Ineffective Thermoregulation
Definition:
Circumstances where an individual experiencing or at risk of inability to maintain normal body temperature effectively with any discrepancies or changes in external factors.
Related Factors:
Situational (Personal, environmental)
Related to fluctuations in environmental temperature
Related to objects that are wet and cold (clothing, bedding)
Related to a wet body surface
Related to clothing that is not compliant with the weather
Related to limited regulation of metabolic compensation
Elderly
Newborns
Expected Outcomes Nursing Care Plan for Ineffective Thermoregulation
Babies will
- Having a temperature between 36.4 to 37.5 º C.
- Explain the techniques to avoid heat loss at home.
Nursng Intervention Nursing Care Plan for Ineffective Thermoregulation
- Reduce or eliminate the sources of heat loss in infants
- Evaporation
- When a shower, prepare a warm environment.
- Wash and dry each section to reduce evaporation
- Limit the time of contact with clothing or a wet blanket
- Convection
- Avoid the flow of air (air conditioning, ceiling fan, open vent)
- Conduction
- Warm all the goods for care (stethoscope, scales, hand care givers, clothes, bed linen)
- Radiation
- Reduce the objects that absorb heat (metal)
- Place the baby swing bed away from the wall (outside) or window if possible.
- Evaporation
- Monitor the baby's body temperature
- If the temperature is below normal
- Use with two blankets
- Wear headgear
- Assess the environmental sources for heat loss
- If hypothermia settled more than 1 hour, refer to the more expert.
- Review of the complications of cold stress, hypoxia, respiratory acidosis, hypoglycemia, fluid and electrolyte imbalance, weight loss.
- If the temperature is above normal
- Remove the blanket
- Remove the headgear, when worn
- Assess the environmental temperature again
- If the temperature hyperthermia settled more than 1 hour, report the physician.
- If the temperature is below normal
- Teach caregivers why babies are vulnerable to temperature (hot and cold)
- Demonstrate how to save heat during the bath.
- Instruct that do not need to routinely measure the temperature at home.
- Teach to measure the temperature if the baby is hot, sore, or sensitive excitatory.
- Teach the elderly why they are vulnerable to heat and cold weather.
- Refer to the hypothermia and hyperthermia for prevention.
Nursing Diagnosis for Ineffective Thermoregulation