Nursing Dx

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
ASSESSMENT/REASSESSMENT
• Identified individual causative/risk factors.
• Record of core temperature, initially and prn.
• Results of diagnostic studies/laboratory tests.
PLANNING
• Plan of care and who is involved in planning.
• Teaching plan, including best ambient temperature, and ways to prevent hypothermia or hyperthermia.
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.