Core body temperature above the normal diurnal range due to failure of thermoregulation

Abnormal posturing

Apnea

Coma

Flushed skin

Hypotension

Infant does not maintain suck

Irritable mood

Lethargy

Seizure

Skin warm to touch

Stupor

Tachycardia

Tachypnea

Vasodilation

NANDA-I approved*

Treatment Related

Related to decreased ability to perspire secondary to (specify)

Situational (Personal, Environmental)

Related to:

Exposure to hot environment

Inappropriate clothing* for climate

No access to air conditioning

Newborn hospital environment warming equipment

Related to decreased circulation secondary to:

Extremes of weight

Dehydration*

Related to insufficient hydration for vigorous activity*

Maturational

Related to ineffective temperature regulation secondary to age (refer to Ineffective Thermoregulation)

Individuals exposed to high environmental temperature

Decreased sweat response

Impaired health status

Increased metabolic rate

Ischemia

Pharmaceutical preparations

Sepsis

Trauma

AUTHOR'S NOTE

The nursing diagnoses Hypothermia and Hyperthermia represent the condition in people with a temperature below and above normal, respectively.

Some levels of hypothermia or hyperthermia are treatable by nursing interventions, such as correcting external causes (e.g., inappropriate clothing, exposure to elements [heat or cold], and dehydration). Nursing interventions focus on preventing or treating mild hypothermia and hyperthermia.

As one reviews the above defining characteristics for Hyperthermia as abnormal posturing, apnea, coma, flushed skin, hypotension, infant does not maintain suck, irritable mood, lethargy, seizure, skin warm to touch, stupor, tachycardia, tachypnea, vasodilation, it is evident that the individual is in a serious metabolic state. As life-threatening situations that require medical and nursing interventions, severe hypothermia and hyperthermia represent collaborative problems and should be labeled Risk for Complications of Hypothermia or Risk for Complications of Hyperthermia, not nursing diagnoses.

Temperature elevation from infections, other disorders (e.g., hypothalamic), or treatments (e.g., hypothermia units) requires collaborative treatment. If desired, the nurse could use the nursing diagnosis Impaired Comfort and the collaborative problem Risk for Complications of Hypothermia or Risk for Complications of Hyperthermia.

The individual will maintain body temperature within normal range for age.

Level 1 Fundamentals Focused Interventions (all settings)

Remove or Reduce Contributing Risk Factors Dehydration

• Monitor intake and output and provide favorite beverage. Teach the importance of maintaining adequate fluid intake (at least 2,000 mL a day of cool liquids unless contraindicated by heart or kidney disease).
• Explain the importance of not relying on thirst sensation as an indication of the need for fluid.
• Monitor amount and color of urine.

R:A good indicator of hydration is to drink enough fluid so that the body does not feel physically thirsty and so that it produces regular, light-colored urine.

Recommended fluid replacement for moderate activities in hot weather (*DeFabio, 2000) is as follows:

• 78° F to 84.9° F (25.6° C to 29.4° C) 16 oz/hr
• 85° F to 89.9° F (29.4° C to 32.2° C) 24 oz/hr
• Greater than 90° F (32.2° C) 32 oz/hr

See also Deficient Fluid Volume.

R:Strategies are used to maintain balance between intake and output.

Explain factors that increase the risk of hypo/hyperthermia in older adults (Miller, 2019):

• Medical conditions (hyperthyroidism, cardiovascular disease, electrolyte imbalances, Parkinson's disease)
• Medications (diuretics, anticholinergics, beta-blockers, angiotensin-converting enzyme inhibitors, selective serotonin reuptake inhibitors, antidepressants, proton pump inhibitors)
• Excess alcohol intake
• Personal (older than 75), extreme climate-temperature variation, substandard living conditions (no air conditioning, poor ventilation)

Initiate Health Teaching as Indicated

Instruct on precautions to take when engaging in activities outside in hot weather to prevent dehydration and heat stroke.

R:It is recommended that men consume around 13 cups of total fluids a day and women consume about 9 cups, which includes water from other beverages as well as high-water-containing foods. A good indicator of hydration is to drink enough fluid so that the body does not feel physically thirsty and so that it produces regular, light-colored urine.

To replace lost fluids during outdoor activity

• Drink 8 oz of water prior to going out in heat.
• Drink cool, not cold, water because cool water is more readily absorbed.
• Avoid caffeinated, protein, and alcoholic drinks (e.g., colored soda, coffee, tea).
• Drink 4 to 8 oz every 30 minutes to 1 hour depending on heat index.
• Do not wait to be thirsty to drink water.
• Avoid sports drinks unless exercising over 1 hour in hot weather and sweating a lot.

R:During hot weather activities/exercising, dehydration occurs more frequently and has more severe consequences. Drink early and at regular intervals. The perception of thirst is a poor index of the magnitude of fluid deficit.

Consider the following:

• Avoid the midday sun by exercising before 10

  AM

  or after 6

  PM

  , if possible.
• Use a sunscreen with a rating of SPF-15 or lower depending on skin type. Ratings above SPF-15 can interfere with the skin's thermal regulation.
• Wear lightweight and breathable clothing.
• If you experience weakness, headache, dizziness, muscle cramps, nausea, or vomiting:
  • Stop and get out of heat.
  • Drink water, wet your skin.
  • Call 911 if you are feeling faint, weak, or confused or have someone take you for medical care.

R:Severe heat stroke is a medical emergency and can result in death if untreated.

• Teach the early signs of hyperthermia or heat stroke:
  • Flushed skin
  • Fatigue
  • Headache/confusion
  • Loss of appetite
  • Nausea/vomiting
  • Muscle cramps