Page 2015 - Saunders Comprehensive Review For NCLEX-RN

E. Surgical intervention: Also see Chapter 38 for additional
information on ventriculoperitoneal shunts (Box 58-8)
VI. Hyperthermia
A. Description
1. Temperature higher than 105° F (40.6° C), which
increases the cerebral metabolism and increases the
risk of hypoxia
2. Causes include infection, heat stroke, exposure to high
environmental temperatures, and dysfunction of the
thermoregulatory center.
B. Assessment
1. Temperature higher than 105° F (40.6° C)
2. Shivering
3. Nausea and vomiting

C. Interventions

1. Maintain a patent airway.
2. Initiate seizure precautions.
3. Monitor intake and output and assess the skin and
mucous membranes for signs of dehydration.
4. Monitor lung sounds.
5. Monitor for dysrhythmias.
6. Assess peripheral pulses for systemic blood flow.
7. Induce normothermia with fluids, cool baths, fans, or a
hypothermia blanket.
D. Inducement of normothermia
1. Prevent shivering, which will increase ICP and oxygen
consumption.
2. Administer medications as prescribed to prevent
shivering and to lower body temperature.
3. Monitor neurological status.
4. Monitor for infection and respiratory complications
because hyperthermia may mask the signs of
infection.
5. Monitor for cardiac dysrhythmias.
6. Monitor intake and output and fluid balance.
7. Prevent trauma to the skin and tissues.
8. Apply lotion to the skin frequently.
9. Inspect for frostbite if a hypothermia blanket is used.

VII. Traumatic Head Injury

A. Description
1. Head injury is trauma to the skull, resulting in mild to
extensive damage to the brain.
2. Immediate complications include cerebral bleeding,
hematomas, uncontrolled increased ICP, infections,
and seizures.

2015