NURSING DIAGNOSIS

DESIRED OUTCOMES

ACTIONS/INTERVENTIONS

EVALUATION

May be related to:

Immature CNS development (temperature regulation center), an inability to shiver or sweat, limited/inability to flex extremities, and frequent medical/nursing manipulations and interventions

Possibly Evidenced by:

Fluctuation of body temperature below/above normal range

Tachypnea/apnea, generalized cyanosis, bradycardia, lethargy (coldstress)Tachycardia, flushed color, lethargy, apnea (hyperthermia)

Baby T’s axilla temperature 37.2 C skin warm and dry, does not appear uncomfortable

RISK FOR INEFFECTIVE THERMOREGULATION

Neonate will

Maintain skin/axillary temperature within 97.7˚F - 99.1˚F (36.5˚C - 37.3˚C). Be free of signs of cold stress.

Assess temperature frequently.

Place infant in warmer, incubator, open bed with radiant warmer, or open crib with appropriate clothing

Use heat lamps during procedures. Warm objects coming in contact with infant’s body, such as stethoscopes, linens, and clothing. Surround infant with warmed receiving blankets. Coverradiant warmers with plastic wrap, if appropriate. Warm blood products, if administered.

Note environmental temperature/monitör temperature-regulating system, radiant warmers, or incubators. (Maintain upper limit at 98.6˚F [37˚C], depending on infant’s size or age.)

Monitor infant’s temperature when out of warmed environment. Provide parents with information about thermoregulation.

Baby T ‘s temp. remained between 36.5˚C-37.3˚C.