Inability to maintain or regulate body temperature within a normal range

• Inactivity
• Inadequate fluid volume
• Inappropriate clothing for environmental temperature
• Inappropriate environmental temperature control
• Increased oxygen demand
• Vigorous activity

• Condition affecting temperature regulation
• Decreased sweat response
• Impaired health status
• Inefficient nonshivering thermogenesis
• Metabolic diseases
• Pharmaceutical preparations
• Sepsis
• Wounds and injuries

• Age
• Vital signs
• History of current illness
• Medication history
• Neurologic status, including level of consciousness (LOC), mental status, motor status, and sensory status
• Cardiovascular status, including blood pressure, capillary refill time, electrocardiogram, heart rate and rhythm, pulses (apical and peripheral), and temperature
• Respiratory status, including arterial blood gas measurements; breath sounds; and rate, depth, and character of respirations
• Integumentary status, including color, temperature, and turgor
• Fluid and electrolyte status, including blood urea nitrogen level, intake and output, serum electrolyte levels, and urine specific gravity
• Laboratory studies, including clotting factors, hemoglobin level, hematocrit, platelet count, and white blood cell count

• Cyanotic nail beds
• Flushed skin
• Hypertension
• Increased body temperature above normal range
• Mild shivering
• Moderate pallor
• Piloerection
• Reduction in body temperature below normal range
• Seizure
• Skin cool to touch
• Skin warm to touch
• Slow capillary refill
• Tachycardia
• Tachypnea

• Patient will maintain body temperature at normothermic levels.
• Patient won't shiver.
• Patient will express feelings of comfort.
• Patient will have warm, dry skin.
• Patient will maintain heart rate, respiratory rate, and blood pressure within normal range.
• Patient won't exhibit signs of compromised neurologic status.
• Patient and family members will voice an understanding of health problem.

Suggested NOC Outcomes

• Monitor patient's body temperature every 4 hours or more often if indicated. Record the temperature and route (keep in mind that the baseline depends on the route). Monitoring determines the effectiveness of therapy or whether intervention is required and allows accurate comparison of data.
• Monitor and record patient's neurologic status every 8 hours. Report any changes to the physician. Changes in LOC can result from tissue hypoxia related to altered tissue perfusion. Hyperthermia increases cerebral edema and thus intracranial pressure (ICP); hypothermia depresses metabolic rate.
• Monitor and record patient's heart rate and rhythm, blood pressure, and respiratory rate every 4 hours. Hyperthermia may create hypoxia by increasing oxygen demand, which results from increased tissue metabolism (metabolism increases 7% with each increase of 1° F [0.6° C]). This in turn results in faster breathing and a rising pulse rate.
• Administer analgesics, antipyretics, and medications that prevent shivering, as prescribed. Monitor and record their effectiveness. Antipyretics help reduce fever. Shivering tends to retard the lowering of body temperature.
• If patient develops excessive fever, take the following steps following institutional protocol:
  • Remove blankets; place a loincloth over patient.
  • Apply ice bags to the axilla and groin.
  • Initiate a tepid water sponge bath.
  • Use a hypothermia blanket if temperature rises above ____. Cool patient to ____.
  These measures help reduce excessive fever.
• Maintain hydration.
  • Monitor intake and output.
  • Administer parenteral fluids, as ordered.
  • Determine patient's fluid preference. Keep oral fluids at the bedside and encourage patient to drink.
  These measures help maintain fluid balance. Keeping preferred fluids at the bedside allows patient to actively participate in the prescribed treatment.
• Maintain the environmental temperature at a comfortable setting.
  • Ensure that all metal and plastic surfaces that come into contact with patient's body are covered.
  • Use or remove blankets as necessary for comfort.
  • Make sure that linens and clothing are clean and dry.
  The temperature of the external environment affects ease of body temperature regulation.
• Instruct patient and family members about:
  • signs and symptoms of altered body temperature;
  • precautionary measures to avoid hypothermia or hyperthermia;
  • adherence to other aspects of health care management to help normalize patient's temperature (such as dietary habits and measures to prevent increased ICP);
  • rationale for treatment.
  These measures allow patient to take an active role in health maintenance.

Suggested NIC Interventions

• Patient's temperature remains within normal parameters.
• Patient doesn't shiver.
• Patient indicates feelings of comfort, either verbally or through behavior.
• Patient's skin remains warm and dry.
• Patient's heart rate and blood pressure remain within normal range.
• Patient and family state understanding of health problem.

• Patient's needs and perceptions of current problem
• Physical findings
• Intake and output
• Patient's response to nursing interventions
• Evaluations for expected outcomes

• Davis, J. K., Stolworthy, N. I., Laurent, C. M., Allen, K. E., Zhang, Y., Welch, T. R., & Nevett, M. E. (2017). Influence of clothing on thermoregulation and comfort during exercise in the heat. Journal of Strength & Conditioning Research (Lippincott Williams & Wilkins), 31(12), 3435-3443. doi:10.1519/JSC.0000000000001754
• Iyoho, A. E., Ng, L. J., & MacFadden, L. (2017). Modeling of gender differences in thermoregulation. Military Medicine, 182, 295-303. doi:10.7205/MILMED-D-16-00213
• Saqe-Rockoff, A., Schubert, F. D., Ciardiello, A., & Douglas, E. (2018). Improving thermoregulation for trauma patients in the emergency department : An evidence-based practice project. Journal of Trauma Nursing, 25(1), 14-20. doi:10.1097/JTN.0000000000000336