A 12-year-old boy was admitted to the hospital two days ago due to hyperthermia. His attending nurse, Dennis, is quite unsure about his plan of care. Which of the following nursing interventions should be included in the care plan for the client?
A. Room temperature reduction
B. Fluid restriction of 2,000 ml/day
C. Axillary temperature measurements every 4 hours
D. Antiemetic agent administration
Correct Answer: A. Room temperature reduction
For the patient with hyperthermia, reducing the room temperature may help decrease the body temperature. Tepid baths, cool compresses, and cooling blankets may also be necessary. Adjust and monitor environmental factors like room temperature and bed linens as indicated. Room temperature may be accustomed to near normal body temperature and blankets and linens may be adjusted as indicated to regulate the temperature of the patient.
Option B: Fluids should be encouraged, not restricted to compensate for insensible losses. Monitor fluid intake and urine output. If the patient is unconscious, central venous pressure or pulmonary artery pressure should be measured to monitor fluid status. Fluid resuscitation may be required to correct dehydration. The patient who is significantly dehydrated is no longer able to sweat, which is necessary for evaporative cooling.
Option C: Tympanic or rectal temperature measurements are generally accepted and are more accurate than axillary measurements. Monitor the patient’s HR, BP, and especially the tympanic or rectal temperature. HR and BP increase as hyperthermia progresses. Tympanic or rectal temperature gives a more accurate indication of core temperature.
Option D: Antipyretics, and not antiemetics, are indicated to reduce fever. Give antipyretic medications as prescribed. Antipyretic medications lower body temperature by blocking the synthesis of prostaglandins that act in the hypothalamus.
No comments:
Post a Comment