INEFFECTIVE THERMOREGULATION Nursing Care Plan

Mr. Luterio, 64 years old, retired construction officer. Mr. Luterio always put his jacket and thick pants even at the peak of the afternoon. It is not because he likes it but because he cannot resist the cold he feels. Mr. Luterio cannot regulate his body temperature that is why he always wears thick layers of clothing. Mr. Luterio cannot explain why this is happening to him. Someone said that he was been cursed by a witch of someone mad at him in the past or still have anger against him. Below is a sample of ineffective thermoregulation nursing care plan of Mr. Luterio.

Assessment:

Subjective: "I always feel cold even when others are not." As verbalized by the patient.

Objectives:

- Shivers

- Slow and shallow breathing

- Mumbled speech

- Weak pulse

- Cold to touch skin

- Bright red skin

 

Diagnosis:

Ineffective thermoregulation related to limited metabolic compensatory regulation secondary to age as an older adult.

 

Planning:

After 2 hours of nursing intervention, the patient will have a temperature 97.5° to 98.6° F (36.4° to 37° C). The patient will explain techniques to avoid heat loss at home. The patient will list situations that increase heat loss. The patient will demonstrate how to conserve heat during bathing. The patient will state appropriate attire for outdoor/indoor climates.

 

Interventions:

- Explain age-related changes that interfere with thermoregulation to Mr. Luterio such as inefficient vasoconstriction, decreased cardiac output, decreased subcutaneous tissue, delayed and diminished shivering. Explain that these changes will distort perception of environmental temperatures. Investigate even a slight elevation of his temperature. Use tympanic route for temperatures, not oral or axillary. Teach Mr. Luterio how to prevent hypothermia and hyperthermia.

 

- Remove any of his wet clothes, hats, gloves, shoes, and socks. Protect Mr. Luterio against wind, drafts, and further heat loss with warm, dry clothes and blankets. Move gently to a warm, dry shelter as soon as possible. Begin rewarming Mr. Luterio with extra clothing. Use warm blankets. Other helpful items for warming are: an electric blanket to the torso area and hot packs and heating pad on the torso, armpits, neck, and groin; however, these can cause burns to the skin. Use your own body heat if nothing else is available. Take Mr. Luterio's temperature if a thermometer is available.

 

- Monitor temperature of Mr. Luterio for at least 2 hours or as indicated. Check temperature monitoring continuously. Monitor his skin color and his temperature. Monitor signs of hyperthermia and hypothermia. Increase intake of fluids and nutrients of Mr. Luterio. Teach him and his families how to prevent heat fatigue. Notify about the occurrence of fatigue and handling emergency needed. Discuss with family or patient the importance of temperature regulation and the possible negative effects of cold. Make collaboration on giving antipyretics. Cold stress increases the need for glucose and oxygen and can lead to problems when Mr. Luterio has acid base anaerobic metabolism when oxygen levels are not enough available. Increased levels of indirect bilirubin may occur due to the release of fatty acids from his fat metabolism by fatty acids compete with bilirubin in the bond part in albumin.

 

Evaluation:

After 2 hours of nursing intervention, the patient had a temperature 97.5° to 98.6° F (36.4° to 37° C). The patient explained techniques to avoid heat loss at home. The patient listed situations that increase heat loss.The patient demonstrated how to conserve heat during bathing.The patient stated appropriate attire for outdoor/indoor climates.

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