Nursing Diagnosis and Nursing Interventions

Nursing Diagnosis and Intervention for Hypothermia - Hyperthermia

Hypothermia

Nursing Diagnosis and Intervention for Hypothermia - Hyperthermia
Hypothermia is a condition where the body's mechanism for temperature regulation difficulties to overcome pressure cold temperatures. Hypothermia can also be defined as the temperature of the inside of the body below 35 ° C. The human body is able to regulate the temperature in termonetral zone, which is between 36.5 to 37.5 ° C. Outside this temperature, the response of the body to regulate temperature will be active balancing heat production and heat loss in the body.

Symptoms of mild hypothermia is patient speaks slurred, the skin becomes slightly gray, lower heart rate, decreased blood pressure, and muscle contraction occurs as the body's attempt to generate heat. In patients with moderate hypothermia, heart rate and respiration weakened until it reaches just 3-4 breaths in one minute. In patients with severe hypothermia, the patient is unconscious self, the body becomes very stiff, dilated pupils, hypotension, acute and very slow breathing to subtle (invisible).

Hypothermia occurs when the core body temperature decreases below 35 ° C (95 ° F). At this temperature, the body's physiological compensatory mechanisms fail to maintain body heat.


Hyperthermia

Nursing Diagnosis and Intervention for Hypothermia - Hyperthermia
Hyperthermia is an increase in the core temperature of the human body that usually occurs due to infection. Hyperthermia can also be defined as a body temperature that is too hot or tall. Generally, people will sweat to lower body temperature. However, in certain circumstances, the temperature may rise rapidly up sweating does not provide sufficient effect. Hyperthermia tend to be more common in infants and children under 4 years of age and older people aged 65 years and above. Selan, people who are overweight, are sick, or in certain treatments also have a greater risk for experiencing hyperthermia. Body temperature that is too high can damage the brain and other vital organs. In patients with severe hyperthermia, symptoms will arise include the mental state of fatigue, anxiety, seizures body, and can lead to coma.

Nursing Diagnosis and Intervention for Hypothermia - Hyperthermia

Altered Body Temperature related to abnormal births, exposure to environmental temperature, cold or hot.

Purpose 1: Identifying infants at risk or actual body temperature instability.

Interventions:

1. Assess the factors related to the risk of fluctuations in body temperature in infants, such as; prematurity, sepsis and infection, asphyxia or hypoxia, CNS trauma, fluid and electrolyte imbalance, the ambient temperature is too hot or cold, birth trauma and maternal history of drug abuse.

2. Assess the potential and actual hypothermia or hyperthermia:
  • Monitor body temperature, do measurements on a regular basis.
  • Monitor the temperature of the environment.
  • Prevent conditions that cause heat loss in infants such as baby clothes are not wet or dry, exposure to outside air or air conditioning.
  • Check the respiratory rate (tachypnea), depth and pattern.
  • Observe the color of the skin.
  • Monitor irritability, tremors and seizures activity.
  • Monitor the presence of flushing, respiratory distress, apnea episodes, moisture, and fluid loss.

Purpose 2: Prevent conditions that can trigger fluctuations in body temperature.

Interventions:
1. Protect the wall incubator with:
  • Laying incubator right place.
  • Room temperature maintenance / operating room maintained.
  • Use protective pads or heat in the incubator.
2. Dry the newborn immediately below the heater.
3. The water bath above 37 ° C and bathing the baby, after the baby is stable and 6-12 hours postnatally, dry immediately.
4. Use a mat on the table resuscitation or heating.
5. Close surface resuscitation table with a warm blanket, first warmed incubator.
6. Keep the skin temperature from 36 to 36.5 ° C.
7. As little as possible to open the incubator.
8. Warm always incubator before use.
9. Hold the baby with skin attached to the mother's skin (kangaroo method).
10. Give a hat and wrap in a blanket.


Purpose 3: Preventing complications cold.

Interventions:
1. Assess signs of cold stress on the baby:
  • Decrease in body temperature to less than 32.2 ° C.
  • Weakness and irritability.
  • Poor feeding and lethargy.
  • Pallor, cyanosis of central or mottling.
  • Cold clammy skin.
  • The redness of the skin.
  • Bradycardia.
  • Slow breathing, irregular accompanied by grunting.
  • Decreased activity and reflexes.
  • Distesi abdomen and vomiting.
2. Give the actual treatment or risk of injury due to cold as follows:
  • Give heat therapy slowly and record body temperature every 15 minutes.
  • Consider administration of plasma proteins (plasmanate) after 30 minutes.
  • Give oxygen that is set humidity.
  • Monitor serum glucose.
  • Give sodium bicarbonate for metabolic acidosis.
  • To replace the intake of food and fluids, give dextrose 10% to temeperatur rises above 35 ° C.

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Nursing Diagnosis - Nursing Interventions

NANDA NURSING

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