Heat Stroke Nursing Diagnosis and Nursing Care Plan

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Heat Stroke Nursing Care Plans Diagnosis and Interventions

Heat Stroke NCLEX Review and Nursing Care Plans

Heat stroke is a medical condition brought about by the overheating of the body, either through prolonged exposure to or physical activities in elevated temperatures. Heat stroke may occur if the patient’s body temperature rises to 40 degree Celsius (104 F) or higher.

This condition is most common in the summer months when temperature is warmer compared to the rest of the year. Heat stroke can be fatal if not addressed quickly and properly.

Signs and Symptoms of Heat Stroke

  • Hyperthermia– the main sign of heat stroke is a core body temperature of 40 Celsius (104 Fahrenheit)
  • Altered mental state – slurring of speech, irritability, agitation, confusion, seizure, and coma may be evident in a patient suffering from heat stroke
  • Alteration in sweating – heat stroke due to hot weather may result to the patient’s skin feeling hot and dry to touch. In exercised-induced heatstroke, the patient’s skin will feel dry or slightly moist.
  • Nausea and vomiting
  • Flushed skin – skin may turn red as a result of increasing body temperature
  • Rapid and shallow breathing
  • Racing heart rate – heart rate will be markedly elevated because the body is compensating for the heat stress
  • Headache

Causes and Risk factors of Heat stroke

The causes of heat stroke can be attributed to two factors:

  • Non-exertional heat stroke. This is a type of heat stroke wherein the body has a prolonged exposure to surroundings with elevated temperatures. This classic type of heatstroke occurs after exposure to hot, humid weather. This happens more often to older adults and those with chronic illnesses.
  • Exertional heat stroke. This type of stroke arises from intensive physical activity in hot weather. Anyone exercising or working in these environments is at high risk for heat stroke, especially those who are not used to high temperatures.

The factors that may contribute to the two types of heat stroke are:

  • Wearing excessive clothing – the layers of clothing worn will prevent the body from cooling effectively
  • Alcohol drinking – consumption of alcoholic beverages can affect the body’s temperature regulation mechanisms.
  • Dehydration – not drinking enough fluids to replenish losses through sweating can increase the risk for heat stroke.

The risk factors that may increase the likelihood of heat stroke include:

  • Age – age determines the strength of the central nervous system to cope with extreme heat. In young patients, the central nervous system is relatively less developed and in adults over 65, already deteriorating, thus making it for the body difficult to handle heat stress.
  • Exertion in hot weather – sports and other activities done in hot weather conditions will increase the probability of heat stroke.
  • Sudden exposure to hot weather – an early-summer heat wave or travel to a hotter climate will make patients susceptible to heat-related stress.
  • Poor ventilation or lack of air conditioning – inadequate and poor ventilation can increase the risk for heat stroke.
  • Certain medications – medications such as vasoconstrictors, beta blockers, diuretics, antipsychotics, antidepressants, stimulants for attention-deficit/hyperactivity disorder (ADHD) and illegal stimulants (e.g., amphetamines) can affect the body’s coping mechanism to heat stress and the body’s effort to stay hydrated.
  • Health conditions – chronic illnesses such as heart or lung disease increases risk for heat stroke. Likewise, those who are obese, have sedentary lifestyle, or with history of previous heatstroke can also make patients vulnerable for heat stress.

Complications of Heat Stroke

If left untreated, heat stroke can result to the following:

  1. Vital organ damage. Delays in the treatment measures to lower the body temperature in heat stroke episodes can cause potential and sustained damage to the vital organs of the body, specifically the brain, kidneys, and heart.
  2. Death. If not addressed quickly and properly, multiple organ damage will occur and consequently result to the death of the patient.
  3. Seizures and other central nervous system problems
  4. Rhabdomyolysis

Diagnosis of Heat Stoke

Diagnosing heat stroke is usually apparent to the healthcare provider; however, confirmatory tests are still needed to confirm the right diagnosis of heatstroke.

  • Vital signs, particularly temperature- core body temperatures are typically based on a rectal thermometer; however, peripheral temperature checks through the ear (tympanic), mouth (oral), or armpit are preferred in many care settings as they are less invasive than a rectal thermometer
  • Blood tests – to check for serum electrolytes like sodium and potassium in order to assess for serum concentrations and level of hydration) and arterial blood gasses (ABGs) to check for the extent of damage to the central nervous system
  • Urine test – patients with heat stroke would usually have concentrated colored urine (darker in color). This would determine the extent of kidney function and the damage heat stroke has caused.
  • Muscle function test – to check for serious damages to the patient’s body (e.g., rhabdomyolysis)
  • X-ray and other imaging tests – to assess for other damage to the patient’s internal organs and to rule out other causes.

Treatment of Heat Stroke

The goal of treatment for heat stroke is to reduce the body’s core temperature to prevent or resolve damage to the vital organs of the body. The treatment options for heat stroke are listed below:

  1. Immersion in cold water. This treatment has been proven effectively lowering the body’s core temperature. The quicker it is done to a patient suffering from heatstroke, the less organ damage there will be, and risk of death is consequently averted.
  2. Use of evaporation cooling techniques. In the event of unavailability of cold-water immersion techniques, cool water will be misted on the body which will cause for evaporation of water and the cooling of the patient’s skin.
  3. Use of ice and cooling blankets. Another cooling method is to wrap the patient in special cooling blankets, application of ice packs on the patient’s crevices (groin, neck, armpits, back) to lower the core body temperature.
  4. Medications
  • Muscle relaxants such as benzodiazepines may be given to manage shivering episodes of the patient. Shivering happens when the body is subjected to cold treatment. In treating heatstroke, shivering can increase the patient’s body temperature, which will make the treatment less effective.
  • Fever reducers or antipyretics are deemed ineffective in reducing core body temperatures. However, some antipyretics can be given for the purpose of pain relief instead (headaches or body pain).
  • Intravenous fluid therapy may be administered for moderate to severe dehydration due to heat stroke.

Prevention of Heat Stroke

  1. Wear lightweight and loose-fitting clothing during summer or when staying in a hot environment.
  2. Always drink plenty of fluids. Consider cold drinks during hot weather.
  3. Take cool showers or baths.
  4. Avoid prolonged intense or extreme exercises.
  5. Protect yourself from the between 10 am and 3 pm (the time may vary depending on where you are).
  6. Avoid excessive intake of alcohol.

Nursing Diagnosis for Heat Stroke

Nursing Care Plan for Heat Stroke 1

Nursing Diagnosis: Hyperthermia related to prolonged exposure to hot weather as evidenced by core body temperature of 40 degrees Celsius, rapid and shallow breathing, racing heart rate, flushed skin, and profuse sweating

        Desired Outcome: Within 2 hours of nursing interventions, the patient will have a stabilized temperature within the normal range.

Heat Stroke Nursing InterventionsRationales
Assess the patient’s vital signs at least every 4 hours.To assist in creating an accurate diagnosis and monitor effectiveness of treatment given.
Remove excessive clothing, blankets, and linens. Adjust the room temperature.To regulate the temperature of the environment and make it more comfortable for the patient.
Encourage the patient to drink cool fluids, preferably those that come with electrolyte replacement such as sports drinks.To replace the water and electrolytes that have been eliminated from the body through the sweat glands.
Provide a body cooling technique as recommended by the physician.To facilitate the body in cooling down and to provide comfort, the following techniques should be considered: Immersion in cold water Use of evaporation cooling techniques Use of ice and cooling blankets
Administer fluids and medications as prescribed.Muscle relaxants may be given to manage shivering episodes of the patient.

Nursing Care Plan for Heat Stroke 2

Nursing Diagnosis: Alteration in Comfort related to hyperthermia

Desired Outcome: Within 4 hours of nursing interventions, the patient will have a stabilized temperature within the normal range and will verbalize feeling more comfortable.

Heat Stroke Nursing InterventionsRationales
Remove excessive clothing, blankets, and linens. Adjust the room temperature.To regulate the temperature of the environment and make it more comfortable for the patient.
Offer a tepid sponge bath.To facilitate the body in cooling down and to provide comfort.
Elevate the head of the bed.Head elevation helps improve the expansion of the lungs, enabling the patient to breathe more effectively.
Offer a cooling blanket to the patient.To facilitate the body in cooling down and to provide comfort.

Nursing Care Plan for Heat Stroke 3

Nursing Diagnosis: Fluid Volume Deficit related to dehydration due to heat stroke as evidenced by temperature of 40 degrees Celsius, skin turgidity, dark yellow urine output, profuse sweating, and blood pressure of 89/58.

Desired Outcome: Within 48 hours of nursing interventions, the patient will have a stabilized temperature within the normal range and will verbalize feeling more comfortable.

Heat Stroke Nursing InterventionsRationales
Commence a fluid balance chart, monitoring the input and output of the patient.To monitor patient’s fluid volume accurately and effectiveness of actions to reverse dehydration.
Encourage oral fluid intake. Start intravenous therapy as prescribed.To replenish the fluids lost from profuse sweating, and to promote better blood circulation around the body.
Educate the patient (or guardian) on how to fill out a fluid balance chart at bedside.To help the patient or the guardian take ownership of the patient’s care, encouraging them to drink more fluids as needed, or report any changes to the nursing team. 
Monitor patient’s serum electrolytes and recommend electrolyte replacement therapy (orally or intravenously) to the physician as needed.Sodium is one of the important electrolytes that are lost when a person is sweating. Hyponatremia or low serum sodium level may cause brain swelling.

More Nursing Diagnosis for Heat Stroke

Nursing References

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.  Buy on Amazon

Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier.  Buy on Amazon

Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.  Buy on Amazon

Disclaimer:

Please follow your facilities guidelines, policies, and procedures.

The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes.

This information is intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment.

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