RISK FOR IMBALANCED BODY TEMPERATURE Nursing Care Plan

Risk for Imbalanced Body Temperature
Hyperthermia
Hypothermia
Ineffective Thermoregulation
NANDA-I Definition
At risk for failure to maintain body temperature within normal

rangeRisk Factors
Treatment Related
Related to cooling effects of:
Parenteral fluid infusion/blood
transfusion
Cooling blanket
Dialysis
Operating suite
Situational (Personal, Environmental)
Related to:
Consumption of alcohol
Exposure to extremes of environmental
temperature*
Inappropriate clothing for environmental
temperature*
Inability to pay for shelter,
heat, or air conditioning
Extremes of weight*
Dehydration*/malnutrition
Newborn birth environment
exposure
Maturational
Related to ineffective temperature regulation secondary to extremes of
age* (e.g., newborn, older adult)

Authors notes
Risk for Imbalanced Body Temperature includes those at risk for
Hyperthermia, Hypothermia, Ineffective Thermoregulation, or all of
these. If the client is at risk for only one (e.g., Hypothermia but not
Hyperthermia), then it is more useful to label the problem with the
specific diagnosis (Risk for Hypothermia). If the client is at risk for two or
more, then Risk for Imbalanced Body Temperature is more appropriate.
The focus of nursing care is preventing abnormal body temperatures
by identifying and treating those with normal temperature who demonstrate
risk factors that nurse-prescribed interventions (e.g., removing
blankets, adjusting environmental temperature) can control. If the imbalance
is related to a pathophysiologic complication that requires nursing
and medical interventions, then the problem should be labeled as a collaborative
problem (e.g., RC of Severe Hypothermia related to hypothalamus
injury). The focus of concern then becomes monitoring to detect
and report significant temperature fluctuations and implementing collaborative
interventions (e.g., a warming or cooling blanket) as ordered.

See also Author’s Note for Hyperthermia and Hypothermia.

Goal
The client will demonstrate a temperature within normal limits
for age evidenced by the following indicators:
• Report measures to prevent temperature fluctuations.
• Report episodes of chills, diaphoresis, shivering, cool skin.
Interventions
• Monitor temperature as needed (1 to 4 hours). Use continuous
temperature monitoring for vulnerable individuals (e.g.,
critically
ill adults, neonates, infants).
• Use oral thermometers if possible.
• Maintain consistent room temperature of 72° F (22.2° C).
Avoid drafts.
• During bathing, expose only small sections of the body. After
washing, cover the area with absorbent blanket.
• Ensure that optimal nutrition and hydration is achieved.
• Refer to Ineffective Thermoregulation for interventions for
newborns.
• Refer to Hypothermia or Hyperthermia for interventions to prevent body temperature disruptions.


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