00220 Risk Of Thermal Injury

Domain 11: security/protection
Class 2: physical injury
Diagnostic Code: 00220
Nanda label: thermal injury risk
Diagnostic focus: thermal injury
Approved 2010 • Revised 2013, 2017 • Evidence level 2.1

NANDA Nursing Diagnosis Definition

Nanda nursing diagnosis « thermal injury risk ” is defined as: susceptible to skin damage and mucous membranes due to extreme temperatures, which can compromise health. >

Risk factors

  • Cognitive dysfunction
  • Fatigue
  • Inappropriate knowledge of the caregiver (a) on security precautions
  • Inappropriate knowledge about safety precautions
  • Inadequate protection clothes
  • Inadequate supervision
  • Lack of attention
  • smoking
  • Insegurous environment

Risk population

  • People exposed to extreme environmental temperatures

Associated problems

  • Alcoholic poisoning
  • Drug poisoning
  • Neuromuscular diseases
  • Neuropathy
  • Therapeutic regime

Suggestions of use

This diagnosis is different from hypothermia and hyperthermia, since it is limited to skin lesions and mucous membranes; It does not refer to the elevation of body temperature. The risk of thermal injury is a potential problem; If skin damage occurs or in mucous membranes, deterioration of skin integrity or deterioration of tissue integrity should be used, depending on the seriousness of the damage. If the body temperature is high, and there are other defining characteristics, hyperthermia should be diagnosed.

Suggested alternative diagnostics

  • Hyperthermia
  • Cutaneous integrity, deterioration of the
  • Tissue integrity, deterioration of the

NOC Results

Note : No results have yet been related to this diagnosis; However, the following could be useful.

  • Risk Control: Sun exposure: Personal actions to prevent or reduce the risks of sun exposure for skin and eyes
  • Sensory function: Degree in which an individual feels correctly tactile stimulation, sounds, self -perception, taste, smell and visual images
  • Tissue integrity: mucous skin and membranes: Structural integrity and normal physiological function of the skin and mucous membranes

Evaluation objectives and criteria

  • Thermal lesion is avoided, as evidenced by risk control: sun exposure and tissue integrity: skin and mucous membranes
  • Demonstrates tissue integrity: skin and mucous membranes, evidenced as manifested by the following indicators (specifying 1 to 5: severely, substantially, moderately, slightly or not compromised): erythema, elasticity, skin temperature
  • Other examples

    • Use an adequate amount of sunscreen with the recommended protection factor (
    • Use ultraviolet protection glasses, as required
    • Avoid exposing yourself to the midday sun (10 a.m. to 4 p.m.)
    • The face and head is protected using a hat with a 10 cm wing approximately

    NIC Interventions

    Note : Nic interventions have not yet been associated with the risk of thermal injury, although the following could be useful:

    • Health check: detection of health risks or problems through history, medical exploration and other procedures
    • Skin surveillance: Patient data collection and analysis to maintain the integrity of the skin and mucous membranes

    Nursing Activities

    • In general, nursing activities for this diagnosis focus on identifying and modifying risk factors to prevent thermal lesion.

    Valuations

    • Assess the presence of cognitive impairment
    • Evaluate physical factors that could increase the risk of thermal injury (for example, neuropathy)
    • Observe the color of the skin (light skin burns more easily than dark skin)
    • Determine the level of development
    • Ask the patient how long it is exposed to the sun
    • Evaluate knowledge about protection measures against solar burns
    • Ask if the patient or other relatives smoke
    • Check if there are evidence of overexposure prior to the sun (for example, redness, detachment of the dermis, ampoules)

    Patient and family education

    • Teach home security measures with respect to fires and burning prevention. For example:
      • Place the handle of the pots towards the back of the stove when cooking
      • Do not leave without attending cigarettes; Do not smoke in bed
      • Do not wear comfortable clothes when cooking
    • Teach the risks of sun exposure (for example, skin cancer, ocular damage)
    • Teach sun protection measures, as required. For example:
      • Wear protective clothing and sunscreen when you are outdoors (use broad spectrum solar filter, of factor 15 or greater)
      • Consult the doctor if a large portion of the body is covered with ampoules or if high fever, intense pain, headache, confusion, nausea or chills
      • Remember the patient who may suffer solar burns even on cloudy days or with mist
      • Do not use tan beds (since they increase the risk of skin cancer)

    At home

    • Inspect the home in search of fire risks

    Babies and Children

    • Keep children under 6 months of age protected from the sun. Always use solar filter with larger children