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Risk for Imbalanced Body Temperature | Nursing Care Plan (NCP) Surgical Intervention

Risk factors may include
Exposure to cool environment
Use of medications, anesthetic agents
Extremes of age, weight; dehydration

Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)

Desired Outcomes/Evaluation Criteria—Client Will
Maintain body temperature within normal range.

Nursing intervention with rationale:
1. Note preoperative temperature related to age and disease process.
Rationale: Used as baseline for monitoring intraoperative temperature. Preoperative temperature elevations may be indicative of disease process, such as appendicitis, abscess, or systemic disease requiring perioperative treatment. Note: Effects of aging on hypothalamus may decrease fever response to infection.

2. Assess environmental temperature and modify, as needed, by providing warming blankets or increasing room temperature.
Rationale: Manipulating ambient air around client will prevent heat loss.

3. Cover skin areas outside of operative field.
Rationale: Heat losses will occur as skin on head, arms, and legs are exposed to cool environmental temperatures.

4. Provide cooling measures for client with preoperative or intraoperative temperature elevations.
Rationale: Cool irrigations, exposure of skin surfaces to air, or cooling blanket may be required to decrease temperature.

5. Increase ambient room temperature (e.g., to 78°F or 80°F [25.6°C to 26.7°C]) at conclusion of procedure.
Rationale: Minimizes client heat loss when drapes are removed and client is prepared for transfer.

6. Apply warming blankets at emergence from anesthesia.
Rationale: Inhalation anesthetics depress the hypothalamus, resulting in poor body temperature regulation.

7. Monitor temperature throughout intraoperative phase.
Rationale: Continuous warm or cool humidified inhalation anesthestics are used to maintain humidity and temperature balance within the tracheobronchial tree. Temperature fluctuations may indicate adverse response to anesthesia. Note: Use of atropine or scopolamine may further increase temperature.

8. Respond promptly to symptoms of malignant hyperthermia (MH).
Rationale: Prompt recognition and immediate action to control temperature is necessary to prevent serious complications or death.

9. Provide iced saline to all body surfaces and orifices.
Rationale: Iced solution lavage of body surfaces and cavities will reduce body temperature.

10. Obtain dantrolene (Dantrium) for IV administration per protocol.
Rationale: Immediate action to control temperature is necessary to prevent intense catabolic process associated with MH.
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