Mr. Pacther is a 45
years old former sports athlete. He is now a professional coach of his home
town team of young football athlete. He handles players with 7 to 14 years of
age. Aside from doing his hobby as a coach, he do jogging every morning before
7am, have his morning breakfast at his favorite cafe restaurant, go home and
sleep. Then he wakes up and prepares to do his coaching. He sometimes come home
so late but still wakes up early to do jogging. Below is a sample of risk
for imbalanced body temperature nursing care plan of Mr. Pacther. Risk for
Imbalanced Body Temperature includes those at risk for Hyperthermia,
Hypothermia, Ineffective Thermoregulation.
Assessment:
Objectives:
- Dehydrated
- Drunk
- Exposure to very hot
environment
- Obese
- Wears jacket in a very
hot environment
- Able to communicate
and understand clearly
- Able to participate
care despite being drunk
Diagnosis:
Risk for imbalanced body
temperature related to consumption of alcohol secondary to being drunk and
dehydrated.
Planning:
After 2 hours of nursing
intervention, the patient will demonstrate a temperature within normal
limits for age.
Interventions:
- Monitor temperature
of Mr. Pacther as needed (1 to 4 hours). Use continuous temperature
monitoring for Mr. Pacther. Use oral thermometers if possible. Maintain
consistent room temperature of 72° F (22.2° C). During bathing, expose only small
sections of his body. After washing, cover the area with absorbent blanket.
Ensure that optimal nutrition and hydration is achieved.
- Identify
causative/risk factors present: Determine if Mr. Pacther presents
illness or condition results from exposure to his environmental factors,
surgery, infection, and trauma. Monitor Mr. Pacther laboratory values
(e.g., tests indicative of infection, drug screens). Note his age as it can
directly impact his ability to maintain or regulate body temperature and
respond to changes in his environment. Assess Mr.
Pacther's nutritional status.
- Prevent occurrence of temperature alteration: Monitor or maintain comfortable
ambient environment. Provide heating or cooling measures as indicated. Cover
head with knit cap; place Mr. Pacther under radiant warmer or
adequate blankets. Heat loss in older adult is greatest through head and by
evaporation and convection. Monitor his core body temperature. Tympanic
temperature may be preferred, as it is the most accurate noninvasive method.
Restore or maintain core temperature within Mr. Pacther's normal
range. Refer at-risk persons to appropriate community resources to provide
assistance to meet individual needs.
- Promote wellness: Review potential problem/individual risk factors
with Mr. Pacther. Instruct in measures to protect from identified risk
factors. Review ways to prevent him from accidental alterations, such as
induced hypothermia as a result of overzealous cooling to reduce his fever or
maintaining too warm an environment for Mr. Pacther who has lost the
ability to perspire. If his body temperature starts to climb and he is unable
to cool himself through sweating, he is experiencing heat stress. Heat stress
can lead to serious complications, such as heat exhaustion and heat stroke. If Mr.
Pacther feels signs of heat stress, get him to a cooler area and rest.
Start Mr. Pacther to drink water or other fluids with electrolytes
that will help him restore hydration.
Evaluation:
After 2 hours of nursing
intervention, the patient demonstrated a temperature within normal
limits for age.
For more samples of nursing care plan you are free to check it out in our NCP LIST page.
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