8) Nursing Diagnosis & Planning Phase For Temperature

Question 1

What are some nursing diagnoses related to body temperature alterations?

Answer 1

• Risk for imbalanced body temperature
• Hyperthermia
• Hypothermia
• Ineffective thermoregulation

Question 2

What defines the diagnosis of hyperthermia?

Answer 2

• Increased body temperature
• Flushed skin
• Skin warm to touch
• Tachycardia

Question 3

What should the nurse do if a patient has risk factors?

Answer 3

• Minimize or eliminate the risk factors

Question 4

What guides the selection of nursing interventions?

Answer 4

• The related factor or cause of the temperature alteration

Question 5

How would nursing interventions differ for hyperthermia?

Answer 5

• Interventions would vary based on related factor (e.g. vigorous activity vs. decreased ability to perspire)

Question 6

What should nurses do during the planning phase?

Answer 6

• Integrate knowledge from assessment and patient history
• Develop and modify a person-centered care plan
• Match patient needs with evidence-based interventions

Question 7

What should the care plan for temperature alteration include?

Answer 7

• Realistic and individualized goals
• Relevant expected outcomes
• Close collaboration with patient

Question 8

What do expected outcomes measure?

Answer 8

• Progress toward returning body temperature to acceptable range

Question 9

What are examples of goals?

Answer 9

• Short-term: Regaining normal temperature in 24 hours
• Long-term: Modifying environment (e.g. proper clothing)

Question 10

How should outcomes be determined?

Answer 10

• Outcomes must relate to what is learned about the patient

Question 11

What factors influence care priorities for temperature alterations?

Answer 11

• Severity of temperature alteration and effects
• Patient’s general health status
• Presence of other medical problems

Question 12

What is a top priority in caring for temperature alterations?

Answer 12

• Safety

Question 13

How can temperature alterations complicate care plans?

Answer 13

• Affect body’s fluid requirements
• Patients with cardiac disease may not tolerate fluid replacement

Question 14

What type of care plan is needed for high-risk patients?

Answer 14

• Individualized plan to maintain normothermia
• Reduce risk factors for temperature alterations

Question 15

What should be an outcome of care for high-risk patients?

Answer 15

• Patient can explain actions during heat wave

Question 16

Why is patient/caregiver education important?

Answer 16

• Teaches importance of thermoregulation
• Prepares for taking action at home for infants/children

Question 17

What is the focus of health promotion for temperature alteration risk?

Answer 17

• Promoting balance between heat production and heat loss
• Considering patient activity, environment temperature, clothing

Question 18

What do nurses teach to prevent hyperthermia?

Answer 18

• Avoid strenuous exercise in hot, humid weather
• Drink fluids before, during, and after exercise
• Wear light, loose, light-colored clothing
• Avoid poorly ventilated areas for exercise
• Wear head covering outdoors
• Gradually expose to heat when entering hot climates

Question 19

Why is prevention key for hypothermia risk?

Answer 19

• Educate patients, caregivers, and friends
• High-risk groups include extremes of age, debilitated, mentally ill
• Those without adequate heating, shelter, diet, clothing

Question 20

What factors increase hypothermia risk?

Answer 20

• Trauma, spinal cord injury, stroke, diabetes
• Drug/alcohol intoxication, sepsis, Raynaud’s disease
• Fatigue, dark skin color, malnutrition, hypoxemia, body piercings