Nursing Care Plan: Risk for imbalanced temperature related to age, inappropriate clothing and dugs.

Scientific Basis:

Risk for altered body temperature exist for all persons, but some situation and individual physical capacities places risk on certain individuals. Older patients are physically incapable of compensating for environmental exposures and are greater risk in life-threatening events.

The older adult has difficulty responding to changes in environmental temperature because of slowed circulation, decreased heat-generating activities, change in skin function. Healthy persons, such as the athlete who is performing under extremely hot conditions, are also at risk. Prevention is accomplished by providing education specific to individual needs.

Gulanick, 2007

Intervention and Rationale

I: Assess for presence of risk factors such as infection.
R: The immune response is fever. The hypothalamus “set point” is higher during fever. The heat regulation mechanism controls heat production and conservation to maintain body core temperature at a higher level.

I: Monitor heart and respiratory rate.
R: This may be increased or decreased.

I: Monitor fluid balance.
R: Dehydration may precipitate decrease in the temperature.

I: Check blood pressure.
R: This may be increased or decreased.

I: Check skin condition.
R: Skin may change in color and temperature.

I: Check mental status.
R: Changes occur with increase or decrease in the core temperature.
I: Measure temperature at frequent intervals. Use the same instrument and method at each intervals,
R: A change of this type usually causes a variance in the .temperature obtained.

I: Provide or instruct SO in the following preventive measure (control environment).
R: Older clients or persons need a warmer environment.

I: Provide appropriate clothing or covering.
R: Buerger’s disease client needs to avoid exposure of hands and feet to extreme cold.

I: Provide adequate fluid and dietary intake.
R: Dehydration contributes to development of hyperthermia.

I: Explain preventions of risk factors and consequences of development of temperature alterations.
R: Clients can implement appropriate environmental temperature controls when they understand the risks associated with changes in body temperature.

I: Ensure the client can read the thermometer being used.
R: Older persons may have difficulty visualizing a mercury thermometer.

Gulanick, 2007; Kruse, et al, 2003; Doenges, et al, 2008

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