Nursing diagnosis – risk for imbalanced body temperature

Risk for Imbalanced body temperature
Definition
At risk for failure to maintain body temperature within normal
range
RISK FACTORS
• RISK FOR IMBALANCED BODY TEMPERATURE
• Altered metabolic rate
• Dehydration
• Exposure to extreme hot/cold
environments
• Advanced age
• Extremes of weight
• Illness/trauma affecting
temperature regulation
• Medications causing vasoconstriction
• Inactivity/vigorous activity
ASSESSMENT FOCUS (Refer to comprehensive assessment parameters.)
• Fluid and electrolytes
• Neurocognition
EXPECTED OUTCOMES
The patient will
• Maintain body temperature of 98.6 F–99.5 F (37 C–37.5 C).
• Maintain weight within 5% of baseline.
• Maintain balanced intake and output within normal limits for age.
• Have a urine-specific gravity between 1.010 and 1.015.
SUGGESTED NOC OUTCOMES
Hydration; Medication Response; Thermoregulation
INTERVENTIONS AND RATIONALES
Determine: Assess temperature every 4 hr. Use a temperature-taking
method appropriate for age and size (rectal or axillary for an infant
or toddler, axillary or oral for a preschooler, and oral for a schoolaged
child or adult). Prolonged elevation of temperature above 104 F
(40 C) may produce dehydration and harmful central nervous system
effects.
Weigh patient every morning and record results. A decrease in
weight may indicate dehydration.
Assess the patient’s knowledge and lifestyle before teaching about
hypothermia and hyperthermia to gear the teaching plan to the
patient’s needs.
Perform: Maintain adequate fluid intake by offering small amounts
of flavored fluids at frequent intervals; record intake and output
every shift. Fever increases fluid requirements by increasing the
metabolic rate. Provide high-calorie liquids, such as colas, fruit
juices, and flavored water sweetened with corn syrup, to help
prevent dehydration.
Administer antipyretics, as ordered, and monitor effectiveness.
Antipyretics act on the hypothalamus to regulate body temperature.
• Nutrition
• Respiratory function
Check and record urine-specific gravity with each voiding. Urinespecific
gravity increases with dehydration. Adequate urine output
and urine-specific gravity between 1.010 and 1.015 indicate
sufficient hydration.
Give a tepid sponge bath for increased temperature to increase
vaporization from skin and decrease body temperature.
Inform: Teach patient to dress in lightweight clothing when experiencing
elevated body temperature to allow perspiration to evaporate,
thereby releasing body heat.
Instruct the patient on the signs and symptoms of imbalanced
body temperature:
– Hypothermia: shallow respirations; slow, weak pulse; decreased
body temperature; low blood pressure; and pallor
– Hyperthermia: shivering, shaking chill; feeling hot; extreme
thirst; elevated body temperature; and high blood pressure.
Listing the signs and symptoms helps the patient learn and identify
warning signals of imbalanced body temperature. Large black
type is easier for the older patient to read.
Explain to the patient or family member why the patient needs
warm clothing in cool climates, even indoors. Suggest socks, nonslip
house shoes, and leg warmers to provide warmth to vulnerable
lower extremities, where vascular changes may cause decreased temperature
sensation.
Instruct the patient or family member to label home thermostats
with large numbers and to use black or bright contrasting colors to
indicate appropriate temperature settings. Easy-to-read labels will
help the patient maintain room temperature.
Teach the patient or his or her family members about the dangers
of too much direct sunlight on warm days to prevent overheating in
an older patient with faulty thermoreceptors.
Attend: Encourage the patient to remain active when in a cool environment
to keep warm and maintain normal metabolism.
Manage: Suggest that a friend, family member, or volunteer from a
local community organization visit the patient daily to help ensure
the patient’s safety.
SUGGESTED NIC INTERVENTIONS
Fever Treatment; Medication Management; Temperature Regulation;
Vital Signs Monitoring
Reference
Braun, C. A. (2006, September–October). Accuracy of pacifier thermometers
in young children. Pediatric Nursing, 32(5), 413–418.

Nursig diagnosis – disturbed body image

Disturbed Body Image
DEFINITION
Confusion in mental picture of one’s physical self
DEFINING CHARACTERISTICS
• Physiologic changes, behavioral changes, usual patterns of coping
with stress
• Missing body part, not looking or touching a body part, negative
feelings about a body part
• Frequent or disparaging comments about aging and its physical
manifestations
• Personal rigidity or unwillingness to change
• Actual change in structure or function
• Change in social relationships
• Hiding or overexposing of a body part (intentional or
unintentional)
• Depersonalization of loss by using third person pronouns
• Unintentional or intentional overexposing of body part
RELATED FACTORS
• DISTURBED BODY IMAGE
• Biophysical
• Cognitive
• Cultural
• Illness
• Surgery
• Trauma
ASSESSMENT FOCUS (Refer to comprehensive assessment parameters.)
• Behavior
• Knowledge
• Sensory perception
EXPECTED OUTCOMES
The patient will
• Identify physical changes without making disparaging comments.
• Identify at least one positive aspect of aging.
• Use vision or hearing aids appropriately.
• Demonstrate increased flexibility and willingness to consider
lifestyles changes.
• Participate in at least one social activity regularly.
• Exercise and engage in other physical activity at level consistent
with desire, ability, and safety.
• Perform self-care activities to tolerance level.
SUGGESTED NOC OUTCOMES
Body Image; Grief Resolution; Self-Esteem
INTERVENTIONS AND RATIONALES
Determine: Monitor physiologic responses to increased activity level,
including respirations, heart rate and rhythm, and blood pressure.
Assess understanding of the current health problem and desire to
• Sexuality
• Values/beliefs
participate in treatment. Assessment information is helpful in determining
appropriate interventions.
Perform: Perform ADL measures that the patient is unable to
perform for self while promoting as much independence as possible.
Inform: Provide patient with information on appropriate self-care
activities (e.g., maintaining proper diet; bathing as needed; using
alcohol-free skin lotions to combat dryness; exercising appropriately
to maintain muscle mass, bone strength, and cardiorespiratory
health; avoiding fractures related to osteoporosis) to ensure that the
patient will be able to perform self-care measures.
Teach patient about isometric exercises to maintain or increase
muscle tone and joint mobility.
Teach caregivers to assist patient with self-care activities in a way
that maximizes patient’s potential. This enables caregivers to participate
in patient’s care while supporting patient’s independence.
Attend: Provide emotional support and encouragement to improve
patient’s self-concept and promote motivation to perform ADLs.
Assist patient to learn how to perform self-care activities. Begin
slowly and increase daily, as tolerated. Performing self-care activities
will assist patient to regain independence and enhance self-esteem.
Involve patient in planning and decision making. Having the ability
to participate will encourage greater compliance with the plan for
activity.
Focus on patient’s strengths and what the patient is able to do for
self.
Encourage patient to engage in social activities with people of all
age groups. Participation once a week will help relieve patient’s
sense of isolation.
Manage: Refer to case manager/social worker to ensure patient
receives long-term assistance with body image problem.
Refer patient to a support group. In the context of a group, the
patient may develop a more positive view of present situation.
Refer for corrective eyewear and hearing aids to address sensory
deficits.
SUGGESTED NIC INTERVENTIONS
Active Listening; Body Image Enhancement; Grief Work Facilitation;
Self-Esteem Enhancement
Reference
Barba, B. E., & Colemen, P. (2006, August). What are old people for? Journal
of Gerontological Nursing, 32(8), 7–8.