00008 Ineffective thermoregulation

Domain 11: security/protection
Class 6: thermoregulation
Diagnostic Code: 00008
Nanda label: ineffective thermoregulation
Diagnostic focus: thermoregulation
Approved 1986 • Revised 2017 • Evidence level 2.1

NANDA Nursing Diagnosis Definition

Nanda nursing diagnosis « ineffective thermoregulation »  is defined as: temperature fluctuation between hypothermia and hyperthermia.

Definite characteristics

  • cyanosis of nail beds
  • Ruborized skin
  • Hypertension
  • Increased body temperature above normal range
  • Increased respiratory rate
  • Mild chills
  • Moderate paleness
  • Piloerecion
  • Body temperature reduction below the normal range
  • Seizures
  • cold skin to touch
  • Hot skin to touch
  • Slow hair filling
  • Tachycardia

Related factors

  • Dehydration
  • Fluctuation in ambient temperature
  • Inactivity
  • Inappropriate clothing for ambient temperature
  • Increased oxygen demand
  • Vigorous activity

Risk population

  • People in weight
  • People exposed to extreme environmental temperatures
  • People with an inadequate amount of subcutaneous fat
  • People with increased body surface area in relation to the weight range

Associated problems

  • Alteration of the metabolic rate
  • Cerebral lesions
  • Problem that affects temperature regulation
  • Decrease in the sweat response
  • Deterioration of health status
  • Thermogenesis without ineffective tremor
  • Pharmacological preparations
  • sedation
  • sepsis
  • Trauma

Suggestions of use

  • This label is more appropriate for patients who are especially vulnerable to environmental conditions (for example, newborns and older people). If the body temperature does not fluctuate, hypertermia, hyperthermia or risk of alteration of body temperature should be used.

Suggested alternative diagnostics

  • Hyperthermia
  • Hypothermia
  • Body temperature, risk of alteration of

NOC Results

  • Thermoregulation: balance between production, gain and heat loss
  • Thermoregulation: Neonate: balance between production, gain and

Evaluation objectives and criteria

  • To review the specific evaluation results and criteria for each patient, see the objectives/criteria for the evaluation of hyperthermia, hypothermia and risk of alteration of body temperature.

NIC Interventions

  • Newborn care: neonate management during transition to extrauterine life and the subsequent stabilization period
  • Temperature regulation: scope or maintenance of a body temperature within the normal range
  • Temperature regulation: Transoperative: Scope or maintenance of the desired body temperature during surgery
  • Newborn surveillance: measurement and interpretation of the physiological state of the neonate during the first 24 hours after childbirth

Nursing Activities

  • Nursing interventions focus on teaching for the prevention of ineffective thermoregulation and maintenance of normal body temperature manipulating external factors such as clothing and room temperature. See nursing activities for alteration of body temperature, hyperthermia and hypothermia. heat loss during the first 28 days of life