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NCP related to Thermoregulation - Assessment, Nursing Diagnosis and Interventions

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Nursing Care Plan related to Thermoregulation


Assessment

Subjective Data:
  • Patients express the degree of body temperature increases or decreases.
  • Patients express a feeling hot or warm or cold and shivering.
  • Patients say the tools in use when cold (eg sweater or blanket).
  • Patients may express risk factors hyperthermia or hypothermia. Eg: metabolic problems due to cancer or hormonal imbalances; the integrity of the skin; history of chronic diseases such as heart and lung disease; medicinal drugs consumed other risk factors that can be identified is the environment in which the patient is or stay.
  • Patients expressed hyperthermia or hypothermia ever experienced.

Objective Data:
  • Changes in skin surface color, moisture, locally or systemically.
  • Level of consciousness.
  • Weight.
  • Hydration and nutrition status.

Nursing Diagnosis

1. Risk for altered body temperature related to:
  • Clothes do not fit.
  • Injury to the central nervous system.
  • Exposure to the environment (hot and cold).
  • Thermoregulation system damage.

2. Ineffective Thermoregulation related to:
  • Immaturity.
  • Physiological changes.
  • Aging.
  • Central nervous system injury.
  • Environmental temperature.
3. Hypothermia related to :
  • The decline in metabolic rate.
  • Inadequate clothing
  • Exposure to a cold environment.
  • Inability to shiver.
  • The consumption of drugs or alcohol.
  • Inactivity.
  • Aging.
4. Hyperthermia related to:
  • Increased metabolic rate.
  • Clothes do not fit.
  • Environmental exposure to heat or cold.
  • Unable to sweat.
  • Medications.
  • Strenuous activity and many.
  • The process of infection caused by viruses or bacteria.


Interventions

1. Health education to clients about the causes, how to resolve, and prevent disruption of thermoregulation.

2. The management of patients heat.

a. During the chills:
  • To increase comfort, the patient may be given a blanket or extra clothing.
  • Provide adequate fluid intake.
  • Observation of vital signs.
b. During an increase in temperature:
  • Give thin clothing.
  • Provide adequate fluid intake.
  • Increase patient rest.
  • Keep moisture lip and nasal mucosa.
  • Give cooling sponge bath.
  • Increase air circulation to improve patient comfort.
  • Take precautionary measures agitated patient injury or seizures.
  • Encourage the patient to obtain oral intake.
  • Limit activity.
  • Put the clothes and blankets are thin.
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