Nursing Interventions for Hyperthermia

Nursing Care Plan for Hyperthermia

The normal human body temperature in health can be as high as 37.7 °C (99.9 °F) in the late afternoon. Hyperthermia is defined as a temperature greater than 37.5–38.3 °C (100–101 °F), depending on the reference used, that occurs without a change in the body's temperature set point. (wikipedia)

Hyperthermia is elevated body temperature due to failed thermoregulation that occurs when a body produces or absorbs more heat than it dissipates.

Hyperthermia: Hyperthermia is an increase in body temperature in the context of an unchanged thermoregulatory point in the brain.

Common causes include heat stroke and adverse reactions to drugs. The former is an acute hyperthermia caused by exposure to excessive heat, or combination of heat and humidity, that overwhelms the heat-regulating mechanisms of the body causing uncontrolled elevation of body temperature.

Both one's general health and/or lifestyle may increase a person's chance of suffering a heat-related illness.

Symptoms of Hyperthermia

• Dry skin and mucus membranes
• Dehydration
• Meiosis
• Hallucinations or delirium
• Signs of heat exposure

Nursing Diagnosis : Hyperthermia 
related to :

• Infection
• Inflammation
• CNS Pathology
• Dehydration
• Impaired physical environment
• Exposure to heat/sun
• Vigorous activity

Evidenced by :

• Temperature over 38.8 C (101 F) rectally, or 37.8 C (100 F) orally.
• Loss of appetite
• Malaise/weakness
• Shivering/goose pimples
• Tachycardia
• Dehydration
• Warm to touch
• Flushed skin
• Increased respiratory rate

Goal :

• The patient will maintian normal body temperature.

Nursing Interventions :

• Administer antipyretics per physician's order.
• Assess possible etiology of increased temperature.
• Remove excess clothing or blankets.
• Assess temperature q ___ hours.
• Encourage fluids when indicated.
• Provide air condition/fan if appropriate.

Angina Pectoris - 4 Nursing Diagnosis

Angina pectoris is the result of myocardial ischemia caused by an imbalance between myocardial blood supply and oxygen demand.

Angina pectoris is the medical term for chest pain or discomfort due to coronary heart disease. It occurs when the heart muscle doesn't get as much anginablood as it needs. This usually happens because one or more of the heart's arteries is narrowed or blocked, also called ischemia.

Angina often occurs when the heart muscle itself needs more blood than it is getting, for example, during times of physical activity or strong emotions.

There are many risk factors for coronary heart disease. Some include:

• Diabetes
• High blood pressure
• High LDL cholesterol and low HDL cholesterol
• Smoking

Other causes of angina include:

• Abnormal heart rhythms (usually ones that cause your heart to beat quickly)
• Anemia
• Coronary artery spasm (also called Prinzmetal's angina)
• Heart failure
• Heart valve disease
• Hyperthyroidism (overactive thyroid)

Angina is usually felt as:

• pressure,
• heaviness,
• tightening,
• squeezing, or
• aching across the chest, particularly behind the breastbone.

Patients may also suffer:

• indigestion,
• heartburn,
• weakness,
• sweating,
• nausea,
• cramping, and
• shortness of breath.

People with angina pectoris or sometimes referred to as stable angina have episodes of chest discomfort that are usually predictable and manageable. You might experience it while running or if you’re dealing with stress.

Normally this type of chest discomfort is relieved with rest, nitroglycerin or both. Nitroglycerin relaxes the coronary arteries and other blood vessels, reducing the amount of blood that returns to the heart and easing the heart's workload. By relaxing the coronary arteries, it increases the heart's blood supply.

If you experience chest discomfort, be sure and visit your doctor for a complete evaluation and, possibly, tests. If you have stable angina and start getting chest pain more easily and more often, see your doctor immediately as you may be experiencing early signs of unstable angina.

Angina Pectoris - 4 Nursing Diagnosis

1. Acute Pain

2. Activity Intolerance

3. Anxiety

4. Knowledge Deficit

NCP COPD - Ineffective Airway Clearance

Chronic obstructive pulmonary disease (COPD) also known as emphysema and chronic bronchitis is a very serious disease. COPD is one of the most common lung diseases.

There are two main forms of COPD:
Chronic bronchitis, which involves a long-term cough with mucus
Emphysema, which involves destruction of the lungs over time

Symptoms of COPD
Cough, with or without mucus
Fatigue
Many respiratory infections
Shortness of breath (dyspnea) that gets worse with mild activity
Trouble catching one's breath
Wheezing

In COPD, less air flows in and out of the airways because of one or more of the following:

The airways and air sacs lose their elastic quality.
The walls between many of the air sacs are destroyed.
The walls of the airways become thick and inflamed.
The airways make more mucus than usual, which can clog them.

Nursing Care Plan for COPD

Nursing Diagnosis : Ineffective Airway Clearance related to the disruption of production increased secretions, retained secretions

Goal : Ventilation / oxygenation to the needs of clients.

Expected outcome : Maintain a patent airway and breath sounds clean

Interventions :

Assess the patient to a comfortable position, such as raising the head of the bed, seat and backrest of the bed.
Review / monitor respiratory frequency, record the ratio of inspiration / expiration.
Auscultation for breath sounds, record the sound of breath for example: wheezing, and rhonchi krokels.
Observation of the characteristic cough, for example: persistent, hacking cough, wet, auxiliary measures to improve the effectiveness of the airway.
Note the presence disepnea, for example: complaints restlessness, anxiety, respiratory distress.
Help the abdominal breathing exercises or lip.
Bronchodilators, eg, β-agonists, efinefrin (adrenaline, vavonefrin), albuterol (Proventil, Ventolin), terbutaline (brethine, brethaire), isoeetrain (brokosol, bronkometer).
Increase fluid intake to 3000 ml / day according to tolerance of the heart.

Risk for Infection - NCP Anemia

Risk for Infection related to inadequate secondary defenses (decreased hemoglobin, leukopenia, or a decrease in granulocytes (inflammatory response depressed)).

Goal: Infection does not occur.
Expected outcomes:

• identify behaviors to prevent / reduce the risk of infection.
• improve wound healing, free purulent drainage or erythema, and fever.

Intervention and Rational:

1. Maintain strict aseptic technique on the procedure / treatment of wounds.
Rational: to reduce the risk of colonization / infection of bacterial

2. Increase good hand washing; by the care givers and patients.
Rational: to prevent cross contamination / bacterial colonization.

.3. Give skin care, oral and perianal carefully.
Rational: reducing the risk of damage to the skin / tissue and infection.

4. Increase enter adequate fluids.
Rational: to assist in the dilution secret breathing to ease spending and prevent stasis of body fluids such as respiratory and kidney.

5. Motivation changes in position / ambulation often, coughing and deep breathing exercises.
Rationale: increased pulmonary ventilation all segments and help mobilize secretions to prevent pneumonia.

6. Monitor body temperature. Note the chills and tachycardia with or without fever.
Rational: the process of inflammation / infection require evaluation / treatment.

7. Monitor / limit visitors. Provide insulation where possible.
Rational: limiting exposure to bacteria / infection. Protection of insulation required in aplastic anemia, when the immune response is very disturbed.

8. Observe erythema / wound fluid.
Rational: indicators of local infection. Note: the formation of pus may not exist when granulocytes depressed.

9. Take a specimen for culture / sensitivity as indicated (collaboration)
Rational: to distinguish the presence of infection, identify specific pathogens and influence the choice of treatment.

10. Leave a topical antiseptic; systemic antibiotics (collaboration).
Rational: may be used to reduce colonization or prophylactic treatment for local infection process.

Postoperative Care for Otosclerosis

Otosclerosis is a disease of the bone surrounding the inner ear. It can cause hearing loss when abnormal bone forms around the stapes, reducing the sound that reaches the inner ear. This is called conductive hearing loss. Less frequently, otosclerosis can interfere with the inner ear nerve cells and affect the production of the nerve signal. This is called sensorineural hearing loss.

Causes of Otosclerosis

There is a specific gene, which if present in the patient’s genetic make up, can result in the development of otosclerosis. Some medical studies have implicated the measles virus as a factor in causing otosclerosis. In some women with otosclerosis, pregnancy can accelerate the process.

Symptoms of Otosclerosis

Otosclerosis tends to target one ear at first, but both ears are eventually affected. The condition doesn’t cause total deafness. The symptoms of otosclerosis include:

• Gradual but progressive loss of hearing
• Hearing may improve in noisy conditions
• Sensations of ringing in the ears (tinnitus)
• Dizziness.

Treatment of Otosclerosis

There is no known cure for otosclerosis. The individual with otosclerosis has several options: do nothing, be fitted with hearing aids, or surgery. No treatment is needed if the hearing impairment is mild. 
Hearing aids amplify sounds so that the user can hear better. The advantage of hearing aids is that they carry no risk to the patient. An audiologist can discuss the various types of hearing aids available and make a recommendation based on the specific needs of an individual.

As hearing aids work well and are completely safe, many patients with otosclerosis decide not to undergo surgery. However, surgery does offer the chance of returning the hearing to normal so that a hearing aid is not required. Surgery can also have a stabilising effect on the otosclerotic process and can offer some degree of protection against otosclerosis advancing to the inner ear.

Postoperative Care of Otosclerosis

1. Do not blow your nose for three weeks following surgery. If you sneeze or cough keep your mouth open.
2. Avoid any heavy lifting (over 4 kg), straining or bending for three weeks following surgery
3. Keep your head elevated as much as possible. Sleep and rest on 2-3 pillows if possible.
4. Do not get water in your ear. If showering/washing your hair, place a cotton wool ball coated in Vaseline in the car canal to seal it. If there is a separate incision keep this dry until your first post-operative visits.
5. If you wear glasses either remove the arm on the operated side, or make certain that it does not rest on the incision behind your ear for one week.
6. Replace the cotton wool ball daily until your first post-operative visit.
7. Take your oral antibiotic as prescribed.
8. You may use Panadol, Panadeine or Panadeine Forte for pain. Do NOT use Aspirin or other analgesics.
9. If there is a separate incision a small amount of drainage may occur from this area also. If the drainage is profuse or develops a foul odour contact us.
10. Popping sounds, a plugged sensation, ringing or fluctuating hearing may be occur during healing.
11. Avoid travel by air for three weeks following surgery.
12. If you should notice any swelling, redness or excessive pain, contact us.
13. Some dizziness may occur after surgery. If severe or is associated with nausea or vomiting, contact us.
14. Please contact our office to make an appointment to be seen 7-10 days after the time of your surgery unless stated otherwise by your physician.

Reference : http://www.ent.com.au/Otosclerosis%20and%20Stapedectomy.htm

Activity Intolerance related to Fatigue

Fatigue NANDA Definition: An overwhelming, sustained sense of exhaustion and decreased capacity for physical and mental work at usual level

Defining Characteristics: Inability to restore energy even after sleep; lack of energy or inability to maintain usual level of physical activity; increase in rest requirements; tired; inability to maintain usual routines; verbalization of an unremitting and overwhelming lack of energy; lethargic or listless; perceived need for additional energy to accomplish routine tasks; increase in physical complaints; compromised concentration; disinterest in surroundings, introspection; decreased performance; compromised libido; drowsy; feelings of guilt for not keeping up with responsibilities.

Activity Intolerance Nanda Definition : Insufficient physiological or psychological energy to endure or complete required or desired daily activities.

Congestive Heart Failure is a condition in which the heart's function as a pump is inadequate to meet the body's needs.

Congestive heart failure can be caused by:

• diseases that weaken the heart muscle,
• diseases that cause stiffening of the heart muscles, or
• diseases that increase oxygen demand by the body tissue beyond the capability of the heart to deliver adequate oxygen-rich blood.

The symptoms of congestive heart failure vary, but can include fatigue, diminished exercise capacity, shortness of breath, and swelling.

The treatment of congestive heart failure can include lifestyle modifications, addressing potentially reversible factors, medications, heart transplant, and mechanical therapies.


Nursing Diagnosis and Interventions : Activity Intolerance related to Fatigue

Goal: an increase in tolerance to the client after nursing actions performed during the hospital

Expected outcomes:

• Heart rate: 60-100 x / min
• Blood pressure: 120-80 mmHg

Interventions:
1. Assess the patient's response to the activity, note pulse rate over 20 beats per minute above the resting frequency; significant increase in blood pressure during / after activity (systolic pressure increased by 40 mmHg or diastolic blood pressure increased by 20 mmHg), dyspnea or chest pain; fatigue and weakness redundant; diaphoresis; dizziness or fainting.

2. Instruct patients about energy saving techniques, eg, using the bath seat, sitting as combing hair or brushing teeth, doing activities slowly.

3. Encourage activity / self-care gradually if tolerated, provide assistance as needed.

Rational:

1. Mention parameter helps in assessing the response to stress physiology and activity, when there is an indicator of excess work-related activity levels.

2. Energy-saving techniques to reduce the use of energy, it also helps balance between supply and demand of oxygen

3. Progress activity increased gradually to prevent sudden cardiac work. Gave the aid was limited to the need for encouraging independence in their daily activities.

Most Common Causes of Fatigue

Fatigue also referred exhaustion, tiredness, lethargy, languidness, languor, lassitude, and listlessness describes a physical and/or mental state of being tired and weak. Unlike weakness, fatigue can be alleviated by periods of rest. Fatigue can have physical or mental causes.

Physical Fatigue

Physical fatigue is the transient inability of a muscle to maintain optimal physical performance, and is made more severe by intense physical exercise.

Psychological (mental) Fatigue

Mental fatigue is a transient decrease in maximal cognitive performance resulting from prolonged periods of cognitive activity. It can manifest as somnolence, lethargy, or directed attention fatigue.

Most Common Causes of Fatigue

1. Cardiac Problems

If you have problems with the heart, such as coronary artery disease or heart failure, the ability of the heart to supply oxygen-rich blood to the heart muscle and the rest of the body will be impaired. This may result in poor exercise tolerance and fatigue.

A sudden change in your exercise tolerance can be an early sign of heart problems such as coronary artery disease. Approximately one third of patients with underlying heart disease have no signs or symptoms (such as chest pain or myocardial infarction). The first sign of any underlying problem in this one third is sudden death. Therefore, it is imperative that you seek further evaluation if you are noticing increased fatigue that is not easily explained.

2. Anemia

A decrease in the amount of oxygen-carrying substance (hemoglobin) found in red blood cells (anemia). This may occur from blood loss related to intestinal bleeding, menstruation, and trauma. Chronic blood loss can result in iron deficiency which is required for the body to maintain appropriate hemoglobin levels required to carry oxygen. Nutritional deficiencies such as Vitamin B12 and folate can also result in anemia.

3. Kidney and Liver Abnormalities

Patients with kidney disease and liver disease have impaired ability to eliminate the waste products of the body. If the level of these chemicals get too high the patient will begin to experience weakness and fatigue.

4. Metabolic Disorders

Patients with metabolic disorders, such as diabetes, have impaired ability to utilize sugar (glucose) which is required to form energy for the body and organs.

5 Thyroid Abnormalities

Abnormalities of the thryoid gland may result in fatigue. It is important to determine if your thyroid gland is performing appropriately. If your gland is underactive you will require thyroid medication to restore your bodies normal levels. This will improve your energy and help with fatigue.

Fatigue may be related to an overactive or high thyroid level (hyperthyroidism). An overactive thyroid requires further evaluation. You may require radioactive ablation to destroy the overactive thyroid tissue. Other options include medication to control the symptoms caused by an overactive thyroid or medication to block the effects of the excess thyroid hormone in your body.

6. Mental Health Problems

Mental health problems can result in fatigue. Patients suffering from anxiety and depression will frequently complain of fatigue. This is an important consideration if no medical explanation for fatigue can be found. Anxiety and depression can also develop in someone with other chronic health problems, so it is important that a thorough evaluation be performed by your health care provider.

7. Chronic Fatigue

Chronic fatigue syndrome is an uncommon cause of severe, persistent fatigue. It is commonly associated with a previous viral infection such as epstein barr virus.