body temperature above normal—occurs because the body cannot promote heat loss fast enough to balance heat production or high environmental temperatures- can lead to heat, exhaustion and heat stroke.
Heat Exhaustion—weakness, nausea, vomiting, syncope, tachycardia, tachypnea, muscle aches, headache, diaphoresis, and flushed skin
Heat stroke- above 103—rapid strong pulse, throbbing headache, delirium, confusion, impaired judgment, lethargy, red hot dry skin, dizziness, and coma. Over 106 Degrees death can occur.
Interventions—monitor temp Q2, observe for clinical signs that accompany a fever, provide antibiotics if necessary, replace fluids, cooling blankets, alcohol or tepid baths, cloth covered ice packs or cool washcloths to the groin, neck or axillae, circulating fan, minimal bed covers, maintain nutritional status, water soluble lip lubricant, keep lining and clothes dry
abnormally low core temperature, less than 95 degrees. As the temperature drops the metabolic process slows, prolonged exposure is no longer corrected by shivering and may become fatal; may be associated with extended periods such as: surgery, extreme weather, immersion in cold water, or lack of shelter & clothing.
S/S—shivering, cyanosis, poor coordination—patient will experience mental impairment, confusion. disorientation, slowing of the HR, and respirations,
Severe hypothermia occurs when the body temp drops below 82.4—patient becomes unconscious and stops shivering, pulse and respirations irregular and difficult to detect, death usually occurs when temp falls below 70-75 Degrees F.
Interventions—Provide dry warm clothing blankets and environment, warmed IV fluids, heating pads, eating blankets, warm, sweet drinks, DO NOT USE electric blankets, or DO NOT apply pulse ox to a vasoconstricted finger.
S/S: flank pain at the CVA, fever, and chills. Patients may feel painful urination, frequency, nocturia, nausea, vomiting, colicky abdominal pain; may have a quiet presentation of frequency, dysuria, nocturia, mild intermitted fever or back/flank pain. Monitor VS, fluid balance, adequate hydration, accurae I&O, 2 liters per day at least, IV access, WBC, BUN and Creat monitor, Pain management. adequate pain management via usual analgesics and urinary antiseptics, such as phenazopyridine (Pyridium) or a combination urinary antiseptic or antispasmodic agent, such as urised (Urisedon or Urisedamine) or urisept (Uriseptic). Low—Liver failure, CHF, Excessive sodium loss, NVD, skin and kidneys
Interventions (Low)—Sodium containing IV fluids, lactated Ringers, NS 0.9% or 0.3%.
High—Dehydration, NVD, Excessive Sweating, DKA, Fever
Interventions (High)—replace fluids d5% Diuretics.
Low—Inadequate intake of K, ETOH abuse, CHF, HTN, Renal Loss, Loop Diuretics.
Interventions (low)—Oral/Parental, K+, Diet Increase in K, Balanced electrolyte solution... Pedialyte, Gatorade, powerade.
High—Metabolic Acidosis, dehydration, Increase in K intake, K sparing diuretics, Renal failure.
Interventions (high)—Insulin, d50% IV, CA, gluconate, sodium bicarbonate.
Low—ETOH abuse, pancreatitis, chronic renal failure, Vit D decrease, lack of weight bearing, loop diuretics, hypomagnesium
Interventions (Low)—Oral Ca/ gluconate Calcium Chloride
High—Prolonged immobilization, dehydration, cancer, excess antacid intake
Interventions (high)—Eliminate through kidneys through IV fluids, & Diuretics
Low—Chronic alcoholism, GI loss, V/D, impaired absorption, Renal disease, Pancreatitis.
Interventions (Low)—Treat underlying cause, GI loss, give mag
High—Dehydration, metabolic acidosis, renal failure, tissue trauma
Interventions (High)—Dialysis, treat underlying cause, monitor cardiac and increased PVC's or V-Tach, Calcium/ Gluconate.
Low—Alcoholism, Increase CA, Decrease phos in diet, Poor nutrition, decreased in vit d, hyperparathyroid.
Interventions (Low)—increase phos in diet, give mag or vit d, IV phos
High—DKA, kidney failure, liver disease, Increase in vit d, increase phos, hypoparathyroid
Interventions (High)—Monitor heart, decrease phos in diet, treat underlying cause, dialysis, IV saliene.
S/S include = abnormal breathing, redness, swelling, hives, wheezing, coughing, stuffy nose, watery eyes, fever.
Support of airway, breathing and circulation for anaphylaxis. Education should include: avoiding contact with pathogen initiating anaphylactic response, proper use of an EpiPen for self-administration of epinephrine.
7th EditionGary A. Thibodeau, Kevin T. Patton
7th EditionJulie S Snyder, Linda Lilley, Shelly Collins
7th EditionKathryn A Booth, Leesa Whicker, Sandra Moaney Wright, Terri D Wyman
9th EditionCarlene Harrison, Karen Judson