-care activities as necessary. Provide Minimizes exhaustion and helps balance
for progressive increase in activities during recovery oxygen supply and demand.
phase. and demand.








































16

CikguOnline
CikguOnline
DEFICIENT KNOWLEDGE




Related Factors
• Lack of exposure
• Misinterpretation of information
• Altered recall
• Unfamiliarity with the disease process and/or transmission of disease

Assessment

• Requests for information
• Questions to health care team
• Statement of misconception
• Failure to improve/recurrence
• Confusion about treatment
• Inability to comply with treatment regimen, including appropriate isolation procedures

Goals and expected outcomes

• Patient and caregiver will verbalize understanding of condition, disease process, and prognosis.
• Patient and caregiver will verbalize understanding of therapeutic regimen.
• Patient will initiate necessary lifestyle changes.
• Patient will participate in treatment program.


Nursing Interventions and Rationale


Nursing Interventions Rationale


Assessment

Determine patient’s understanding of
pneumonia complications and its treatment Provides a starting point in education.
regimen.

Promotes understanding of current situation
Review normal lung function, pathology of
condition. and importance of cooperating with treatment
regimen.

Information can enhance coping and help
reduce anxiety and excessive concern.
Discuss debilitating aspects of disease, length of Respiratory symptoms may be slow to resolve,
convalescence, and recovery expectations. and fatigue and weakness can persist for an
Identify self-care and homemaker needs. extended period. These factors may be
associated with depression and the need for
various forms of support and assistance.


Therapeutic regimen will continue after
Assess potential home care needs. hospital discharge and home care needs will
depend on the availability of supportive people



17

CikguOnline
CikguOnline

Nursing Interventions Rationale

including the patient’s energy level and
cognitive level.

Therapeutic Interventions

Fatigue and depression can affect ability to
Provide information in written and verbal form. assimilate information and follow therapeutic
regimen.


Reinforce importance of continuing During initial 6–8 wk after discharge, patient is
effective coughing and deep-breathing
exercises. at greatest risk for recurrence of pneumonia.

Full-course antibiotic treatment is required to
reduce the recurrence of pneumonia and
promote a healthy immune system. Early
Emphasize necessity for continuing antibiotic discontinuation of antibiotics may result in
therapy for prescribed period.
failure to completely resolve infectious process
and may cause recurrence or rebound
pneumonia.

Smoking destroys tracheobronchial ciliary
action, irritates bronchial mucosa, and inhibits
Review the importance of cessation of smoking.
alveolar macrophages, compromising body’s
natural defence against infection.

Outline steps to enhance general health and
well-being: balanced rest and activity, well- Increases natural defence, limits exposure to
rounded diet, avoidance of crowds during pathogens.
cold/flu season and persons with URIs.

Stress importance of continuing medical follow- May prevent recurrence of pneumonia and/or
up and obtaining vaccinations as appropriate. related complications.

Identify signs and symptoms requiring
notification of health care provider: increasing Prompt evaluation and timely intervention may
dyspnea, chest pain, prolonged fatigue, weight prevent complications.
loss, fever, chills, persistence of productive
cough, changes in mentation.


This may results in upper airway colonization
with antibiotic-resistant bacteria. If the patient
Instruct patient to avoid using antibiotics then develops pneumonia, the organisms
indiscriminately during minor viral infections.
producing the pneumonia may require
treatment with more toxic antibiotics.


Encourage Pneumovax and annual flu shots for
high-risk patients. To help prevent occurrence of the disease.




18

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

CikguOnline
CikguOnline

Antipyretic medications lower body temperature
Give antipyretic medications as prescribed. by blocking the synthesis of prostaglandins that
act in the hypothalamus.

Hyperthermia increases the metabolic demand
Ready oxygen therapy for extreme cases.
for oxygen.










































































20


Click to View FlipBook Version