Nursing Care Plan for Ineffective Thermoregulation

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Definition of Thermoregulation

Thermoregulation is a physiological regulation of the human body, the balance of heat production and heat loss so the body temperature can be maintained constantly.

Balance body temperature is regulated by physiological and behavioral mechanisms. In order for the body temperature remains constant and is within normal limits, the relationship between heat production and heat dissipation must be maintained. The relationship is regulated through the mechanism of neurological and cardiovascular. Nurses apply knowledge of temperature control mechanism to improve temperature regulation.

The hypothalamus is located between the cerebral hemispheres, controlling body temperature as the thermostat in the house work. The hypothalamus senses light changes in body temperature. Anterior hypothalamus controlling heat dissipation, and posterior hypothalamic control of heat production.


Factors influencing thermoregulation

Many factors affect body temperature. Changes in body temperature within the normal range occurs when the relationship between heat production and heat loss plagued by physiological or behavioral variables. Here are the factors that influence body temperature:

1. Age

At birth, the baby left the warm environment, which is relatively constant, entered in an environment where the temperature fluctuates rapidly. Baby's body temperature may respond dramatically to changes in environmental temperature. Newborns spend more than 30% of body heat through the head is therefore necessary to use a head covering to prevent heat dissipation. When protected from extreme environments, the baby's body temperature was maintained at 35.5 º C to 39.5 º C. Heat production will increase along with the growth of infants entering children. Individual difference of 0.25 º C to 0.55 º C is normal (Whaley and Wong, 1995).

Temperature regulation is not stable until puberty. Normal temperature range down gradually until someone nearing the elderly. Elderly have a narrower temperature range than early adulthood. Oral temperature of 35 º C are not uncommon in the elderly in cold weather. However, the range of body temperature in elderly around 36 º C. Elderly particularly sensitive to extreme temperatures due to deterioration mechanisms of control, especially in vasomotor control (control of vasoconstriction and vasodilatation), a decrease in the amount of subcutaneous tissue, decreased sweat gland activity and a decrease in metabolism.

2. Sports

Muscle activity requires an increased blood supply in the breakdown of carbohydrates and fats. This leads to increased metabolism and heat production. Any type of exercise can increase heat production, consequently increasing the body temperature. Long strenuous exercise, such as long-distance running, can increase body temperature temporarily to 41 º C.

3. Hormone levels

In general, women experience fluctuations in body temperature greater than men. Hormonal variations during the menstrual cycle causes fluctuations in body temperature. Progesterone levels increase and decrease gradually during the menstrual cycle. When progesterone levels are low, the body temperature a few degrees below the limit level. Low body temperature that lasted until ovulation. Temperature changes also occur in postmenopausal women. Women who had stopped menstruation may experience periods of body heat and sweating a lot, from 30 seconds to 5 minutes. This is due to the unstable vasomotor control in doing vasodilation and vasoconstriction. (Bobak, 1993)

4. Circadian rhythms

Normal body temperature change of 0.5 º C to 1 º C over a period of 24 hours. However, the temperature is a steady rhythm in humans. Lowest body temperature is usually between 1:00 pm and 4:00 am. Throughout the day the body temperature rises, until about 18:00 and then down like in the early days. Important note, the temperature patterns are not automatically on the people who work at night and sleep during the day. It took 1-3 weeks for the rotation change. In general, the temperature circadian rhythm does not change with age. Research shows, the peak temperature is early days in the elderly (lenz, 1984)

5. Stress

Physical and emotional stress increases the body temperature through hormonal and neural stimulation. The physiological changes increase the heat. Clients are anxious while in the hospital or doctor's office, her body temperature can be higher than normal.

6. Environment

Environment affecting body temperature. If the temperature is studied in a very warm room, the client may not be able to regulate body temperature through heat flushing mechanism and body temperature will rise. If the client is in an environment without warm clothes, body temperature may be low due to the effective deployment and conductive heat dissipation. Infants and the elderly most often influenced by environmental temperature because they are less efficient mechanism of temperature.



Changes in body temperature

Changes in body temperature outside the range of normal influences hypothalamic set point. These changes may be associated with the production of excessive heat, excessive heat dissipation, heat production is minimal. Spending minimal heat or any combination of these changes. The nature of these changes affect the clinical problems experienced by clients.

1. Fever

Fever or hyperpyrexia occur because heat dissipation mechanism is not able to maintain the speed of spending excess heat production, resulting in an abnormal increase in body temperature. Health-threatening levels when fever is often a source of debate among health care providers. Fever is usually not harmful if it is at a temperature below 39 º C. Single temperature readings may not signify a fever. Davis and Lentz (1989) recommends for determining fever by some temperature readings at different times in one day compared to the normal temperature at the same time, in addition to vital signs and symptoms of infection. Fever is actually a consequence of changes in the hypothalamic set point.

2. Tired due to the heat

Exhausted by heat occur when diaphoresis which many result in loss of fluid and electrolytes in excess. Caused by exposure to hot environments. Signs and symptoms of fluid volume is less common during melting due to the heat. The first action is to move clients to cooler environments as well as improving the balance of fluids and electrolytes.

3. Hyperthermia

Increased body temperature with respect to the inability of the body to increase or decrease the heat dissipation of heat production is hyperthermia. Each disease or trauma to the hypothalamus may affect the mechanism of heat dissipation. Malignant hyperthermia is a congenital condition can not control the heat production, which occurs when people are prone to use certain anesthetic drugs.

4. Heatstroke

Long exposure to sunlight or high temperature environments may affect the mechanism of heat dissipation. This condition is called heatstroke, heat a dangerous emergency with a mortality rate that high. Clients at risk include very young or very old, who has cardiovascular disease, hypothyroidism, diabetes or alcoholism. Also included is a risk that people who consume a drug that lowers the body's ability to remove heat and those who underwent exercise or heavy work. Signs and symptoms of heatstroke include; giddy, confusion, delirium, thirst, nausea, muscle cramps, visual disturbances, and even incontinence. Signs of heatstroke are the most warm and dry skin.

Heatstroke patients do not sweat because of the loss of electrolytes is very heavy and the hypothalamus malfunctions. Heatstroke at temperatures greater than 40.5 º C lead to tissue damage in the cells of all organs of the body. Vital signs stating body temperature sometimes as high as 45 º C, tachycardia and hypotension. The brain may be the first organ affected because of their sensitivity to electrolyte imbalance. If the condition persists, the client becomes unconscious, non-reactive pupils. Nourologis permanent damage occurs unless the cooling action is about to begin.

5. Hypothermia

Spending heat due to continuous exposure to cold affects the body's ability to produce heat, resulting in hypothermia. Hypothermia is classified by measuring core temperature. This can happen by chance or accident during a surgical procedure to reduce the metabolic needs and the needs of the body for oxygen.

Accidental Hypothermia usually occurs gradually and go unnoticed for several hours. When the body temperature drops to 35 ° C, client experience uncontrollable shaking, memory loss, depression, and are not able to judge. If the body temperature drops below 34.4 ° C, heart rate, respiration, and blood pressure drops. skin becomes cyanotic.



Nursing Care Plan for Ineffective Thermoregulation

Nursing Diagnosis:

Risk for Infection r / t:

  • The decrease in the body's system.
  • Failure to recognize and treat infections.
  • Invasive procedures.
  • Nosocomial.

Objectives / outcomes:
  • Showed healing over time.
  • Free of purulent secretion, free from febrile.

Interventions

1. Give isolation / monitor indications within their visitors.
R :/ Isolation wound / linen and wash hands for wound drainage / visitor restrictions are needed to protect patients and reduce the chance of infection.

2. Wash hands before and after the action.
R :/ Reduces cross-contamination.

3. Encourage the patient to cover mouth and nose when coughing / sneezing.
R :/ Preventing the spread of infection by droplet infection.

4. Limit the use of tools / invasive procedures if possible.
R :/ Subtraction number of locations that can be the entry point of the organism.

5. Use gloves in wound care.
R :/ Preventing the spread of infection / contamination.

6. Use sterile technique at the time of dressing change / exploitation / gave the location of care, for example ; infusion, catheter.
R :/ Prevent entry of bacteria, reducing the risk of nosocomial infection.

7. Monitor body temperature
R :/ Fever 38.5 C - 40 C endotoxin effect on the hypothalamus.
Hypothermia sign of decreased tissue perfusion.

8. Give anti-infective drugs as directed.
R : To eradicate / provide temporary immunity to common infection / disease specific.

Source : http://nandacareplan.blogspot.com/2014/03/nursing-care-plan-for-ineffective.html

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