Buenviaje, Lorraine Tuesday Patient 615 Vocal Cord Paralysis

BSN III-01 September 16, 2022

CUES NURSING RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS

Subjective cues Ineffective Initially/mildly impaired Short term Independent Independent Short term
thermoregulation thermoregulatory Goal Met
- “Pinatay related to exposure function is the outcome After 2 hours of 1. Assess for 1. Causative factors
namin yung to cold environment of hypothermia, which nursing precipitating can guide the After 2 hours of
aircon kasi and decreased is defined as a dip in intervention patient situations and risk appropriate nursing intervention
nilalamig ako subcutaneous fat and core body temperature will be able to: factors. treatment. patient was able to:
eh” as muscle mass as below 35 C. When
verbalized by the evidence by low hypothermia becomes - Maintain body 2. Review client’s 2. Some groups of - Maintain body
patient body temperature, more severe, which is temperature within medications for drugs can contribute temperature within
pale skin, and cold defined as a core body normal levels possible to vasodilation and normal levels
Objective Cues skin. temperature below 28 C, thermoregulatory heat loss.
more severe impairment - Verbalized side effects. - Verbalized
- Temperature : develops. A wasting understanding of 3. Inadequate diet understanding of
34 °C syndrome known as individual factors 3. Evaluate the reduces energy individual factors
cachexia is and appropriate patient’s nutrition and stores and limits the and appropriate
- Blood pressure characterized by the loss interventions. weight. body's capacity to interventions.
: 90/60 of adipose and skeletal produce heat
muscle tissues, which 4. Modify the through calorie
- Decreased causes significant patient’s environment consumption.
subcutaneous fat weight loss. Cachexia temperature or
and muscle mass affects about half of all provide patient with 4. The body will
cancer patients (Kir & beside heat lamp. warm up more
- Cold skin Spiegelman, 2016). This Make sure linens are gradually using
weight loss which dry and not damped. these techniques.
- Pale skin includes loss of Evaporative heat
subcutaneous fat and 5. Provide extra loss is enhanced by
muscle can affect the covering such as moisture.
person’s clothing and blankets
thermoregulation 5. ​Warm blankets
mechanics when 6. Give heated oral provide a passive
exposed to a cold fluids for alert method for
environment. patients. rewarming.
 6. Warm fluids can
7. Provide oral and serve as a heat
written information source.
concerning client’s
disease Processes, 7. Allows for review
postdischarge of instructions for
precautions regarding early
hypothermia. intervention and
implementation of
preventive or
corrective
measures.

Collaborative Collaborative

1. Refer to medical 1. Reviewing

technician for laboratory studies
laboratory. can identify
potential internal
causes of
temperature
imbalance.

REFERENCES

Kir, S., & Spiegelman, B. M. (2016). CACHEXIA & BROWN FAT: A BURNING ISSUE IN CANCER. Trends in cancer, 2(9), 461–463.
https://doi.org/10.1016/j.trecan.2016.07.005

Yousef, H., Ahangar, E.R., & Varacallo M. (2022). Physiology, thermal regulation - statpearls - NCBI bookshelf. Retrieved September 17, 2022,
from https://www.ncbi.nlm.nih.gov/books/NBK499843/

Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2022). Nurse's pocket guide: Diagnoses, prioritized interventions, and rationales. F.A. Davis
Company.