Seizure Disorder, Todd’s Paralysis

January 5 2015

Estacio, Precious Ann S.

I. Patient Profile

a. Demographics

Name: DML Religion: Roman CatholicHospital Number: 00429430 Occupation: Not ApplicableBirthday: November 10, 2009 Civil Status: SingleAge: 5 years old Educational Attainment: Student

b. Nursing Assessment: Neurological Assessment: GCS: 15 E4: Spontaneous, M6: Obeys, V5: Oriented to time place and person.Cardiovascular/Peripheral Assessment: Full and Symmetric peripheral pulsations, Apical Heart rate of 115-138 beats per minute. Respiratory Assessment: Clear breath sounds. Symmetrical chest expansion. Respiratory rate of 32-35 cycles per minute. Nail beds and mucous membranes are pink. Capillary refill test 3 seconds.EENT Assessment: Normocephalic and symmetric, with frontal, parietal and occipital prominences. Symmetric facial movements. Hair evenly distributed. Pink palpebral conjunctiva. Pupils black in color, equal in size 3mm in diameter. Pupils equally round and reactive to light and accommodation. Auricles are mobile, firm, and not tender. Audible in normal voice tone. Pink nasal mucosa with nasal septum intact and in midline. No lesion or discharge noted. Moist, smooth and soft Lips and buccal mucosa. Neck Muscles are Coordinated, Smooth Movements with no discomfort. No noted tenderness on throat. Gastrointestinal Assessment: Rounded Abdomen, Normo-Active bowel Sounds heard in all four quadrants. No pain upon palpation. Patient was able to tolerate full meals. Genitourinary Assessment: Light yellow colored urine with no presence of bleeding.Integumentary Assessment: Skin color is brown generally uniformed in all areas of body. No visible signs of skin problems or trauma. Skin is warm to touch, smooth and shiny in appearance. Noted Good skin turgorMusculoskeletal Assessment: Right side body weakness, occasional mild stiffening of right leg with flaccid right arm, unable to walk properly. Psychological Assessment: Normal affect, response appropriate in certain situationsCoping Stress Tolerance Assessment: Good support system mainly the family regarding financial and emotional/physical wellbeing of the patient Values-Belief Assessment: No religion restrictions with regards to treatment.Intravenous Therapy Assessment: D5IMB 500ml x 49 cc/hr inserted at right metacarpal vein, patent and intact, no redness and swelling on surrounding site noted. Dressing is dry and intact.

II. Sample

Signs and Symptoms Fever 38.4C, Entire body stiffening with jerking movements and upward rolling of the eyeballs

Allergies No known AllergiesMedication Paracetamol, Diazepam, Valproic AcidPast Medical History Amoebiasis (2014)Last Meal Taken Chicken, rice and BananaEvents That Lead to Prior to admission Dec. 6 2014 patient was first hospitalized to St. James Admission Hospital at Sta. Rosa, where he is diagnosed of ameobiasis with first

time occurrence of seizure episode, after 4 days of hospitalization and upon discharged on Dec. 16, 3 episodes of seizure lasting to 15- 20 second happened at home, 8 episode of occasional leg and hand stiffening and jerking movement lasting about a minute. 2nd admission on Dec. 19 on same hospital with EEG lab result done at Calamba Doctors, Dec. 23 follow up with their neuropedia, his father forgot to bring lab results but was able to obtain a video of his son on his seizure episode, Doctor and the father got an argument that he opted to consult another specialized doctor in Asian hospital hence admitted his son on Dec. 25 with ongoing recurrences of seizures.

III. Introduction

What happens inside your child's brain during a seizure? Here is a simplified explanation: Your brain is made up of millions of nerve cells called neurons, and these cells communicate with one another through tiny electrical impulses. A seizure occurs when a large number of the cells send out an electrical charge at the same time. This abnormal and intense wave of electricity overwhelms the brain and results in a seizure, which can cause muscle spasms, a loss of consciousness, strange behavior, or other symptoms.

Anyone can have a seizure under certain circumstances. For instance, a fever, lack of oxygen, head trauma, or illness could bring on a seizure. People are diagnosed with epilepsy when they have seizures that occur more than once without such a specific cause. In most cases -- about seven out of 10 -- the cause of the seizures can't be identified. This type of seizure is called "idiopathic" or "cryptogenic," meaning that we don't know what causes them. The problem may be with an uncontrolled firing of neurons in the brain that trigger a seizure.

Seizures are over so quickly that your doctor probably will never see your child having one. The first thing a doctor needs to do is rule out other conditions, such as nonepileptic seizures. These may resemble seizures, but are often caused by other factors such as drops in blood sugar or pressure, changes in heart rhythm, or emotional stress.

Your description of the seizure is important to help your doctor with the diagnosis. You should also consider bringing the entire family into the doctor's office. The siblings of children with epilepsy, even very young kids, may notice things about the seizures that parents may not. Also, you may want to keep a video camera handy so that you can tape your child during a seizure. This may sound like an insensitive suggestion, but a video can help the doctor enormously in making an accurate diagnosis.

Todd's paralysis is a neurological condition characterized by a brief period of transient (temporary) paralysis following a seizure. The paralysis — which may be partial or complete — generally occurs on one side of the body and usually subsides completely within 48 hours. Todd's paralysis may also affect speech or vision. The cause is not known. Examination of an individual who is experiencing or who has just experienced Todd's paralysis may help physicians identify the origin of the seizure. It is important to distinguish the condition from a stroke, which requires different treatment

The researcher chose this study because it is rare and a mystery for everyone, it is simple yet very informative to study this case.

The researcher would like to thank the father and the patient for the cooperation and the statements to make this study complete, also the researcher used the patient’s chart as the basis of this study which is validated by the family and the patient. This study focuses on the second day the patient was admitted and handled by the care of the researcher on 6th floor

IV. Anatomy and Physiologya. Seizure

The word "seizure," when used accurately, describes the excessive, chaotic discharge of cerebral neurons. The actual seizure is the aberrant neuronal activity taking place in the brain. The resultant observable events (such as tonic-clonic jerky movements of the musculoskeletal system; bowel and/or bladder incontinence; biting of the buccal mucosa and/or tongue; and accompanying "post-ictal" period of confusion) are somatic, neurological and musculoskeletal manifestations of the "neuronal seizure" activity.

The brain, spinal cord, and musculature interact via nerve cells called neurons, the functional units of the central nervous system.

The neuron is made up of a soma or cell body; dendrites that receive information from other axons or various receptors; and axons that transmit information from the cell body to the terminal boutons at the distal end of the axons. Neurons interface with other nerve cells via small gaps called synapses. At the synapse, an axonal terminal bouton is in close proximity to a dendrite of another axon. At the synapse, a chemical neurotransmitter is released from the axonal terminal bouton as a result of an action potential, the electrophysiologic voltage change manifested in the axon due to a transient variation in the sodium and potassium permeability of the axon. This neurotransmitter diffuses across the synapse and binds to receptors on the dendrites of the next axon.

When the permeabilities of the membrane's ionic channels for sodium and potassium are varied sequentially, a fluctuation in the membrane voltage occurs, which is termed the action potential.

As the sodium attempts to enter the nerve cell, the potassium permeability increases as the potassium channels open, and the membrane begins to repolarize to the "resting" membrane potential. The nerve cell repolarizes and is ready for the next action potential to come along. These action potentials are also modified by the flux of chloride ions and the presence or absence of GABA activity in the membrane of the axon.

The pathways for information exchange between the brain and musculature can be divided into two general groups. One group of neurons provides afferent (sensory) input to the spinal cord and brain from the skeletal muscle and various receptors in the muscle and skeletal tissue, ligaments and tendons. Another group of neurons provide efferent (motor) output from the brain and spinal cord to the musculature or muscular motor unit.

A neuron or group of neurons in the brain can become hyperexcitable or irritable due to hypoxia, ischemia, hypoglycemia, or electrolyte abnormalities that affect the action potential and cause these nerve cells to discharge action potentials irregularly without adequate suppression and attenuation of the abnormal activity. If this occurs, the corresponding muscle fascicles may begin to contract inappropriately, thus producing seizure-like activity.

Depending on where the focus of this aberrant discharge is in a particular region of the brain, the corresponding motor or sensory area will be affected, leading to either motor symptoms such as tonic-clonic contractions or sensory manifestations of seizure-like activity, such as paresthesias, déjà vu, or hallucinations (auditory, visual, or olfactory).

These foci of aberrant electrical activity (the seizure) may be isolated, or the focus may spread and involve various areas of the brain, leading to chaotic, uninhibited discharge of electrical activity of various neurons in the brain. The resultant motor and/or sensory activity manifested by and experienced by the patient is clinically described as a seizure.

Control of the seizure can be accomplished by suppressing the action potential via manipulation of sodium and potassium ion permeabilities, rendering the axon refractory to the action potential, or blocking transmission of impulses at the synapse by blocking the neurotransmitter from binding to its receptor site, or preventing its release and/or synthesis.

V. Pathophysiology Nervous System

Etiology/Factors

-an electrical disturbance in the nerve cell in one section of the brain, causing (hypoxemia, then to emit abnormal, recurring, uncontrolled injury, electrical discharges.

Predisposing factor

-idiophatic (genetic, developmental defects)

-acquired vascular insufficiency, fever (childhood), head injury, hypertension, CNS infections, metabolic and toxic conditions, brain tumor, drug and alcohol withdrawal and allergies

Cellular/Metabolic Changes

-when the integrity of the neuronal cell membrane is altered, the cell begins firing with increased frequency and amplitude. When the intensity discharges reaches the threshold, the neuronal firing spreads to adjacent neurons, ultimately resulting to seizure. Inhibitory neurons have slow neuronal firing in the cortex. Anterior thalamus, and basal ganglia. Once the inhibitory processes develop or the epileptogenic neurons are exhausted, the seizure stops then later events depress the CNS activity and impair consciousness.

Gross Anatomical Physical Changes

-involuntary movements may spread centrally and involve the entire limb, including one side of the face and lower extremities. The client also may exhibit changes in posture or spoken utterances.

Physiologic Manifestation

-epigastric sensation, pallor, sweating, flushing, goose flesh, (piloerection) pupillary dilation, tachycardia and tachypnea.

Signs and Symptoms

Tonic phase:

-fall, loss of consciousness, yell or “tonic cry”, extension of arms, legs and/or face, fingers and jaw clenched. AUTONOMIC SYMPTOMS include increase in blood pressure, heart rate and bladder pressure, flushing, sweating, increased salivation and bronchial secretion and apnea.

Clonic phase:-muscle relax completely, then muscle tone returns which causes rhythmic jerking of head and body.

Post-Ictal phase:-biting of the tongue, cheek or lip, and urinary incontinence are common.

Laboratory Findings

-MRI may detect lesions in the brain, focal abnormalities and cerebral degenerative changes

-EEG may allow diagnosis of the type and include increase in blood pressure, flushing, sweating, increased salivation and bronchial secretion, occurring seizure.

-SPECT may identify the epileptogenic zone area in the brain giving rise to seizure can surgically seizure

Complications

-Hypoxic Brain damage and mental retardation may follow repeated seizures

-Depression and anxiety may develop. Long Term social isolation may occur

-“Noong bata sya parati syang nagkakalagnat ng sobrang taas hindi nya kinakaya, kinukumbulsyon sya” as verbalized by the father.

-Still recovering from Amoebiasis (2014)

Musculoskeletal Assessment: Right side body weakness, occasional mild stiffening of right leg with flaccid right arm, unable to walk properly.

Cardiovascular/Peripheral Assessment: Full and Symmetric peripheral pulsations, Apical Heart rate of 115-138 beats per minute.

Respiratory Assessment: Clear breath sounds. Symmetrical chest expansion. Respiratory rate of 32-35 cycles per minute.

“kapag namanhid ung kanang paa nya alam nya na magsisimula na syang manginig” as verbalized by the father

EEG

This is an abnormal sleep, drowsy and awake EEG study due to the presence of intermittent epileptiform activities coming from the left parietal lobe with occasional spread towards the left centro-pareital and temporal areas predisposing the patient to focal epilepsy with secondary generalization.

Todd's paralysis is a neurological condition characterized by a brief period of transient (temporary) paralysis following a seizure.

VI. Medical and Nursing Management

Laboratory ExamDiagnostic Exam

Rationale Nursing InterventionNursing Responsibilities

Blood Urea Nitrogen 4.2mmmol/L

Creatinine 31.0 umol/L

ALT/SGPT 20.0 (Low)

Valproic Acid (Depakene) 774.2 umol (Therapeutic)

Monitoring of liver enzymes, blood cell counts and Depakene levels have increased the safety and efficacy of Depakene.

Tell the patient that the BUN test is used to evaluate kidney function. ALT/SGPT and Depakene to monitor medications that cause liver-related side effects

Inform the patient that he need not to restrict food and fluids, but should avoid diet high in meat.

Tell the patient that the test requires a blood sample. Explain who will perform the venipuncture and when.

Explain to the patient that he may experience slight discomfort from the tourniquet and needle puncture.Notify the laboratory and physician of medications the patient is taking that may affect test results; they may need to be restricted.

Laboratory Exam Rationale Nursing Intervention

Diagnostic Exam Nursing ResponsibilitiesUrinalysisRoutine Physical ExamColor yellowTransparency clearChemical ReactionGlucose negativeBilirubin NegativeKetone traceSpecific Gravity 1.010Blood Negative pH 7.0Protein NegativeUrobilinogen NegativeNitrite NegativeLeucocyte NegativeMicroscopic Exam By FCMRBC 0.9/uLWBC 0.3/uLEPITHELIAL Cells 0.7/uL Type SquamousCast 0.0Bacteria 25.4

It is part of baseline, screening and evaluation based on patient’s symptoms.

Collect specimens form infants and young children into a disposable collection apparatus consisting of a plastic bag with an adhesive backing around the opening that can be fastened to the perineal area or around the penis to permit voiding directly to the bag. Depending on hospital policy, the collected urine can be transferred to an appropriate specimen container.

Cover all specimens tightly, label properly and send immediately to the laboratory.

If a urine sample is obtained from an indwelling catheter, it may be necessary to clamp the catheter for about 15-30 minutes before obtaining the sample. Clean the specimen port with antiseptic before aspirating the urine sample with a needle and a syringe.

Observe standard precautions when handling urine specimens.

If the specimen cannot be delivered to the laboratory or tested within an hour, it should be refrigerated or have an appropriate preservative added.

Laboratory ExamDiagnostic Exam

Rationale Nursing InterventionNursing Responsibilities

Brain MRINormal MRI of the Brain

Imaging tests that allow a doctor to view the brain and evaluate the cause and location of a possible source of epilepsy within the brain. The scans can reveal scar tissue, tumors, or structural problems in the brain that may be the cause of seizures or epilepsy.

Make sure the scanner can accommodate the patient’s weight and abdominal girth.

Patient PreparationExplain to the patient that skeletal MRI assesses bone and soft tissue. Tell him who will perform the test and where it will take place.

Explain that the test takes 30 to 90 minutes.

Explain to the patient that although MRI is painless and involves no exposure to radiation from the scanner, a contrast medium may be used, depending on the type of tissue being studied.

If the patient is claustrophobic or if extensive time is required for scanning, explain to him that a mild sedative may be administered to reduce anxiety. Open scanners have been developed for use on the patient with extreme claustrophobia or morbid obesity, but tests using such machine take longer.An anesthesiologist may need to be present to monitor a heavily sedated patient.

Tell the patient that he must lie flat, and describe the test procedure.

Explain to the patient that he’ll hear the scanner clicking, whirring, and thumping as it moves inside its housing.

Reassure the patient that he’ll be able to

communicate with the technician at all times.

Instruct the patient to remove all metallic objects, including jewelry, hairpins, or watches.Stop I.V. infusion pumps, feeding tubes with metal tips, pulmonary artery catheters, and similar devices before the test.

Ask whether the patient has any surgically implanted joints, pins, clips, valves, pumps, or pacemakers containing metal that could be attracted to strong MRI magnet. If he does, he won’t be able to have the test.

Note and report all allergies.

Make sure that the patient or a responsible family member has signed an informed consent form, if required.

ProcedureAt the scanner room door, check the patient one last time for metal objects.

The patient is placed on a narrow, padded, nonmetallic table that moves into the scanner tunnel. Fans continuously circulate air in the tunnel, and a call bell or intercom is used to maintain verbal contact.

Remind the patient to remain still throughout the procedure.

While the patient lies within the strong

magnetic field, the area to be studied in stimulated with radio-frequency waves.

If the test is prolonged with the patient lying flat, monitor him for orthostatic hypotension.Provide comfort measures and pain medication as needed and ordered because of prolonged positioning in the scanner.

After the test, tell the patient that he may resume his usual activity.

Provide emotional support to the patient with claustrophobia or anxiety over his diagnosis.

Laboratory ExamDiagnostic Exam

Rationale Nursing InterventionNursing Responsibilities

EEGThis is an abnormal sleep, drowsy and awake EEG study due to the presence of intermittent epileptiform activities coming from the left parietal lobe with occasional spread towards the left centro-pareital and temporal areas predisposing the patient to focal epilepsy with secondary generalization.

A computer records your brain's electrical patterns as wavy lines. The EEG may show abnormal spikes or waves in brain's electrical activity patterns.

Explain the procedure, emphasizing the importance of cooperation.

Withhold fluids, foods, and medications (as prescribed) thatmay stimulate or depress brain waves.These include anticonvulsants,tranquilizers, depressants, and caffeine-containingfoods (e.g., coffee, tea, colas, and chocolate).

Medications areusually withheld for 24 to 48 hours before the test. Help the client wash the hair before the test.

Drug Name

Route, Dose and

Frequency

Indication Mechanism of Action

Side Effects Adverse Effects

Nursing Considerations

Generic Name: ParacetamolBrand Name:

Biogesic Class:

Antipyretic, Analgesia

Route: IntravenousDose: 140mgFrequency: As needed

Mild to moderate pain caused by headache, muscle ache, backache, minor arthritis, common cold, toothache or menstrual cramps; fever

Fever Reduction may result from vasodilation and increased peripheral blood flow in hypothalamus, which dissipates heat and lowers body temperature.

rash, itching/swelling (especially of the face/tongue/throat), severe dizziness, trouble breathing...

Rash, urticarial, thrombocytopenia, haemolytic anemia, neutropenia, leukopenia, pancytopenia, heptotoxicity

Assess patient’s pain or temperature before giving medication

Determine Intervals of at least 4 hours after the last medication

Drug Name

Route, Dose and Frequency

Indication Mechanism of Action Side Effects Adverse Effects Nursing Considerations

Generic Name: Valproic AcidBrand Name:

Depakene Class: Anti

epileptic

Route: OralDose: 2.5mlFrequency: once a day

Sole and adjunctive therapy in simple (petit mal) and complex absence seizuresAdjunctive therapy with multiple seizure types, including absence seizures

antiepileptic activity may be related to the metabolism of the inhibitory neurotransmitter, GABA; divalproex sodium is a compound containing equal proportions of valproic acid and sodium valproate.

Black, tarry stoolsbleeding gumsbloating or swelling of the face, arms, hands, lower legs, or feetblood in the urine or stools

Nausea, vomiting, indigestion, diarrhea, abdominal cramps, constipation, anorexia with weight loss, increased appetite with weight gain, life-threatening pancreatitis, hepatic failure

Monitor patient alertness especially with multiple drug therapy for seizure control. Evaluate plasma levels of the adjunctive anticonvulsants periodically as indicators for possible neurologic toxicity

Drug Name

Route, Dose and Frequency

Indication Mechanism of Action Side Effects Adverse Effects Nursing Considerations

Generic Name: Diazepam

Brand Name: Vallium

Class: Antianxiety

agents,anticonvulsants,sedative/hyptonics,skeletal muscle relaxants

Route: Intravenous Dose: 4mg Frequency: As Needed

Adjunct in statusepilepticus andsevere recurrentconvulsive seizures,adjunct in convulsivedisorders

Depress the CNS, probably by potentiating GABA, aninhibitory neurotransmitter.- Produces skeletal musclerelaxation by inhibitingspinal polysynaptic afferent pathways

dizziness drowsiness lethargy hangover headache depression

Respiratory depression, blurred vision, hypotension

Monitor BP, PR,RR prior to periodically throughout therapy andfrequently during IV therapy.- Assess IV site frequently duringadministration, diazepam may cause phlebitis and venous thrombosisObserve and record intensity, durationand location of seizure activity. Theinitial dose of diazepam offers seizurecontrol for 15-20 min after

administration.VII. Drug Analysis

VIII. Nursing Care Plan

Assessment Diagnosis Planning Intervention Rationale EvaluationObjective Cues:

-Body weakness on right side of the body

-GCS: 15, 5 years old, Male. High Risk Fall humpty dumpy scale

-Recurrent seizure episodes

Verbal Cues:“Nanghihina yung kanang kamay at paa nya” as verbalized by the father

Risk for Trauma as evidenced by previous episodes of muscle stiffening

Short Term Goals:To promote safety and secured environment to avoid injury within 8 hour shift

Long Term Goals: After 1-2 days the patient’s father will demonstrate behaviors, or lifestyle changes to reduce risk factor and protect patient from self injury

Independent Nursing Intervention:

Assessed client’s muscle strength, gross and fine motor coordination

Maintained bed/chair in lowest position with wheels and side rails locked

Instructed client/Significant other to request assistance if needed; make sure call light is within reach

Note preseizure activity, presence of aura or unusual behavior, type of seizure activity (location or duration of motor activity, loss of consciousness, incontinence, eye activity, respiratory impairment or cyanosis), and frequency or recurrence. Note whether patient fell, expressed vocalizations, drooled, or had

To Identify risk for falls

Prevents or minimizes injury when seizures (frequent or generalized) occur while patient is in bed.

Promotes safety measures.

Helps localize the cerebral area of involvement.

Short term goal:Goal Met, No noted Injury within 8 hour Shift

Long term goal:Goal Met, Patient’s father understood health teaching and demonstrates measurements for the patient’s safety

automatisms (lip-smacking, chewing, picking at clothes).

Provide neurological or vital sign check after seizure (level of consciousness, orientation, ability to comply with simple commands, ability to speak; memory of incident; weakness or motor deficits; blood pressure (BP), pulse and respiratory rate).

Explore and expound seizure warning signs (if appropriate) and usual seizure pattern. Teach SO to determine and familiarize warning signs and how to care for patient during and after seizure attack.

Documents postictal state and time or completeness of recovery to normal state. May identify additional safety concerns to be addressed.

Enables patient to protect self from injury and recognize changes that require notification of physician and further intervention. Knowing what to do when seizure occurs can prevent injury or complications and decreases SO’s feelings of helplessness.

Assessment Diagnosis Planning Intervention Rationale EvaluationObjective Cues:

-Seizure episodes

-respiratory rate of 35-28 cycles per minute

Ineffective Airway Clearance as evidenced by previous episodes of seizure

Short term goal:To maintain patent airway within 8 hour shift

Long term goal:After a day, the patient’s father will verbalize understanding the need of supplemental oxygen and airway clearance if needed

Independent NursingIntervention:

Ensure patient to empty mouth of dentures or foreign objects if aura occurs and to avoid chewing gum and sucking lozenges if seizures occur without warning.

Maintain in lying position, flat surface; turn head to side during seizure activity.

Loosen clothing from neck or chest and abdominal areas.

Provide and insert plastic airway or soft roll as indicated and only if jaw is relaxed.

Helps in drainage of secretions; prevents tongue from obstructing airway.

Helps in drainage of secretions; prevents tongue from obstructing airway.

Aids in breathing or chest expansion.

If inserted before jaw is tightened, these devices may prevent biting of tongue and facilitate suctioning or respiratory support if required. Airway adjunct may be indicated after cessation of seizure activity if patient is unconscious and unable to maintain safe position of tongue.

Short term goal:Goal met, after 8 hour of shift the patient maintained patent airway

Long term goal:Goal Met, significant other understood health teaching

Suction as needed.

Supervise supplemental oxygen or bag ventilation as needed postictally

Get ready for or assist with intubation, if indicated.

Reduces risk of aspiration or asphyxiation. Note: Risk of aspiration is low unless individual has eaten within the last 40 min.

May lessen cerebral hypoxia resulting from decreased circulation or oxygenation secondary to vascular spasm during seizure. Note: Artificial ventilation during general seizure activity is of limited or no benefit because it is not possible to move air in or out of lungs during sustained contraction of respiratory musculature. As seizure abates, respiratory function will return unless a secondary problem exists (foreign body or aspiration).

Presence of prolonged apnea postictally may need ventilatory support.

Assessment Diagnosis Planning Intervention Rationale EvaluationObjective Cues:

-Flushed and warm to touch

Hyperthermia as evidenced by temperature of 38.3C

Short term goal:After 4 hours of nursing interventions, the patient’s temperature will decrease from 38.3C to normal range of 36.5C to 37C.

Long term goal:After 2 days of nursing interventions, the patient will be able to be free of complications and maintain core temperature within normal range.

Independent Nursing Intervention:Assess underlying condition and body temperature.

To note for progress and evaluate effects of hyperthermia

Remove unnecessary clothing that could only aggravate heat

Promote adequate rest periods

Provide TSB

Advise to increase fluid intake

Administer IV fluids at prescribed rate. Monitor regulation rate frequently.

Administer antipyretics as ordered

To obtain baseline data

To note for progress and evaluate effects of hyperthermia

To provide proper ventilation and promote release of heat through evaporation

Reduces metabolic demands or oxygen

To promote surface cooling

To help decrease body temperature

To promote fluid management

Antipyretics lower core temperature

Short term goal:Goal met, patient’s temperature is 37.0C

Long term goal:The patient shall have been able to be free of complications and maintain core temperature within normal range