I am writing a nursing care plan for a newborn whose temps have been WNL.
According to my Carpenito book, ineffective thermoregulation is a nursing diagnosis ( not risk for ineffective thermoregulation).
However, when I read the definition of ineffective thermoregulation it says " the state in which an individual experiences or is at risk of experiencing an inability to maintain a stgable core body temperature in the presense of adverse or changing conditions".
That leads me to think the diagnosis could be Risk for ineffective thermoregulation....
And isn't it true that if I had a risk for dx that I would not have an " as evidenced by" section?
The only thing I can think of for the "as evidenced by" is the pathophysiologic reasons why this is an issue for newborns in general.
I really need help knowing:
1. Should the dx start with Risk for ....
2. Do I need an "as evidenced by" section and if so, what would I put there since it is really a risk for dx?
Dec 7, '11
Whenever you are using a "Risk for" diagnosis, you will not have an "as evidenced by" section of the diagnosis. You can't have evidence for a condition that doesn't exist yet. The diagnosis would be "Risk for ineffective thermoregulation related to...". If temps have been WNL, I see no reason why you could not use the risk for.
Dec 13, '11
You could cover it under a broader problem of transition to extrauterine life.