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Thermoregulation
00005
Risk for imbalanced body temperature
(1986, 2000, 2013; LOE 2.1)
Definition
Vulnerable to failure to maintain body temperature within normal
parameters, which may compromise health.
Risk Factors
Definition
Core body temperature above the normal diurnal range due to failure
of thermoregulation.
Defining Characteristics
Related Factors
Definition
Core body temperature below the normal diurnal range due to failure
of thermoregulation.
Defining Characteristics
Neonates
■■ Delay in breastfeeding ■■ Increase in pulmonary vascular
■■ Early bathing of newborn resistance (PVR)
■■ High risk out of hospital birth ■■ Ineffective vascular control
■■ Immature stratum corneum ■■ Inefficient nonshivering
■■ Increased body surface area to thermogenesis
weight ratio ■■ Unplanned out-of-hospital birth
■■ Increase in oxygen demand
11. Safety/Protection
Definition
Vulnerable to a failure of thermoregulation that may result in a core
body temperature below the normal diurnal range, which may com-
promise health.
Risk Factors
11. Safety/Protection
Definition
Vulnerable to an inadvertent drop in core body temperature below
36 °C/96.8 °F occuring one hour before to 24 hours after surgery, which
may compromise health.
Risk Factors
Definition
Temperature fluctuation between hypothermia and hyperthermia.
Defining Characteristics
Related Factors
Hopelessness—cont’d
Outcomes Associated with Related Factors or Intermediate Outcomes
Adaptation to Physical Disability Play Participation
Coping Quality of Life
Depression Self-Control Relocation Adaptation
Fatigue Level Self-Care: Activities of Daily Living (ADL)
Fear Self-Control Self-Management: Chronic Disease
Grief Resolution Social Involvement
Immobility Consequences: Psycho-Cognitive Spiritual Health
Neglect Recovery Stress Level
Pain: Adverse Psychological Response Suffering Severity
Pain: Disruptive Effects Symptom Severity
Physical Aging
Hyperthermia
Definition: Body temperature elevated above normal range
Outcomes to Measure Resolution of Diagnosis
Thermoregulation Thermoregulation: Newborn
Additional Outcomes to Measure Defining Characteristics
Neurological Status Vital Signs
Neurological Status: Autonomic
Outcomes Associated with Related Factors or Intermediate Outcomes
Blood Transfusion Reaction Knowledge: Acute Illness Management
Comfort Status: Physical Medication Response
Discomfort Level Physical Injury Severity
Hydration Risk Control: Hyperthermia
Infection Severity Self-Management: Acute Illness
Infection Severity: Newborn
Hypothermia
Definition: Body temperature below normal range
Outcomes to Measure Resolution of Diagnosis
Thermoregulation Thermoregulation: Newborn
Hyperthermia
Definition: Body temperature elevated above normal range
Suggested Nursing Interventions For Problem Resolution: Temperature Regulation
Bathing Temperature Regulation: Perioperative
Environmental Management Vital Signs Monitoring
Fever Treatment
Fluid Management Additional Optional Interventions:
Hemodynamic Regulation Heat/Cold Application
Infant Care: Newborn Nutrition Management
Infection Control Oxygen Therapy
Infection Protection Peripherally Inserted Central Catheter (PICC) Care
Malignant Hyperthermia Precautions Seizure Management
Medication Management Seizure Precautions
Medication Prescribing Skin Surveillance
Shock Management Total Parenteral Nutrition (TPN) Administration
470 Body Image, Disturbed
Bowel Incontinence
Definition: Change in normal bowel habits, characterized by involuntary passage of stool
Suggested Nursing Interventions for Problem Resolution: Additional Optional Interventions:
Bowel Incontinence Care Bathing
Bowel Incontinence Care: Encopresis Dementia Management
Bowel Management Emotional Support
Bowel Training Environmental Management
Diarrhea Management Exercise Promotion
Perineal Care Exercise Therapy: Ambulation
Rectal Prolapse Management Nutrition Management
Self-Care Assistance: Toileting
Skin Surveillance
Teaching: Toilet Training
Thermoregulation, Ineffective
Definition: Temperature fluctuation between hypothermia and hyperthermia
Suggested Nursing Interventions for Problem Resolution: Temperature Regulation
Bathing Temperature Regulation: Perioperative
Environmental Management Vital Signs Monitoring
Fever Treatment
Fluid Management Additional Optional Interventions:
Fluid Monitoring Anxiety Reduction
Hemodynamic Regulation Blood Products Administration
Hyperthermia Treatment Medication Administration
Infant Care: Newborn Peripherally Inserted Central Catheter (PICC) Care
Infant Care: Preterm Phlebotomy: Arterial Blood Sample