Domain 11. Safety/Protection Class 6.

 Thermoregulation
00005
Risk for imbalanced body temperature
(1986, 2000, 2013; LOE 2.1)

Definition
Vulnerable to failure to maintain body temperature within normal
parameters, which may compromise health.

Risk Factors

■■ Acute brain injury ■■ Increase in oxygen demand

■■ Alteration in metabolic rate
■■ Condition affecting
temperature regulation
■■ Decreased sweat response
■■ Dehydration
■■ Extremes of age
■■ Extremes of environmental
temperature
■■ Extremes of weight
■■ Inactivity
■■ Inappropriate clothing for
environmental temperature
11. Safety/Protection
■■ Increased body surface area to
weight ratio
■■ Inefficient nonshivering
thermogenesis
■■ Insufficient supply of
subcutaneous fat
■■ Pharmaceutical agent
■■ Sedation
■■ Sepsis
■■ Vigorous activity

426  Domain 11: Safety/Protection

Domain 11. Safety/Protection Class 6. Thermoregulation
00007
Hyperthermia
(1986, 2013; LOE 2.2)

Definition
Core body temperature above the normal diurnal range due to failure
of thermoregulation.

Defining Characteristics

■■ Abnormal posturing ■■ Lethargy

■■ Apnea ■■ Seizure
■■ Coma ■■ Skin warm to touch
■■ Convulsions ■■ Stupor
■■ Flushed skin ■■ Tachycardia
■■ Hypotension ■■ Tachypnea
■■ Infant does not maintain suck ■■ Vasodilation
■■ Irritability

Related Factors

■■ Decreased sweat response ■■ Increase in metabolic rate

■■ Dehydration ■■ Ischemia
■■ High environmental ■■ Pharmaceutical agent
temperature ■■ Sepsis 11. Safety/Protection
■■ Illness ■■ Trauma
■■ Inappropriate clothing ■■ Vigorous activity

Original literature support available at www.nanda.org

 Class 6: Thermoregulation  427

 Domain 11. Safety/Protection Class 6. Thermoregulation
00006
Hypothermia
(1986, 1988, 2013; LOE 2.2)

Definition
Core body temperature below the normal diurnal range due to failure
of thermoregulation.

Defining Characteristics

■■ Acrocyanosis ■■ Increase in oxygen

■■ Bradycardia consumption
■■ Cyanotic nail beds ■■ Peripheral vasoconstriction
■■ Decrease in blood glucose level ■■ Piloerection
■■ Decrease in ventilation ■■ Shivering
■■ Hypertension ■■ Skin cool to touch
■■ Hypoglycemia ■■ Slow capillary refill
■■ Hypoxia ■■ Tachycardia
■■ Increase in metabolic rate

Accidental Low Body Temperature in Children and Adults

■■ Mild hypothermia, core ■■ Severe hypothermia, core
temperature 32-35 °C temperature <30 °C
■■ Moderate hypothermia, core
temperature 30-32 °C
Injured Adults and Children
11. Safety/Protection

■■ Hypothermia, core ■■ Severe hypothermia, core

temperature <35 °C temperature <32 °C
Neonates
■■ Grade 1 hypothermia, core ■■ Infant with insufficient weight
temperature 36-36.5 °C gain (<30 g/d)
■■ Grade 2 hypothermia, core ■■ Irritability
temperature 35-35.9 °C ■■ Jaundice
■■ Grade 3 hypothermia, core ■■ Metabolic acidosis
temperature 34-34.9 °C ■■ Pallor
■■ Grade 4 hypothermia, core ■■ Respiratory distress
temperature <34 °C
■■ Infant with insufficient energy
to maintain sucking

428  Domain 11: Safety/Protection

Related Factors
■■ Alcohol consumption
■■ Damage to hypothalamus
■■ Decrease in metabolic rate
■■ Economically disadvantaged
■■ Extremes of age
■■ Extremes of weight
■■ Heat transfer (e.g., conduction,
convection, evaporation,
radiation)
■■ Inactivity
Neonates
■■ Delay in breastfeeding
■■ Early bathing of newborn
■■ High risk out of hospital birth
■■ Immature stratum corneum
■■ Increased body surface area to
weight ratio
■■ Increase in oxygen demand
Original literature support available at www.nanda.org
 Class 6: Thermoregulation  429
■■ Insufficient caregiver knowledge
of hypothermia prevention
■■ Insufficient clothing
■■ Insufficient supply of
subcutaneous fat
■■ Low environmental
temperature
■■ Malnutrition
■■ Pharmaceutical agent
■■ Radiation
■■ Trauma
■■ Increase in pulmonary vascular
resistance (PVR)
■■ Ineffective vascular control
■■ Inefficient nonshivering
thermogenesis
■■ Unplanned out-of-hospital birth
11. Safety/Protection
 Domain 11. Safety/Protection Class 6. Thermoregulation
00253
Risk for hypothermia
(2013; LOE 2.1)

Definition
Vulnerable to a failure of thermoregulation that may result in a core
body temperature below the normal diurnal range, which may com-
promise health.

Risk Factors

■■ Alcohol consumption ■■ Insufficient clothing

■■ Damage to hypothalamus ■■ Insufficient supply of
■■ Economically disadvantaged subcutaneous fat
■■ Extremes of age ■■ Low environmental
■■ Extremes of weight temperature
■■ Heat transfer (e.g., conduction, ■■ Malnutrition
convection, evaporation, ■■ Pharmaceutical agent
radiation) ■■ Radiation
■■ Inactivity ■■ Trauma
■■ Insufficient caregiver
knowledge of hypothermia
prevention
Children and Adults: Accidental
■■ Mild hypothermia, core ■■ Severe hypothermia, core
11. Safety/Protection

temperature approaching 35 °C temperature approaching 30 °C

■■ Moderate hypothermia, core
temperature approaching 32 °C
Children and Adults: Injured Patients
■■ Hypothermia, core tempera-
ture approaching 35 °C
Neonates
■■ Decrease in metabolic rate
■■ Delay in breastfeeding
■■ Early bathing of newborn
■■ Grade 1 hypothermia, core
temperature approaching
36.5 °C
■■ Severe hypothermia, core
temperature approaching 32 °C
■■ Grade 2 hypothermia, core
temperature approaching
36.0 °C
■■ Grade 3 hypothermia, core
temperature approaching
35.0 °C

430  Domain 11: Safety/Protection

■■ Grade 4 hypothermia, core
temperature approaching
34.0 °C
■■ High-risk out-of-hospital birth
■■ Immature stratum corneum
■■ Increased body surface area to
weight ratio
■■ Increase in oxygen demand
■■ Increase in pulmonary vascular
resistance (PVR)
■■ Ineffective vascular control
■■ Inefficient nonshivering
thermogenesis
■■ Unplanned out-of-hospital birth

Original literature support available at www.nanda.org

11. Safety/Protection

 Class 6: Thermoregulation  431

 Domain 11. Safety/Protection Class 6. Thermoregulation
00254
Risk for perioperative hypothermia
(2013; LOE 2.1)

Definition
Vulnerable to an inadvertent drop in core body temperature below
36 °C/96.8 °F occuring one hour before to 24 hours after surgery, which
may compromise health.

Risk Factors

■■ American Society of ■■ Low body weight

Anesthesiologists (ASA) ■■ Low environmental
Physical Status classification temperature
score >1 ■■ Low preoperative temperature
■■ Cardiovascular complications (<36 °C/96.8 °F)
■■ Combined regional and general ■■ Surgical procedure
anesthesia
■■ Diabetic neuropathy
■■ Heat transfer (e.g., high
volume of unwarmed infusion,
unwarmed irrigation >20 liters)

Original literature support available at www.nanda.org

11. Safety/Protection

432  Domain 11: Safety/Protection

Domain 11. Safety/Protection Class 6. Thermoregulation
00008
Ineffective thermoregulation
(1986)

Definition
Temperature fluctuation between hypothermia and hyperthermia.

Defining Characteristics

■■ Cyanotic nail beds ■■ Moderate pallor

■■ Fluctuations in body tempera- ■■ Piloerection
ture above and below the ■■ Reduction in body temperature
normal range below normal range
■■ Flushed skin ■■ Seizures
■■ Hypertension ■■ Skin cool to touch
■■ Increase in body temperature ■■ Skin warm to touch
above normal range ■■ Slow capillary refill
■■ Increase in respiratory rate ■■ Tachycardia
■■ Mild shivering

Related Factors

■■ Extremes of age ■■ Illness

■■ Fluctuating environmental ■■ Trauma
temperature 11. Safety/Protection

 Class 6: Thermoregulation  433

602 Hyperthermia

Hopelessness—cont’d
Outcomes Associated with Related Factors or Intermediate Outcomes
Adaptation to Physical Disability Play Participation
Coping Quality of Life
Depression Self-Control Relocation Adaptation
Fatigue Level Self-Care: Activities of Daily Living (ADL)
Fear Self-Control Self-Management: Chronic Disease
Grief Resolution Social Involvement
Immobility Consequences: Psycho-Cognitive Spiritual Health
Neglect Recovery Stress Level
Pain: Adverse Psychological Response Suffering Severity
Pain: Disruptive Effects Symptom Severity
Physical Aging

Hyperthermia
Definition: Body temperature elevated above normal range
Outcomes to Measure Resolution of Diagnosis
Thermoregulation Thermoregulation: Newborn
Additional Outcomes to Measure Defining Characteristics
Neurological Status Vital Signs
Neurological Status: Autonomic
Outcomes Associated with Related Factors or Intermediate Outcomes
Blood Transfusion Reaction Knowledge: Acute Illness Management
Comfort Status: Physical Medication Response
Discomfort Level Physical Injury Severity
Hydration Risk Control: Hyperthermia
Infection Severity Self-Management: Acute Illness
Infection Severity: Newborn

Hypothermia
Definition: Body temperature below normal range
Outcomes to Measure Resolution of Diagnosis
Thermoregulation Thermoregulation: Newborn

Additional Outcomes to Measure Defining Characteristics

Hypertension Severity Vital Signs
Tissue Perfusion: Peripheral
Outcomes Associated with Related Factors or Intermediate Outcomes
Comfort Status: Physical Physical Injury Severity
Medication Response Risk Control: Alcohol Use
Neurological Status: Autonomic Risk Control: Hypothermia
Nutritional Status: Nutrient Intake Self-Management: Acute Illness
Physical Aging
 Hyperthermia 505

Counseling Mutual Goal Setting

Crisis Intervention Patient Contracting
Distraction Phototherapy: Mood/Sleep Regulation
Electroconvulsive Therapy (ECT) Management Resiliency Promotion
Exercise Promotion Self-Care Assistance
Exercise Therapy: Ambulation Self-Modification Assistance
Grief Work Facilitation Spiritual Support
Grief Work Facilitation: Perinatal Death Suicide Prevention
Music Therapy Therapeutic Play

Human Dignity, Risk for Compromised

Definition: At risk for perceived loss of respect and honor
Suggested Nursing Interventions for Problem Resolution: Additional Optional Interventions:
Anticipatory Guidance Abuse Protection Support
Culture Brokerage Admission Care
Decision-Making Support Bowel Incontinence Care
Examination Assistance Coping Enhancement
Health Care Information Exchange Discharge Planning
Health System Guidance Family Involvement Promotion
Patient Rights Protection Financial Resource Assistance
Presence Multidisciplinary Care Conference
Risk Identification

Hyperthermia
Definition: Body temperature elevated above normal range
Suggested Nursing Interventions For Problem Resolution: Temperature Regulation
Bathing Temperature Regulation: Perioperative
Environmental Management Vital Signs Monitoring
Fever Treatment
Fluid Management Additional Optional Interventions:
Hemodynamic Regulation Heat/Cold Application
Infant Care: Newborn Nutrition Management
Infection Control Oxygen Therapy
Infection Protection Peripherally Inserted Central Catheter (PICC) Care
Malignant Hyperthermia Precautions Seizure Management
Medication Management Seizure Precautions
Medication Prescribing Skin Surveillance
Shock Management Total Parenteral Nutrition (TPN) Administration
470 Body Image, Disturbed

Additional Optional Interventions: Mutual Goal Setting

Amputation Care Ostomy Care
Anticipatory Guidance Patient Contracting
Bowel Incontinence Care: Encopresis Prenatal Care
Calming Technique Suicide Prevention
Childbirth Preparation Teaching: Sexuality
Cognitive Restructuring Truth Telling
Decision-Making Support Unilateral Neglect Management
Lactation Counseling Urinary Incontinence Care: Enuresis

Body Temperature, Risk for Imbalanced

Definition: At risk for failure to maintain body temperature within normal range
Suggested Nursing Interventions for Problem Resolution: Fluid Resuscitation
Cerebral Edema Management Heat/Cold Application
Environmental Management Hemodynamic Regulation
Environmental Management: Comfort Infection Control
Fever Treatment Infection Protection
Fluid Management Kangaroo Care
Fluid Monitoring Nutrition Management
Malignant Hyperthermia Precautions Resuscitation: Neonate
Medication Management Risk Identification
Postanesthesia Care Sedation Management
Temperature Regulation Surveillance
Temperature Regulation: Perioperative Weight Management
Vital Signs Monitoring Wound Care: Burns

Additional Optional Interventions:

Bathing
Energy Management

Bowel Incontinence
Definition: Change in normal bowel habits, characterized by involuntary passage of stool
Suggested Nursing Interventions for Problem Resolution: Additional Optional Interventions:
Bowel Incontinence Care Bathing
Bowel Incontinence Care: Encopresis Dementia Management
Bowel Management Emotional Support
Bowel Training Environmental Management
Diarrhea Management Exercise Promotion
Perineal Care Exercise Therapy: Ambulation
Rectal Prolapse Management Nutrition Management
Self-Care Assistance: Toileting
Skin Surveillance
Teaching: Toilet Training
 Thermoregulation, Ineffective
Definition: Temperature fluctuation between hypothermia and hyperthermia
Suggested Nursing Interventions for Problem Resolution: Temperature Regulation
Bathing Temperature Regulation: Perioperative
Environmental Management Vital Signs Monitoring
Fever Treatment
Fluid Management Additional Optional Interventions:
Fluid Monitoring Anxiety Reduction
Hemodynamic Regulation Blood Products Administration
Hyperthermia Treatment Medication Administration
Infant Care: Newborn Peripherally Inserted Central Catheter (PICC) Care
Infant Care: Preterm Phlebotomy: Arterial Blood Sample