Nursing Care Plan Risk for Imbalanced Body Temperature
Risk for Imbalanced Body Temperature
Taxonomy II: Safety/Protection—Class 6 Thermoregulation (00005)
[Diagnostic division: Safety]
Submitted 1986; Revised 2000
Definition: At risk for failure to maintain body temperature within normal range
Risk Factors
Extremes of age, weight
Exposure to cold/cool or warm/hot environments
Dehydration
Inactivity or vigorous activity
Medications causing vasoconstriction/vasodilation, altered metabolic rate, sedation, [use or overdose of certain drugs or exposure to anesthesia]
Inappropriate clothing for environmental temperature
Illness or trauma affecting temperature regulation [e.g., infections, systemic or localized; neoplasms, tumors; collagen/ vascular disease]
NOTE: A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention.
Desired Outcomes/Evaluation
Criteria—Client Will:
Maintain body temperature within normal range.
Verbalize understanding of individual risk factors and appropriate interventions.
Demonstrate behaviors for monitoring and maintaining appropriate body temperature.
Actions/Interventions
NURSING PRIORITY NO. 1. To identify causative/risk factors present:
Determine if present illness/condition results from exposure to environmental factors, surgery, infection, trauma.
Monitor laboratory values (e.g., tests indicative of infection, drug screens).
Note client’s age (e.g., premature neonate, young child, or aging individual), as it can directly impact ability to maintain/ regulate body temperature and respond to changes in environment.
Assess nutritional status.
NURSING PRIORITY NO. 2. To prevent occurrence of temperature alteration:
Monitor/maintain comfortable ambient environment. Provide heating/cooling measures as indicated.
Cover head with knit cap, place infant under radiant warmer or adequate blankets.Heat loss in newborn/infants is greatest through head and by evaporation and convection.
Monitor core body temperature. (Tympanic temperature may be preferred, as it is the most accurate noninvasive method.)
Restore/maintain core temperature within client’s normal range. (Refer to NDs Hypothermia and Hyperthermia.)
Refer at-risk persons to appropriate community resources (e.g., home care/social services, Foster Adult Care, housing agencies) to provide assistance to meet individual needs.
NURSING PRIORITY NO. 3. To promote wellness (Teaching/ Discharge Considerations):
Review potential problem/individual risk factors with client/ SO(s).
Instruct in measures to protect from identified risk factors (e.g., too warm, too cold environment; improper medication regimen; drug overdose; inappropriate clothing/shelter; poor nutritional status).
Review ways to prevent accidental alterations, such as induced hypothermia as a result of overzealous cooling to reduce fever or maintaining too warm an environment for client who has lost the ability to perspire.
Documentation Focus
NURSING ASSESSMENT/REASSESSMENT
Identified individual causative/risk factors.
Record of core temperature, initially and prn.
Results of diagnostic studies/laboratory tests.
NURSING PLANNING
Plan of care and who is involved in planning.
Teaching plan, including best ambient temperature, and ways to prevent hypothermia or hyperthermia.
NURSING IMPLEMENTATION/EVALUATION
Response to interventions/teaching and actions performed.
Attainment/progress toward desired outcome(s).
Modifications to plan of care.
DISCHARGE PLANNING
Long-term needs and who is responsible for actions.
Specific referrals made.
Taxonomy II: Safety/Protection—Class 6 Thermoregulation (00005)
[Diagnostic division: Safety]
Submitted 1986; Revised 2000
Definition: At risk for failure to maintain body temperature within normal range
Risk Factors
Extremes of age, weight
Exposure to cold/cool or warm/hot environments
Dehydration
Inactivity or vigorous activity
Medications causing vasoconstriction/vasodilation, altered metabolic rate, sedation, [use or overdose of certain drugs or exposure to anesthesia]
Inappropriate clothing for environmental temperature
Illness or trauma affecting temperature regulation [e.g., infections, systemic or localized; neoplasms, tumors; collagen/ vascular disease]
NOTE: A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention.
Desired Outcomes/Evaluation
Criteria—Client Will:
Maintain body temperature within normal range.
Verbalize understanding of individual risk factors and appropriate interventions.
Demonstrate behaviors for monitoring and maintaining appropriate body temperature.
Actions/Interventions
NURSING PRIORITY NO. 1. To identify causative/risk factors present:
Determine if present illness/condition results from exposure to environmental factors, surgery, infection, trauma.
Monitor laboratory values (e.g., tests indicative of infection, drug screens).
Note client’s age (e.g., premature neonate, young child, or aging individual), as it can directly impact ability to maintain/ regulate body temperature and respond to changes in environment.
Assess nutritional status.
NURSING PRIORITY NO. 2. To prevent occurrence of temperature alteration:
Monitor/maintain comfortable ambient environment. Provide heating/cooling measures as indicated.
Cover head with knit cap, place infant under radiant warmer or adequate blankets.Heat loss in newborn/infants is greatest through head and by evaporation and convection.
Monitor core body temperature. (Tympanic temperature may be preferred, as it is the most accurate noninvasive method.)
Restore/maintain core temperature within client’s normal range. (Refer to NDs Hypothermia and Hyperthermia.)
Refer at-risk persons to appropriate community resources (e.g., home care/social services, Foster Adult Care, housing agencies) to provide assistance to meet individual needs.
NURSING PRIORITY NO. 3. To promote wellness (Teaching/ Discharge Considerations):
Review potential problem/individual risk factors with client/ SO(s).
Instruct in measures to protect from identified risk factors (e.g., too warm, too cold environment; improper medication regimen; drug overdose; inappropriate clothing/shelter; poor nutritional status).
Review ways to prevent accidental alterations, such as induced hypothermia as a result of overzealous cooling to reduce fever or maintaining too warm an environment for client who has lost the ability to perspire.
Documentation Focus
NURSING ASSESSMENT/REASSESSMENT
Identified individual causative/risk factors.
Record of core temperature, initially and prn.
Results of diagnostic studies/laboratory tests.
NURSING PLANNING
Plan of care and who is involved in planning.
Teaching plan, including best ambient temperature, and ways to prevent hypothermia or hyperthermia.
NURSING IMPLEMENTATION/EVALUATION
Response to interventions/teaching and actions performed.
Attainment/progress toward desired outcome(s).
Modifications to plan of care.
DISCHARGE PLANNING
Long-term needs and who is responsible for actions.
Specific referrals made.
