Hyperthermia Nursing Diagnosis & Care Plan

Hyperthermia is an abnormally high body temperature – usually greater than 40°C – that occurs due to failed thermoregulation in the brain, the hypothalamus. It occurs when the body produces more heat than it can release.

There are many external and internal causes of hyperthermia. Hyperthermia is an umbrella term that comprises illnesses such as heat exhaustion, heat fatigue, and heat stroke. These conditions need to be quickly addressed as they can become life-threatening. 

Related Factors  

  • Physical exertion/ increased metabolic rate
  • Lack of air conditioning
  • Alcohol consumption 
  • Being in hot environments 
  • Inappropriate clothing/personal protective equipment(PPE) 
  • Medications (i.e., anesthesia) 
  • Decreased sweating
  • Sepsis 

Signs and Symptoms  

  • Flushed skin 
  • Tachycardia 
  • Tachypnea  
  •  Dry skin/warm to touch 
  • Confusion 
  • Nausea/ vomiting
  • Weakness 
  • Syncopy 
  • Body temperature above the normal range 

Expected Outcome 

  • Patient will maintain a core body temperature within a normal range 
  • Patient will verbalize signs and symptoms of hyperthermia and strategies to prevent it

Nursing Assessment for Hyperthermia 

Monitor the patient’s core temperature continuously or at least every hour.

Core temperature measurements are the most accurate. Continuous measurements allow for the monitoring of a trend in temperature rise or fall. Accurate and frequent documentation allows for quick recognition of changes and whether treatment is effective.
Monitor the patient’s heart rate and blood pressure. 

Increasing heart rate and blood pressure indicate progressing hyperthermia. One would find a fast and thready pulse in patients with hyperthermia.
Assess for signs of hyperthermia and dehydration. 

A patient suffering from hyperthermia may present with a flushed face, respiratory distress, weakness, dizziness, confusion, headache, dry mucous membranes, nonelastic skin turgor, sweating, and low urine output.
Monitor fluid status.

Measuring correct intake and output is crucial so fluid status can be corrected. If the patient is severely dehydrated, fluid status should be measured via central venous pressure.
Assess neurological status frequently.

Hyperthermia can cause confusion and delirium. 
Identify the underlying cause of hyperthermia considering the patient’s age, history, current conditions, and recent procedures.

Many different factors can bring on hyperthermia. Being aware of the cause helps treat hyperthermia and prevent the illness from happening again. Malignant hyperthermia, for example, is a life-threatening illness that can be caused by anesthesia.
Assess environmental factors.

Room temperature and bed linens may contribute to an increased body temperature.
Monitor electrolyte balance.

Electrolytes, especially sodium, may be lost during excessive sweating. Low sodium levels can cause complications such as brain swelling and altered mental status.

Nursing Interventions for Hyperthermia

Remove thick clothing and blankets and adjust the thermostat in the room.

External factors such as room temperature, extra clothing, and blankets affect the patient’s body temperature.
Provide a tepid sponge bath. 

This may provide comfort and a further decrease in body temperature. Use lukewarm water to prevent shivering. Shivering may cause an increased metabolic rate, and temperature may rise even further.
Use a cooling blanket. 

The use of cooling blankets is a continuous way to reduce an increased body temperature. Cooling blankets that circulate water can be adjusted in temperature. However, the temperature should not be set much lower than the patient’s to avoid shivering, which could cause an increase in metabolic rate and, therefore, an increase in body temperature.
Apply ice packs to the neck, axillae, groin, and torso. 

These areas are most effective in decreasing the body’s core temperature.
Monitor the patient’s skin during cooling measures. 

Prolonged exposure to ice packs and cooling blankets may cause damage to the skin. Therefore, frequent adjustment is necessary, and barriers such as wrapping ice packs in towels may help prevent skin damage.
Administer antipyretic medications.

Antipyretics work on the hypothalamus to reduce the body’s temperature. The hypothalamus is a structure in the brain responsible for body temperature regulation.
Promote sufficient fluid intake.

Fluid helps in body temperature regulation. Severe dehydration can cause an elevated temperature.
Infuse cooled IV saline as ordered. 

This helps with hydration and further decreases body temperature.
Assist with invasive cooling methods. 

Cooling techniques such as gastric or peritoneal lavage may be helpful in specific cases. There are, however, risks and contraindications.
Implement seizure precautions. 

Hyperthermia can increase the risk for seizures. All bed rails should be padded, and the bed should be kept in the lowest position. A suction canister should be set up, and the patient should be turned on to the side during a seizure to protect the airway.
Provide wound care and keep lines and devices clean. 

Wounds, incisions, and invasive equipment, such as catheters and chest tubes, need to be cleaned regularly to prevent infection, another potential cause for hyperthermia.
Collaborate with the dietitian to support nutritional intake.

Due to increased metabolic rate, the patient’s caloric and nutritional needs may need to be adjusted. 

Nursing Interventions for Malignant Hyperthermia 

Malignant hyperthermia (MH) is a life-threatening, inherited muscle disorder triggered by general anesthesia. The patients display a very high body temperature, among other signs and symptoms.

Obtain a thorough history of reactions in the past to general anesthesia and that of family members. 

According to the Malignant Hyperthermia Association of the United States, there is a 50% chance of inheriting a gene defect as a sibling or a child of the affected person. Therefore, information about complications with anesthesia of family members is essential.
Assess for signs and symptoms of malignant hyperthermia.

Dangerously high body temperature (as high as 111.2 Fahrenheit is a late sign of MH) 
Sweating
Muscle spasms
Severe muscle rigidity (especially in the jaw and upper chest)
Tachycardia
Hypotension
Respiratory distress 
Dysrhythmias
Mottled skin color 
Cyanosis 
Rise in end-tidal carbon dioxide level with a decrease in oxygen saturation  

Lab values: 
Elevated serum potassium 
Elevated serum calcium 
Myoglobinuria (presence of muscle protein in urine) 
Hyperventilate by administering 100% oxygen using the highest possible flow rate.

This is done to rid volatile anesthetics and decrease end-tidal carbon dioxide levels. According to the Malignant Hyperthermia Association of the United States, it is best practice to insert activated charcoal filters into the patient’s breathing circuit. Healthcare staff should change it every hour. 
Administer IV dantrolene. 

A dose of 2.5mg/kg should be administered rapidly. It may be repeated until one can see an improvement in end-tidal carbon dioxide, improved muscle rigidity, and normalizing heart rate. (Malignant Hyperthermia Association of the United States) 
Implement cooling measures if temperatures rise beyond 39°C

Increased body temperatures may cause damage to major organs, including the brain and kidneys. Stop cooling measures once the body temperature is less than 38°C to prevent hypothermia. 
Obtain blood gases to correct metabolic acidosis. 

Sodium bicarbonate may be administered to correct metabolic acidosis.
Treat hyperkalemia. 

Treatment consists of calcium chloride, sodium bicarbonate, glucose, and insulin. 
Administer diuretics. 

Malignant hyperthermia causes damage to the muscles, and that causes an increased build-up of myoglobin which can get lodged in the urinary tract obstructing urine flow. Diuretics may prevent possible obstruction.
Assist with iced lavage. 

Lavage of the stomach, bladder, and rectum helps decrease core body temperature. 
Refer the patient and family to the Malignant Hyperthermia Association of the United States. 

Malignant hyperthermia is a genetic disorder with a 50% chance of being passed on. 

Patient Education about Hyperthermia 

Educate about the signs and symptoms of hyperthermia. 

Recognizing signs early helps accelerate treatment and ensure the best outcome.
Teach about first aid treatment until help arrives. 

Move into a shaded or airconditioned building
Drink water or a sports drink
Take a cold bath or shower   
Take off extra clothing
Apply cold packs to the neck, underarms, and groin

These measures can already help cool the individual before professional help arrives.
Teach preventative measures of hyperthermia. 

Stay hydrated in hot and humid environments, and take frequent exercise breaks. Plan exercise routines early in the day when it is still cool outside. Wear loose, lightweight clothes.

More Care Plans:

Deficient Fluid Volume Nursing Diagnosis & Care Plan

Fatigue Nursing Diagnosis & Care Plan

Knowledge Deficit Nursing Diagnosis & Care Plan

Ineffective Health Maintenance Nursing Diagnosis & Care Plan

References:

Wasserman, D., Creech, J., & Healy, M. (2021). Cooling Techniques For Hyperthermia. Ncbi.nlm.nih.gov. Retrieved 6 June 2022, from https://www.ncbi.nlm.nih.gov/books/NBK459311/.

FAQs – MHAUS. Mhaus.org. Retrieved 6 June 2022, from https://www.mhaus.org/faqs/.

Managing A Crisis – MHAUS. Mhaus.org. Retrieved 6 June 2022, from https://www.mhaus.org/healthcare-professionals/managing-a-crisis/.

UpToDate. Uptodate.com. (2022). Retrieved 6 June 2022, from https://www.uptodate.com/contents/heat-stroke-the-basics/print#:~:text=What%20is%20heat%20stroke%3F,people%20who%20are%20not%20exercising.

Ignatavicius, D., & Workman, M. (2016). Medical-surgical nursing (8th ed.). Elsevier.

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