Nanda Nursing Diagnosis

Hypothermia: Definition : Body temperature below the normal range Defining Characteristics : body temperature below normal range, cool, pale skin, dizziness, hypertension, increased heart rate, lack of coordination, piloerection, shivering, slow capillary refill Related Factors : alcohol and drug use, decreased metabolic rate, exposure to cold environment, extreme evaporative heat loss from skin, illness, inability to shiver, inadequate nutrition, poor clothing, medications, trauma NOC: Thermoregulation Thermoregulation: neonate Expected Outcomes: Body temperature in the normal range Pulse and respiratory rate are in the normal range NIC: Temperature Regulation Monitor temperature at least every 2 hours. Plan temperature monitoring continuously. Blood pressure monitor, pulse, and respiratory rate. Monitor skin color and temperature. Monitor signs of hyperthermia and hypothermia. Increase intake of fluids and nutrients. Cover the patient to prevent loss of body warmth. Teach patients ho...

Hypothermia Hypothermia is a condition in which core temperature drops below the required temperature for normal metabolism and body functions which is defined as 35.0 °C (95.0 °F). Body temperature is usually maintained near a constant level of 36.5–37.5 °C (98–100 °F) through biologic homeostasis or thermoregulation. If exposed to cold and the internal mechanisms are unable to replenish the heat that is being lost, a drop in core temperature occurs. As body temperature decreases, characteristic symptoms occur such as shivering and mental confusion. Nursing Care Plan for Hypothermia Related Factors: Situational (Personal, environmental) Heat, rain, wind Clothing that does not comply with the climate Decrease in circulation: Extreme weight loss Consuming alcohol Dehydration Inactivity Maturisional Ineffective temperature regulation: Newborns Elderly Major Data: Temperatures below 35.5 º C per rectal Cold skin Pallor (medium) Shivering (mild) Minor Data: Mental disorder / sleepy / rest...