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INEFFECTIVE THERMOREGULATION Nursing Care Plan

NANDA-I Definition
Temperature fluctuation between hypothermia and hyperthermia
Defining Characteristics
Refer to Defining Characteristics for Hypothermia and Hyperthermia
Related Factors
Situational (Personal, Environmental)
Related to:
Fluctuating environmental
temperatures
Cold or wet articles (clothes,
cribs, equipment)
Inadequate housing
Wet body surface
Inadequate clothing for
weather (excessive,
insufficient)
Maturational
Related to limited metabolic compensatory regulation secondary to age
(e.g., neonate, older adult)
Ineffective Thermoregulation is a useful diagnosis for people with difficulty
maintaining a stable core body temperature over a span of environmental
temperatures. This diagnosis most commonly applies to older adults
and newborns. Thermoregulation involves balancing heat production
and heat loss. Nursing care focuses on manipulating external factors
(e.g., clothing and environmental conditions) to maintain body temperature

within normal limits and on teaching prevention strategies.

Goals
• The infant will have a temperature 97.5° to 98.6° F (36.4° to
37° C).
• The parent will explain techniques to avoid heat loss at home.
• List situations that increase heat loss.
• Demonstrate how to conserve heat during bathing.
• Demonstrate how to take infant’s temperature.
• State appropriate attire for outdoor/indoor climates.
Interventions
Pediatric Interventions
Reduce or Eliminate the Sources of Heat Loss in Infants
Evaporation
• After delivery, quickly dry skin and hair with a heated towel
and place infant in a prewarmed, heated environment.
• When bathing, provide a warm environment or bathe under a
heat source.
• Wash and dry in sections to reduce evaporation.
• Limit time in contact with wet clothing or blankets.
Convection
• Avoid drafts (e.g., air conditioning, fans, windows, open portholes
on isolette).
• Place sides of radiant warmer bed up at all times.
• Use only portholes for infant access in isolette whenever possible.
Conduction
• Warm all articles for care (e.g., stethoscopes, scales, hands of
caregivers, clothes, bed linens).
• Place infant close to mother to conserve heat and promote
bonding.
• Warm or cover any equipment that may come in contact with

the infant’s skin.

• Limit objects in the room that absorb heat (e.g., metal).
• Place crib or bed as far away from walls (outside) or windows
as possible.
Monitor Temperature of Infants
• If temperature is below normal:
• Wrap in two blankets.
• Put on head cap.
• Assess for environmental sources of heat loss.
• If hypothermia persists for . 1 hour, notify physician.
• Assess for complications of cold stress such as hypoxia,
respiratory
acidosis, hypoglycemia, fluid and electrolyte
imbalances, weight loss.
• If temperature is above normal:
• Loosen blanket.
• Remove cap, if on.
• Assess environment for thermal gain.
• If hyperthermia persists for . 1 hour, notify physician.
Assess for Signs of Sepsis (Respiratory Function, Skin, Poor
Feeding, Irritability, Signs of Localized Infections [Skin, Umbilicus,
Circumcision, Eyes]).
Teach Caregiver Why Infant Is Vulnerable to Temperature
Fluctuations (Cold and Heat).
Demonstrate How to Conserve Heat During Bathing
Instruct That It Is Not Necessary to Check Temperature Routinely
at Home
Teach to Check Temperature If Infant Is Hot, Sick, or Irritable
Geriatric Interventions
• Explain age-related changes that interfere with thermoregulation
(Miller, 2009):
• Cold (e.g., inefficient vasoconstriction, decreased cardiac output,
decreased subcutaneous tissue, delayed and diminished
shivering)
• Heat (e.g., delayed sweating response, diminished sweating
response)
• Explain that these changes will distort perception of environmental
temperatures.
• Investigate even a slight elevation of temperature. Use
tympanic
route for temperatures, not oral or axillary.
• Teach how to prevent hypothermia and hyperthermia (refer to
Hypothermia, Hyperthermia).

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