Introduction to NANDA Nursing Diagnosis: Risk Of Thermal Injury
Thermal injury is a broad term that describes any type of injury resulting from exposure to extreme temperatures. It can occur due to exposure to fire, hot objects, steam burns, radiation, caustic chemicals, or electrical currents. It can be a life-threatening injury, so it is important for nurses to be familiar with its signs and symptoms, as well as the interventions necessary for successful outcomes.
NANDA Nursing Diagnosis Definition
Risk for thermal injury is defined by the NANDA International nursing diagnosis organization as “the state in which an individual is at greater risk than the average person for developing physical harm from environmental temperatures that are either too high or too low.”
- Perceived lack of control to prevent injury due to temperature extremes
- Expressions of concern about the environment
- Statements of distress related to high or low temperatures
- Signs of potential exposure to extreme temperatures
- Inadequate clothing or protective equipment
- Activity levels that may increase the risk of thermal injury
- Ineffective thermoregulation: The failure to maintain body temperature within normal limits due to inadequate circulating blood volume, activity level, rest periods, or the use of inappropriate clothing.
- Environmental exposure: Prolonged gross motor activities in hot or cold climates.
- Chronic illnesses: Severity of illness, specific medical treatments, and metabolic causes may increase the risk of thermal injury.
Those most at risk for thermal injury include:
- Infants and young children: Their immature physiology makes them more susceptible to heat or cold stress.
- Elderly adults: Many elderly suffer from chronic illnesses that make them more susceptible to extreme temperatures.
- People with limited mobility: Immobility can reduce skin circulation, making it more difficult to dissipate excess body heat and thus increasing the risk of thermal injury.
If left untreated, thermal injury can lead to complications such as shock, infections, burns, and even death.
Suggestions for Use
It is important for nurses to recognize the signs and symptoms of thermal injury and take steps to prevent it. Nurses can assess for risk and intervening factors associated with thermal injury for each patient. They can reinforce the importance of safety measures to help prevent thermal injury, including wearing appropriate layers of clothing, changing clothes often, and providing adequate rest periods.
Suggested Alternative NANDA Diagnoses
Alternative diagnoses should be used whenever possible. These include:
- Ineffective thermoregulation
- Risk for decreased cardiac output
- Activity intolerance
- Ineffective tissue perfusion
When describing the severity of a patient’s risk for thermal injury, it is important to use objective data such as temperature, skin turgor, and color of the patient’s skin, as well as subjective data such as the patient’s perception and distress associated with the environment.
The following NOC results may be seen when a patient has a risk of thermal injury:
- Skin Integrity: Skin is intact with no evidence of burns or other signs of thermal injury
- Self-Care Status: Patient is able to dress appropriately for temperatures outside the home
- Cardiac Output: Adequate peripheral circulation is maintained
- Thermoregulation: Patient is able to maintain body temperature within normal limits
- Knowledge: Patient demonstrates an understanding of the signs and symptoms of thermal injury and preventive measures
The following NIC interventions may be implemented when a patient is at risk for thermal injury:
- Thermoregulation Enhancement: Monitor temperature, provide hydration and electrolyte maintenance, provide comfortable room temperature.
- Environmental Temperature Management: Monitor temperature of external environment, provide appropriate clothing and protective gear.
- Health Teaching: Educate the patient on the signs and symptoms of thermal injury, preventive measures.
- Risk Identification: Assess for environmental and metabolic factors that may increase the risk of thermal injury.
Conclusion and FAQ
Thermal injury is a serious condition that can have devastating consequences if left untreated. Nurses must be aware of the risk factors and signs and symptoms of thermal injury and be prepared to provide care for these patients. All staff members should be knowledgeable about the best practices for preventing thermal injury in all patient populations.