RISK FOR IMBALANCED BODY TEMPERATURE Nursing Care Plan

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 prepare 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. bodyRisk 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, 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.

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