Ineffective Thermoregulation - Nursing Diagnosis, NOC and NIC

Physiological and behavioral mechanisms regulate the balance between heat lost and produced or more commonly referred to as thermoregulation. The body's mechanism must maintain the connection between heat production and heat loss so that the body temperature remains constant and normal. This relationship is governed by neurological and cardiovascular mechanisms. (Potter and Perry, 2010)

Nursing Diagnosis

 Ineffective Thermoregulation r/t :
  • Aging
  • Changes in ambient temperature
  • Disease
  • Immaturity
  • Trauma
Objective Data :
  • Cold skin
  • Bluish nails
  • Changes in body temperature above and below normal values
  • Reddish skin
  • Hypertension
  • Increase RR
  • Shivering
  • Pale
  • Seizures
  • Slow CRT
  • Tachycardia
  • Warm to the touch
NOC:
  • Thermoregulation (temperature regulation)
  • Newborn thermoregulation (setting the temperature of a newborn)
After nursing actions have been carried out for ......., it is expected to be effective thermoregulation, with the results criteria:
Thermoregulation (temperature regulation)
  • Skin temperature as expected
  • Body temperature as expected
  • There is no headache
  • There is no muscle pain
  • There is no change in skin color
  • There is no tremor and trembling
  • Vital signs are within normal limits
  • There is no irritation
  • Sweating when heat
  • Shivering when cold
  • Not sleepy

Newborn thermoregulation (setting the temperature of a newborn)
  • Increased weight
  • Not shivering
  • There is no hypothermia
  • Skin temperature within the expected range
  • Pulse and breathing are within the expected range
  • Blood sugar is within normal limits
NIC:

 Temperature Regulation (temperature regulation)
  • Monitor temperature for at least 2 hours or as indicated
  • Plan temperature monitoring continuously
  • Monitor skin color and temperature
  • Monitor signs of hyperthermia and hypothermia
  • Increase intake of fluids and nutrients
  • Teach patients and 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
  • Collaboration on giving antipyretics
Intraoperative temperature regulation
  • Monitor the room regulator
  • Adjust the operating room temperature for therapeutic effects
  • Measure the right temperature with a reflective / thick blanket
  • Move the baby into a warmed isolation room
  • Keep an eye on the patient's temperature
  • Keep the temperature warm
  • Cover the patient with a blanket when the patient is taken to the anesthesia unit
  • Cover the patient to prevent loss of body heat

Ineffective Thermoregulation Nursing Diagnosis NOC and NIC