Review Question Question

vashtee, RN · Nov 4, 2007

Hyperthermia is the problem. The exposure to warm temperature was the cause of the problem, and the flushed skin and elevated body temperature are evidence that the problem exists.

The nursing diagnosis is always the probelm, I believe.

Daytonite, BSN, RN · Nov 4, 2007

"in this nursing diagnosis, 'hyperthermia related to exposure to hot environment as evidenced by temp 101 fahrenheit, skin flushed and warm to touch,' which part represents the problem?"
a) exposure to hot environment
b) hyperthermia
c) skin flushed and warm to touch
d) temp 101 fahrenheit
the book says b is the correct choice and i don't know why

hyperthermia is an officially recognized nursing diagnosis in the nanda taxonomy. hyperthermia related to exposure to hot environment as evidenced by temp 101 fahrenheit, skin flushed and warm to touch is a 3-part nursing diagnostic statement. it might look a little more familiar to you if written this way:

hyperthermia r/t exposure to hot environment aeb temp of 101 f, skin flushed and warm to touch.

a three part nursing diagnostic statement consists of the following parts:

p (the problem)

which is expressed as a nursing diagnosis. the nursing diagnosis in this case is

hyperthermia

e (the etiology)

which is the cause of the problem. nanda calls these related factors. in the three part statement they are referred to as "related to". the etiology of this problem is

exposure to hot environment.

s (the symptoms)

which are the symptoms that the nurse found in the patient during the assessment of the patient. nanda calls these defining characteristics. in the three part statement they are referred to as "as evidenced by". the symptoms of this patient are

temp 101 fahrenheit, skin flushed and warm to touch.

and it is put together this way:

p - e - s

or

problem - etiology - symptom

or

nursing diagnosis - related factor - defining characteristic

or

hyperthermia related to exposure to hot environment as evidenced by temp 101 fahrenheit, skin flushed and warm to touch

what this diagnostic statement is telling us is that the patient was exposed to a very hot setting for a long period of time which caused his entire body to become overheated as a result. he developed a fever and his skin became flushed and very warm to the touch. the name that we nurses can attach to this problem is hyperthermia (elevated body temperature). the doctor may want to call this heat stroke, but we nurses can't do that.

this was a straight forward question of knowledge about what a nursing diagnostic statement is. if you have a care plan book you need to read the very beginning of the book on how a care plan is written. this information on the construction of a nursing diagnostic statement that i've given above is in the very first pages of nursing diagnosis handbook: a guide to planning care, 7th edition, by betty j. ackley and gail b. ladwig (it's actually on page 3). if you know someone who has a copy of this book, ask them if they will xerox pages 2 - 14 for you.

GeauxNursing · Nov 5, 2007

but I thought that hyperthermia was a temp above, lets say, 104? not 101.

Daytonite, BSN, RN · Nov 6, 2007

but I thought that hyperthermia was a temp above, lets say, 104? not 101.

However, when you are referring to the NANDA nursing diagnosis of Hyperthermia you want to refer to the NANDA taxonomy and what it says. NANDA does not give specific numbers that the temperature must obtain, only that it is elevated above normal range. This gives wide berth. There are also other symptoms to consider. You must use your judgment. You said in another post that you were just learning care plans and working with nursing diagnoses. You need to have a nursing diagnosis reference to refer to so you use and classify diagnoses correctly. This is the information on the nursing diagnosis of Hyperthermia (page 108, NANDA-I Nursing Diagnoses: Definitions & Classification 2007-2008):

"Hyperthermia

Definition: Body temperature elevated above normal range.

Related Factors:

Anesthesia
Decreased perspiration
Dehydration
Exposure to hot environment
Inappropriate clothing
Increased metabolic rate
Illness
Medications
Trauma
Vigorous activity

Defining Characteristics:

Convulsions
Flushed skin
Increase in body temperature above normal range
Seizures
Tachycardia
Tachypnea
Warm to touch"

GeauxNursing · Nov 6, 2007

thanks Daytonite! That was pretty informative. I'll have to get one of those books, too!

Daytonite, BSN, RN · Nov 6, 2007

thanks daytonite! that was pretty informative. i'll have to get one of those books, too!

please don't take nursing diagnosis lightly. doctors take medical diagnosing seriously and we nurses should take nursing diagnosing seriously too. when you begin working, your care plans will become part of the patient's permanent medical record. we have the nanda taxonomy to help us out. a nursing diagnosis book is a good reference to use. most people will buy these books because they want to use the nursing interventions and somehow they end up ignoring the most important information which is the

definition
related factors
defining characteristics

of each nursing diagnosis. these are the things that help you to classify someone and assign them each particular nursing diagnosis. a very inexpensive reference book that you can get comes from nanda (north american nursing diagnosis association) who owns, writes and maintains the taxonomy for $24.95. you have to order it directly from them. all the nursing diagnosis books on the commercial market as well as the nursing care plan books have the information that is in this official nanda publication in them.

nanda-i nursing diagnoses: definitions & classification 2007-2008 http://www.nanda.org/html/nursing_diagnosis.html