Askep Thermoregulasi Nanda Nic Noc.pdf
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Domain 11. Safety/Protection
Class 6. 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 Acute brain injury Alteration in metabolic rate ■■ Condition affecting temperature regulation ■■ Decreased sweat response ■■ Dehydration ■■ Extremes of age ■■ Extremes of environmental temperature ■■ Extremes of weight ■■ Inactivity ■■ Inappropriate clothing for environmental temperature
Increase in oxygen demand Increased body surface area to weight ratio ■■ Inefficient nonshivering thermogenesis ■■ Insufficient supply of subcutaneous fat ■■ Pharmaceutical agent ■■ Sedation ■■ Sepsis ■■ Vigorous activity
■■
■■
■■
■■
11. Safety/Protection 426 Domain 11: Safety/Protection
Domain 11. Safety/Protection
Class 6. Thermoregulation
00007
Hyperthermia
(1986, 2013; LOE 2.2)
Definition
Core body temperature above the normal diurnal range due to failure of thermoregulation.
Defining Characteristics Abnormal posturing Apnea ■■ Coma ■■ Convulsions ■■ Flushed skin ■■ Hypotension ■■ Infant does not maintain suck ■■ Irritability
Lethargy Seizure ■■ Skin warm to touch ■■ Stupor ■■ Tachycardia ■■ Tachypnea ■■ Vasodilation
■■
■■
■■
■■
Decreased sweat response Dehydration ■■ High environmental temperature ■■ Illness ■■ Inappropriate clothing
Increase in metabolic rate Ischemia ■■ Pharmaceutical agent ■■ Sepsis ■■ Trauma ■■ Vigorous activity
■■
■■
■■
■■
Original literature support available at www.nanda.org
Class 6: Thermoregulation 427
11. Safety/Protection
Related Factors
Domain 11. Safety/Protection
Class 6. Thermoregulation
00006
Hypothermia
(1986, 1988, 2013; LOE 2.2)
Definition
Core body temperature below the normal diurnal range due to failure of thermoregulation.
Defining Characteristics Acrocyanosis Bradycardia ■■ Cyanotic nail beds ■■ Decrease in blood glucose level ■■ Decrease in ventilation ■■ Hypertension ■■ Hypoglycemia ■■ Hypoxia ■■ Increase in metabolic rate ■■ ■■
Increase in oxygen consumption ■■ Peripheral vasoconstriction ■■ Piloerection ■■ Shivering ■■ Skin cool to touch ■■ Slow capillary refill ■■ Tachycardia ■■
Accidental Low Body Temperature in Children and Adults
Mild hypothermia, core temperature 32-35 °C ■■ Moderate hypothermia, core temperature 30-32 °C ■■
11. Safety/Protection
■■
Severe hypothermia, core temperature <30 °C
■■
Severe hypothermia, core temperature <32 °C
Injured Adults and Children ■■
Hypothermia, core temperature <35 °C
Neonates
Grade 1 hypothermia, core temperature 36-36.5 °C ■■ Grade 2 hypothermia, core temperature 35-35.9 °C ■■ Grade 3 hypothermia, core temperature 34-34.9 °C ■■ Grade 4 hypothermia, core temperature <34 °C ■■ Infant with insufficient energy to maintain sucking ■■
428 Domain 11: Safety/Protection
Infant with insufficient weight gain (<30 g/d) ■■ Irritability ■■ Jaundice ■■ Metabolic acidosis ■■ Pallor ■■ Respiratory distress ■■
Related Factors Alcohol consumption Damage to hypothalamus ■■ Decrease in metabolic rate ■■ Economically disadvantaged ■■ Extremes of age ■■ Extremes of weight ■■ Heat transfer (e.g., conduction, convection, evaporation, radiation) ■■ Inactivity ■■ ■■
Insufficient caregiver knowledge of hypothermia prevention ■■ Insufficient clothing ■■ Insufficient supply of subcutaneous fat ■■ Low environmental temperature ■■ Malnutrition ■■ Pharmaceutical agent ■■ Radiation ■■ Trauma ■■
Neonates
Delay in breastfeeding Early bathing of newborn ■■ High risk out of hospital birth ■■ Immature stratum corneum ■■ Increased body surface area to weight ratio ■■ Increase in oxygen demand ■■ ■■
Increase in pulmonary vascular resistance (PVR) ■■ Ineffective vascular control ■■ Inefficient nonshivering thermogenesis ■■ Unplanned out-of-hospital birth ■■
11. Safety/Protection
Original literature support available at www.nanda.org
Class 6: Thermoregulation 429
Domain 11. Safety/Protection
Class 6. Thermoregulation
00253
Risk for hypothermia (2013; LOE 2.1)
Definition
Vulnerable to a failure of thermoregulation that may result in a core body temperature below the normal diurnal range, which may compromise health.
Risk Factors Alcohol consumption Damage to hypothalamus ■■ Economically disadvantaged ■■ Extremes of age ■■ Extremes of weight ■■ Heat transfer (e.g., conduction, convection, evaporation, radiation) ■■ Inactivity ■■ Insufficient caregiver knowledge of hypothermia prevention
Insufficient clothing Insufficient supply of subcutaneous fat ■■ Low environmental temperature ■■ Malnutrition ■■ Pharmaceutical agent ■■ Radiation ■■ Trauma
■■
■■
■■
■■
Children and Adults: Accidental 11. Safety/Protection
Mild hypothermia, core temperature approaching 35 °C ■■ Moderate hypothermia, core temperature approaching 32 °C ■■
■■
Severe hypothermia, core temperature approaching 30 °C
■■
Severe hypothermia, core temperature approaching 32 °C
Children and Adults: Injured Patients ■■
Hypothermia, core temperature approaching 35 °C
Neonates
Decrease in metabolic rate Delay in breastfeeding ■■ Early bathing of newborn ■■ Grade 1 hypothermia, core temperature approaching 36.5 °C ■■ ■■
430 Domain 11: Safety/Protection
Grade 2 hypothermia, core temperature approaching 36.0 °C ■■ Grade 3 hypothermia, core temperature approaching 35.0 °C ■■
Grade 4 hypothermia, core temperature approaching 34.0 °C ■■ High-risk out-of-hospital birth ■■ Immature stratum corneum ■■ Increased body surface area to weight ratio ■■
Increase in oxygen demand Increase in pulmonary vascular resistance (PVR) ■■ Ineffective vascular control ■■ Inefficient nonshivering thermogenesis ■■ Unplanned out-of-hospital birth ■■ ■■
11. Safety/Protection
Original literature support available at www.nanda.org
Class 6: Thermoregulation 431
Domain 11. Safety/Protection
Class 6. Thermoregulation
00254
Risk for perioperative hypothermia (2013; LOE 2.1)
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 American Society of Anesthesiologists (ASA) Physical Status classification score >1 ■■ Cardiovascular complications ■■ Combined regional and general anesthesia ■■ Diabetic neuropathy ■■ Heat transfer (e.g., high volume of unwarmed infusion, unwarmed irrigation >20 liters) ■■
Low body weight Low environmental temperature ■■ Low preoperative temperature (<36 °C/96.8 °F) ■■ Surgical procedure ■■ ■■
Original literature support available at www.nanda.org 11. Safety/Protection 432 Domain 11: Safety/Protection
Domain 11. Safety/Protection
Class 6. Thermoregulation
00008
Ineffective thermoregulation (1986)
Definition
Temperature fluctuation between hypothermia and hyperthermia.
Defining Characteristics Cyanotic nail beds Fluctuations in body temperature above and below the normal range ■■ Flushed skin ■■ Hypertension ■■ Increase in body temperature above normal range ■■ Increase in respiratory rate ■■ Mild shivering
Moderate pallor Piloerection ■■ Reduction in body temperature below normal range ■■ Seizures ■■ Skin cool to touch ■■ Skin warm to touch ■■ Slow capillary refill ■■ Tachycardia
■■
■■
■■
■■
■■ ■■
Extremes of age Fluctuating environmental temperature
■■ ■■
Illness Trauma
Class 6: Thermoregulation 433
11. Safety/Protection
Related Factors
602 Hyperthermia
Hopelessness—cont’d Outcomes Associated with Related Factors or Intermediate Outcomes
Adaptation to Physical Disability Coping Depression Self-Control Fatigue Level Fear Self-Control Grief Resolution Immobility Consequences: Psycho-Cognitive Neglect Recovery Pain: Adverse Psychological Response Pain: Disruptive Effects Physical Aging
Play Participation Quality of Life Relocation Adaptation Self-Care: Activities of Daily Living (ADL) Self-Management: Chronic Disease Social Involvement Spiritual Health Stress Level Suffering Severity Symptom Severity
Hyperthermia Definition: Body temperature elevated above normal range Outcomes to Measure Resolution of Diagnosis
Thermoregulation: Newborn
Thermoregulation Additional Outcomes to Measure Defining Characteristics
Neurological Status Neurological Status: Autonomic
Vital Signs
Outcomes Associated with Related Factors or Intermediate Outcomes
Knowledge: Acute Illness Management Medication Response Physical Injury Severity Risk Control: Hyperthermia Self-Management: Acute Illness
Blood Transfusion Reaction Comfort Status: Physical Discomfort Level Hydration Infection Severity Infection Severity: Newborn
Hypothermia Definition: Body temperature below normal range Outcomes to Measure Resolution of Diagnosis
Thermoregulation
Thermoregulation: Newborn
Additional Outcomes to Measure Defining Characteristics
Hypertension Severity Tissue Perfusion: Peripheral
Vital Signs
Outcomes Associated with Related Factors or Intermediate Outcomes
Comfort Status: Physical Medication Response Neurological Status: Autonomic Nutritional Status: Nutrient Intake Physical Aging
Physical Injury Severity Risk Control: Alcohol Use Risk Control: Hypothermia Self-Management: Acute Illness
Hyperthermia 505 Counseling Crisis Intervention Distraction Electroconvulsive Therapy (ECT) Management Exercise Promotion Exercise Therapy: Ambulation Grief Work Facilitation Grief Work Facilitation: Perinatal Death Music Therapy
Mutual Goal Setting Patient Contracting Phototherapy: Mood/Sleep Regulation Resiliency Promotion Self-Care Assistance Self-Modification Assistance Spiritual Support Suicide Prevention Therapeutic Play
Human Dignity, Risk for Compromised Definition: At risk for perceived loss of respect and honor Suggested Nursing Interventions for Problem Resolution: Anticipatory Guidance Culture Brokerage Decision-Making Support Examination Assistance Health Care Information Exchange Health System Guidance Patient Rights Protection Presence
Additional Optional Interventions: Abuse Protection Support Admission Care Bowel Incontinence Care Coping Enhancement Discharge Planning Family Involvement Promotion Financial Resource Assistance Multidisciplinary Care Conference Risk Identification
Hyperthermia Definition: Body temperature elevated above normal range Suggested Nursing Interventions For Problem Resolution: Bathing Environmental Management Fever Treatment Fluid Management Hemodynamic Regulation Infant Care: Newborn Infection Control Infection Protection Malignant Hyperthermia Precautions Medication Management Medication Prescribing Shock Management
Temperature Regulation Temperature Regulation: Perioperative Vital Signs Monitoring Additional Optional Interventions: Heat/Cold Application Nutrition Management Oxygen Therapy Peripherally Inserted Central Catheter (PICC) Care Seizure Management Seizure Precautions Skin Surveillance Total Parenteral Nutrition (TPN) Administration
470 Body Image, Disturbed Mutual Goal Setting Ostomy Care Patient Contracting Prenatal Care Suicide Prevention Teaching: Sexuality Truth Telling Unilateral Neglect Management Urinary Incontinence Care: Enuresis
Additional Optional Interventions: Amputation Care Anticipatory Guidance Bowel Incontinence Care: Encopresis Calming Technique Childbirth Preparation Cognitive Restructuring Decision-Making Support Lactation Counseling
Body Temperature, Risk for Imbalanced Definition: At risk for failure to maintain body temperature within normal range Suggested Nursing Interventions for Problem Resolution: Cerebral Edema Management Environmental Management Environmental Management: Comfort Fever Treatment Fluid Management Fluid Monitoring Malignant Hyperthermia Precautions Medication Management Postanesthesia Care Temperature Regulation Temperature Regulation: Perioperative Vital Signs Monitoring
Fluid Resuscitation Heat/Cold Application Hemodynamic Regulation Infection Control Infection Protection Kangaroo Care Nutrition Management Resuscitation: Neonate Risk Identification Sedation Management Surveillance Weight Management Wound Care: Burns
Additional Optional Interventions: Bathing Energy Management
Bowel Incontinence Definition: Change in normal bowel habits, characterized by involuntary passage of stool Suggested Nursing Interventions for Problem Resolution: Bowel Incontinence Care Bowel Incontinence Care: Encopresis Bowel Management Bowel Training Diarrhea Management Perineal Care Rectal Prolapse Management Self-Care Assistance: Toileting Skin Surveillance Teaching: Toilet Training
Additional Optional Interventions: Bathing Dementia Management Emotional Support Environmental Management Exercise Promotion Exercise Therapy: Ambulation Nutrition Management
Thermoregulation, Ineffective Definition: Temperature fluctuation between hypothermia and hyperthermia Suggested Nursing Interventions for Problem Resolution: Bathing Environmental Management Fever Treatment Fluid Management Fluid Monitoring Hemodynamic Regulation Hyperthermia Treatment Infant Care: Newborn Infant Care: Preterm
Temperature Regulation Temperature Regulation: Perioperative Vital Signs Monitoring Additional Optional Interventions: Anxiety Reduction Blood Products Administration Medication Administration Peripherally Inserted Central Catheter (PICC) Care Phlebotomy: Arterial Blood Sample
Class 6. 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 Acute brain injury Alteration in metabolic rate ■■ Condition affecting temperature regulation ■■ Decreased sweat response ■■ Dehydration ■■ Extremes of age ■■ Extremes of environmental temperature ■■ Extremes of weight ■■ Inactivity ■■ Inappropriate clothing for environmental temperature
Increase in oxygen demand Increased body surface area to weight ratio ■■ Inefficient nonshivering thermogenesis ■■ Insufficient supply of subcutaneous fat ■■ Pharmaceutical agent ■■ Sedation ■■ Sepsis ■■ Vigorous activity
■■
■■
■■
■■
11. Safety/Protection 426 Domain 11: Safety/Protection
Domain 11. Safety/Protection
Class 6. Thermoregulation
00007
Hyperthermia
(1986, 2013; LOE 2.2)
Definition
Core body temperature above the normal diurnal range due to failure of thermoregulation.
Defining Characteristics Abnormal posturing Apnea ■■ Coma ■■ Convulsions ■■ Flushed skin ■■ Hypotension ■■ Infant does not maintain suck ■■ Irritability
Lethargy Seizure ■■ Skin warm to touch ■■ Stupor ■■ Tachycardia ■■ Tachypnea ■■ Vasodilation
■■
■■
■■
■■
Decreased sweat response Dehydration ■■ High environmental temperature ■■ Illness ■■ Inappropriate clothing
Increase in metabolic rate Ischemia ■■ Pharmaceutical agent ■■ Sepsis ■■ Trauma ■■ Vigorous activity
■■
■■
■■
■■
Original literature support available at www.nanda.org
Class 6: Thermoregulation 427
11. Safety/Protection
Related Factors
Domain 11. Safety/Protection
Class 6. Thermoregulation
00006
Hypothermia
(1986, 1988, 2013; LOE 2.2)
Definition
Core body temperature below the normal diurnal range due to failure of thermoregulation.
Defining Characteristics Acrocyanosis Bradycardia ■■ Cyanotic nail beds ■■ Decrease in blood glucose level ■■ Decrease in ventilation ■■ Hypertension ■■ Hypoglycemia ■■ Hypoxia ■■ Increase in metabolic rate ■■ ■■
Increase in oxygen consumption ■■ Peripheral vasoconstriction ■■ Piloerection ■■ Shivering ■■ Skin cool to touch ■■ Slow capillary refill ■■ Tachycardia ■■
Accidental Low Body Temperature in Children and Adults
Mild hypothermia, core temperature 32-35 °C ■■ Moderate hypothermia, core temperature 30-32 °C ■■
11. Safety/Protection
■■
Severe hypothermia, core temperature <30 °C
■■
Severe hypothermia, core temperature <32 °C
Injured Adults and Children ■■
Hypothermia, core temperature <35 °C
Neonates
Grade 1 hypothermia, core temperature 36-36.5 °C ■■ Grade 2 hypothermia, core temperature 35-35.9 °C ■■ Grade 3 hypothermia, core temperature 34-34.9 °C ■■ Grade 4 hypothermia, core temperature <34 °C ■■ Infant with insufficient energy to maintain sucking ■■
428 Domain 11: Safety/Protection
Infant with insufficient weight gain (<30 g/d) ■■ Irritability ■■ Jaundice ■■ Metabolic acidosis ■■ Pallor ■■ Respiratory distress ■■
Related Factors Alcohol consumption Damage to hypothalamus ■■ Decrease in metabolic rate ■■ Economically disadvantaged ■■ Extremes of age ■■ Extremes of weight ■■ Heat transfer (e.g., conduction, convection, evaporation, radiation) ■■ Inactivity ■■ ■■
Insufficient caregiver knowledge of hypothermia prevention ■■ Insufficient clothing ■■ Insufficient supply of subcutaneous fat ■■ Low environmental temperature ■■ Malnutrition ■■ Pharmaceutical agent ■■ Radiation ■■ Trauma ■■
Neonates
Delay in breastfeeding Early bathing of newborn ■■ High risk out of hospital birth ■■ Immature stratum corneum ■■ Increased body surface area to weight ratio ■■ Increase in oxygen demand ■■ ■■
Increase in pulmonary vascular resistance (PVR) ■■ Ineffective vascular control ■■ Inefficient nonshivering thermogenesis ■■ Unplanned out-of-hospital birth ■■
11. Safety/Protection
Original literature support available at www.nanda.org
Class 6: Thermoregulation 429
Domain 11. Safety/Protection
Class 6. Thermoregulation
00253
Risk for hypothermia (2013; LOE 2.1)
Definition
Vulnerable to a failure of thermoregulation that may result in a core body temperature below the normal diurnal range, which may compromise health.
Risk Factors Alcohol consumption Damage to hypothalamus ■■ Economically disadvantaged ■■ Extremes of age ■■ Extremes of weight ■■ Heat transfer (e.g., conduction, convection, evaporation, radiation) ■■ Inactivity ■■ Insufficient caregiver knowledge of hypothermia prevention
Insufficient clothing Insufficient supply of subcutaneous fat ■■ Low environmental temperature ■■ Malnutrition ■■ Pharmaceutical agent ■■ Radiation ■■ Trauma
■■
■■
■■
■■
Children and Adults: Accidental 11. Safety/Protection
Mild hypothermia, core temperature approaching 35 °C ■■ Moderate hypothermia, core temperature approaching 32 °C ■■
■■
Severe hypothermia, core temperature approaching 30 °C
■■
Severe hypothermia, core temperature approaching 32 °C
Children and Adults: Injured Patients ■■
Hypothermia, core temperature approaching 35 °C
Neonates
Decrease in metabolic rate Delay in breastfeeding ■■ Early bathing of newborn ■■ Grade 1 hypothermia, core temperature approaching 36.5 °C ■■ ■■
430 Domain 11: Safety/Protection
Grade 2 hypothermia, core temperature approaching 36.0 °C ■■ Grade 3 hypothermia, core temperature approaching 35.0 °C ■■
Grade 4 hypothermia, core temperature approaching 34.0 °C ■■ High-risk out-of-hospital birth ■■ Immature stratum corneum ■■ Increased body surface area to weight ratio ■■
Increase in oxygen demand Increase in pulmonary vascular resistance (PVR) ■■ Ineffective vascular control ■■ Inefficient nonshivering thermogenesis ■■ Unplanned out-of-hospital birth ■■ ■■
11. Safety/Protection
Original literature support available at www.nanda.org
Class 6: Thermoregulation 431
Domain 11. Safety/Protection
Class 6. Thermoregulation
00254
Risk for perioperative hypothermia (2013; LOE 2.1)
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 American Society of Anesthesiologists (ASA) Physical Status classification score >1 ■■ Cardiovascular complications ■■ Combined regional and general anesthesia ■■ Diabetic neuropathy ■■ Heat transfer (e.g., high volume of unwarmed infusion, unwarmed irrigation >20 liters) ■■
Low body weight Low environmental temperature ■■ Low preoperative temperature (<36 °C/96.8 °F) ■■ Surgical procedure ■■ ■■
Original literature support available at www.nanda.org 11. Safety/Protection 432 Domain 11: Safety/Protection
Domain 11. Safety/Protection
Class 6. Thermoregulation
00008
Ineffective thermoregulation (1986)
Definition
Temperature fluctuation between hypothermia and hyperthermia.
Defining Characteristics Cyanotic nail beds Fluctuations in body temperature above and below the normal range ■■ Flushed skin ■■ Hypertension ■■ Increase in body temperature above normal range ■■ Increase in respiratory rate ■■ Mild shivering
Moderate pallor Piloerection ■■ Reduction in body temperature below normal range ■■ Seizures ■■ Skin cool to touch ■■ Skin warm to touch ■■ Slow capillary refill ■■ Tachycardia
■■
■■
■■
■■
■■ ■■
Extremes of age Fluctuating environmental temperature
■■ ■■
Illness Trauma
Class 6: Thermoregulation 433
11. Safety/Protection
Related Factors
602 Hyperthermia
Hopelessness—cont’d Outcomes Associated with Related Factors or Intermediate Outcomes
Adaptation to Physical Disability Coping Depression Self-Control Fatigue Level Fear Self-Control Grief Resolution Immobility Consequences: Psycho-Cognitive Neglect Recovery Pain: Adverse Psychological Response Pain: Disruptive Effects Physical Aging
Play Participation Quality of Life Relocation Adaptation Self-Care: Activities of Daily Living (ADL) Self-Management: Chronic Disease Social Involvement Spiritual Health Stress Level Suffering Severity Symptom Severity
Hyperthermia Definition: Body temperature elevated above normal range Outcomes to Measure Resolution of Diagnosis
Thermoregulation: Newborn
Thermoregulation Additional Outcomes to Measure Defining Characteristics
Neurological Status Neurological Status: Autonomic
Vital Signs
Outcomes Associated with Related Factors or Intermediate Outcomes
Knowledge: Acute Illness Management Medication Response Physical Injury Severity Risk Control: Hyperthermia Self-Management: Acute Illness
Blood Transfusion Reaction Comfort Status: Physical Discomfort Level Hydration Infection Severity Infection Severity: Newborn
Hypothermia Definition: Body temperature below normal range Outcomes to Measure Resolution of Diagnosis
Thermoregulation
Thermoregulation: Newborn
Additional Outcomes to Measure Defining Characteristics
Hypertension Severity Tissue Perfusion: Peripheral
Vital Signs
Outcomes Associated with Related Factors or Intermediate Outcomes
Comfort Status: Physical Medication Response Neurological Status: Autonomic Nutritional Status: Nutrient Intake Physical Aging
Physical Injury Severity Risk Control: Alcohol Use Risk Control: Hypothermia Self-Management: Acute Illness
Hyperthermia 505 Counseling Crisis Intervention Distraction Electroconvulsive Therapy (ECT) Management Exercise Promotion Exercise Therapy: Ambulation Grief Work Facilitation Grief Work Facilitation: Perinatal Death Music Therapy
Mutual Goal Setting Patient Contracting Phototherapy: Mood/Sleep Regulation Resiliency Promotion Self-Care Assistance Self-Modification Assistance Spiritual Support Suicide Prevention Therapeutic Play
Human Dignity, Risk for Compromised Definition: At risk for perceived loss of respect and honor Suggested Nursing Interventions for Problem Resolution: Anticipatory Guidance Culture Brokerage Decision-Making Support Examination Assistance Health Care Information Exchange Health System Guidance Patient Rights Protection Presence
Additional Optional Interventions: Abuse Protection Support Admission Care Bowel Incontinence Care Coping Enhancement Discharge Planning Family Involvement Promotion Financial Resource Assistance Multidisciplinary Care Conference Risk Identification
Hyperthermia Definition: Body temperature elevated above normal range Suggested Nursing Interventions For Problem Resolution: Bathing Environmental Management Fever Treatment Fluid Management Hemodynamic Regulation Infant Care: Newborn Infection Control Infection Protection Malignant Hyperthermia Precautions Medication Management Medication Prescribing Shock Management
Temperature Regulation Temperature Regulation: Perioperative Vital Signs Monitoring Additional Optional Interventions: Heat/Cold Application Nutrition Management Oxygen Therapy Peripherally Inserted Central Catheter (PICC) Care Seizure Management Seizure Precautions Skin Surveillance Total Parenteral Nutrition (TPN) Administration
470 Body Image, Disturbed Mutual Goal Setting Ostomy Care Patient Contracting Prenatal Care Suicide Prevention Teaching: Sexuality Truth Telling Unilateral Neglect Management Urinary Incontinence Care: Enuresis
Additional Optional Interventions: Amputation Care Anticipatory Guidance Bowel Incontinence Care: Encopresis Calming Technique Childbirth Preparation Cognitive Restructuring Decision-Making Support Lactation Counseling
Body Temperature, Risk for Imbalanced Definition: At risk for failure to maintain body temperature within normal range Suggested Nursing Interventions for Problem Resolution: Cerebral Edema Management Environmental Management Environmental Management: Comfort Fever Treatment Fluid Management Fluid Monitoring Malignant Hyperthermia Precautions Medication Management Postanesthesia Care Temperature Regulation Temperature Regulation: Perioperative Vital Signs Monitoring
Fluid Resuscitation Heat/Cold Application Hemodynamic Regulation Infection Control Infection Protection Kangaroo Care Nutrition Management Resuscitation: Neonate Risk Identification Sedation Management Surveillance Weight Management Wound Care: Burns
Additional Optional Interventions: Bathing Energy Management
Bowel Incontinence Definition: Change in normal bowel habits, characterized by involuntary passage of stool Suggested Nursing Interventions for Problem Resolution: Bowel Incontinence Care Bowel Incontinence Care: Encopresis Bowel Management Bowel Training Diarrhea Management Perineal Care Rectal Prolapse Management Self-Care Assistance: Toileting Skin Surveillance Teaching: Toilet Training
Additional Optional Interventions: Bathing Dementia Management Emotional Support Environmental Management Exercise Promotion Exercise Therapy: Ambulation Nutrition Management
Thermoregulation, Ineffective Definition: Temperature fluctuation between hypothermia and hyperthermia Suggested Nursing Interventions for Problem Resolution: Bathing Environmental Management Fever Treatment Fluid Management Fluid Monitoring Hemodynamic Regulation Hyperthermia Treatment Infant Care: Newborn Infant Care: Preterm
Temperature Regulation Temperature Regulation: Perioperative Vital Signs Monitoring Additional Optional Interventions: Anxiety Reduction Blood Products Administration Medication Administration Peripherally Inserted Central Catheter (PICC) Care Phlebotomy: Arterial Blood Sample
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