Ineffective Thermoregulation Adult Standard Care Plan by wuyunqing


									                                                                                                                   Policy #CC_16
                                                                                                                   Issue Date: 3/12/04
                                                                                                                   Effective Date: 7/13/07
                                             DEPARTMENT OF NURSING
                                              STANDARD CARE PLAN

TITLE:_______Ineffective Thermoregulation/Adult____________________                                      Date Initiated:_______________

Prepared by: __Adult Medical/Surgical Standards Committee__________                                      Page ____1_____ of ____1____
                                                                                                         Applicable Patient Care Area(s):
Approved by:__Nurse Executive Council 11/07/03___________________                                        (x) Med/Surg       ( ) Pediatric
                                                                                                         ( ) LTC            ( ) Maternity
Effective Date:_3/26/2004_Review Date:_2/6/07, 8/10 Revision Date:_______                                (x) Critical Care  ( ) Neonatal

   DIAGNOSIS/OUTCOME/                                                                                                  DATE AND INTIALS
 COLLABORATIVE PROBLEMS                                       INTERVENTIONS                                    Start     D/C     Start       D/C

NURSING DIAGNOSIS:                       1. Monitor body temperature and vital signs every___ hours.

ALTERED BODY TEMPERATURE                 2. Observe/assess for:

a. Hyperthermia                             a. flushing or pallor of skin.

b. Hypothermia                              b. warmth/coolness of skin to touch.

                                            c. increase/decrease of pulse and/or respiratory rate.

R/T:                                        d. increase/decrease in blood pressure or orthostasis.

1.                                          e. change in mentation; apathy, drowsiness, impaired

2.                                             judgement, confusion, restlessness.

                                            f. complains of headache, weakness, shivering.

                                         3. Report temperature below 35.5 celcius and above 38.3


OUTCOME: Patient will:                   4. Prevent heat loss/gain by:

1. Maintain normal body temperature.        a. maintain adequate fluid and caloric intake.

2. Maintain adequate hydration status.      b. dress appropriately for environment, state of

3. Other:________________________              wellness, and level of activity.

                                            c. cover head with cap/scarf if patient at risk for losing

                                               body heat.

                                            d. keep skin dry and prevent direct contact with cold


                                            e. reduce/eliminate modifiable risk factors.

                                         5. Provide comfort measures for increased temperatures

                                             with cool washcloths, tepid baths.

                                         6. Accurate intake and outake.

                                         7. Hypo/hyperthermia Blanket Adult Protocol. [TX.21]

Form #DTBGH0495 [11/03]

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