Unit 3: Hyperthermia Flashcards
1
Q
Hyperthermia
A
- body temperature of more than 103 degrees F
- occurs when the body produces or absorbs more heat than it can dissipate
- medical emergency; requires immediate treatment to prevent disability or death
2
Q
Risk Factors for Hyperthermia in the very young, less than 5 years of age
A
- produce proportionally more metabolic heat
- core body temperature rises faster in response to dehydration
- smaller organ system that is not efficient in dissipating heat
3
Q
Risk Factors for Hyperthermia in older adults, older than 65 years of age
A
- more commonly have a chronic illness that interferes with normal thermoregulation such as chronic lung or heart disease
- more likely to be taking medications that alters the body’s response to heat
4
Q
Medication taken by older adults that alter the body’s response to heat
A
- Phenothiazines, which depress the hypothalamus
- Anticholinergic medications, which inhibit sweating
- Diuretics, which cause or exacerbate dehydration
- TCAs and amphetamines, which stimulate the hypothalamus and increase muscle activity
- Beta blockers or calcium channel blockers, which decrease the cardiovascular response to heat
5
Q
Risk Factors for Hyperthermia
A
- Patients with an illness that causes a fever
- Patients that have diabetes, peripheral vascular disease, or uncontrolled hypertension
- Patients who have taken drugs or alcohol
- Athletes exercising strenuously in hot climates
- Obese people who generate more heart during activity and dissipate heat more slowly
6
Q
Pathophysiology of Hyperthermia
A
- the hypothalamus in the brain helps the body maintain a normal temperature by balancing heat production and heat loss
- during hot weather or in a hot environment, the body works to regulate its internal temperature by producing sweat, which cools the body as it evaporates
- a humid environment reduces evaporation of sweat and decreases cooling
- when the sweat does not evaporate effectively, or the person is not sweating at all, there is likelihood for a hear-related illness
7
Q
Heat Cramps
A
- painful, involuntary muscle spasms of the arms, legs, or abdomen that occur b/c of sweating profusely during strenuous activity
- loss of sodium, magnesium, or calcium is responsible for muscle cramps
- cramps last 1 to 3 minutes
- muscles are tender and hard, and patient may have some involuntary twitching
- skin is moist and cool
- temperature normal or slightly elevated; vital sign WNL
8
Q
Heat Edema
A
occurs when exposure to a hot environment causes swelling of the feet, ankles, and hands
9
Q
Heat Stress
A
occurs when your body can no longer regulate your temperature and you become too hot
10
Q
Heat Syncope
A
- occurs when standing still for an extended period or when moving too quickly from sitting to standing while in the heat
- occurs in response to a sudden drop in perfusion to the brain as the body tries to cool itself by diverting blood flow to the skin through peripheral dilation
- as a result of peripheral dilation and gravity, blood pools in the legs and blood pressure drops
- as a response to the pooling in the lower extremities, patient experiences dizziness, vertigo, tunnel vision, weakness, and nausea before finally losing consciousness
11
Q
Heat Exhaustion
A
- occurs when a person performs strenuous activity in a hot environment for an extended time without drinking enough fluid to replace sodium and water lost from profuse sweating
- symptoms: fatigue, weakness, dizziness, headache, N/V, and muscle cramps
- may have some confusion, but no neurological impairment
- may also be tachycardic, hypotensive, and tachypneic
- temperature higher than 100.4 Degrees F and lower than 104 Degrees F
12
Q
Heat Stroke
A
- medical emergency
- body’s thermoregulatory mechanism has failed, and body temperature rises uncontrollably
- immediate intervention to prevent organ damage and death
- classic heat stroke develops over several days during a heat wave
- Present with: red, dry skin; patient has stopped sweating altogether
- exertional heat stroke occurs in younger healthy people who are participating in strenuous physical activity; S/S of heat exhaustion and CNS dysfunction, which may appear as confusion, irrational behavior, delirium, seizures, or coma
- core temperature greater than 104 degrees F
- w/o immediate interventions pulmonary edema, dysrythmias, and rhabdomyolysis can occur
- hypovolemic shock, cardiogenic shock, and multiorgan failure can occur
13
Q
Medical Management of Hyperthermia
A
- vital to reduce the patient’s core temperature
- all interventions start with removal to a cooler environment and hydration
- heat stress or heat edema may require nothing more than moving to a cooler environment
- patient with heat syncope requires safety maneuvers to help prevent injury from falling; after being helped to the floor, the patient should be placed in the recovery position until full recovery of consciousness
- heat cramping requires rehydration with oral fluids containing electrolytes to correct fluid and electrolyte loss
14
Q
Cooling Interventions for the patient with heat exhaustion
A
- moving the patient to a cool environment
- have patient lie down and elevate his/her feet
- removal of extra clothing
- drink cool, nonalcoholic beverages; sports drinks, water, and fruit juices
- application of cool cloth or towel
- encourage individual to shower, bathe, or sponge off with cool water
- in hospital, cooling blankets, ice packs, or fans
- fluid replacement with IV 0.9% normal saline if vital signs are abnormal or patient is unable to tolerate oral fluid replacement
- rest for at least 24 hours before resuming normal activity
15
Q
Immediate Interventions for Heat Stroke
A
- reducing patients temperature (to approximately 102.2 Degrees F) is the number one priority b/c the duration of elevated temperature is the primary determinant of outcome
- attention to airway, breathing, and circulation is essential in resuscitating adequately
- requires intensive hemodynamic monitoring and continuous core temperature monitoring
- requires IV fluids
- avoid aggressive fluid resuscitation b/c it puts patient at risk for pulmonary edema d/t fluid overload
- Foley catheter for accurate measurement of intake and output
- cooling methods: ice packs to the axilla and groin, cooling blankets or fans, and submersion in tepid water if the patient’s condition allows
- treat agitation and shivering with benzodiazepines
16
Q
Nursing Management: Assessment and Analysis
A
- patients w/ early stage or mild hyperthermia such as heat stress or heat syncope sweat profusely
- patients w/ heat exhaustion manifest some mild symptoms of CNS dysfunction such as confusion
- patients w/ heat stroke manifest severe symptoms of CNS dysfunction such as delirium and seizures
- severe heat stroke results in dysrythmias and cardiac and/or respiratory failure
17
Q
Nursing Diagnoses
A
- ineffective airway clearance
- impaired gas exchange
- deficient fluid volume
18
Q
Nursing Assessments
A
- Vital signs with temperature
- Neurological status
- Skin assessment
19
Q
Assessment: Vital signs and with temperature
A
- continual monitoring of temperature is essential to determine severity of hyperthermia and effectiveness of the interventions
- hypotension and tachycardia may be present b/c of fluid loss
20
Q
Assessment: Neurological status
A
signs of CNS dysfunction such as confusion occur w/ heatstroke
21
Q
Assessment: Skin Assessment
A
- patients sweat profusely during early stages of hyperthermia
- skin becomes flushed and dry during later stages
22
Q
Nursing Actions
A
- Move the patients into a cool environment
- Encourage intake of oral fluids such as cool nonalcoholic beverages, fruit juices, or sports drinks
- Administer IV fluids as necessary; when fluid by mouth is not adequate or possible
- Active Cooling methods
23
Q
Patient Teaching
A
> Avoid hyperthermia
- avoid excessive activity in high-heat environments
- drink plenty of fluids in the heat and while exercising
- know the signs and symptoms of hyperthermia
24
Q
Evaluating Care Outcomes
A
- best treatment is prevention
- evaluating heat risk in the environment
- modulating activity as necessary in a hot environment
- drinking plenty of fluids
- well-managed patient is discharged alert and oriented, safe from injury or falls, and hemodynamically stable with a normal temperature and understanding of how to avoid future occurrences
25
Q
Connection Check: The nurse is caring for a patient who came into the ED with a temperature of 105 Degrees F. This patient was found at home in an apartment without air conditioning; the current heat wave has temperatures higher than 100 Degrees F for the last 3 days. Which of the following actions should the nurse plan to take first? A. Apply cooling blankets B. Obtain laboratory specimens C. Establish IV access D. Administer Tylenol
A
A. Apply Cooling Blankets
