Nursing diagnosis – HYPOTHERMIA

HYPOTHERMIA

DEFINITION

Body temperature below normal range

DEFINING CHARACTERISTICS

• Body temperature below normal range

• Cool, pale skin

• Cyanotic nail beds

• Increased blood pressure, heart rate, and capillary refill time

• Piloerection

• Shivering

RELATED FACTORS

• Aging

• Exposure to cool environment

• Consumption of alcohol

• Illness

• Damage to hypothalamus

• Inactivity

• Decreased ability to shiver

• Inadequate clothing

• Decreased metabolic rate

• Malnutrition

• Evaporation from skin in cool

• Medications

environment

• Trauma

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Fluid and electrolytes

• Neurocognition

• Pharmacological function

• Respiratory function

• Physical regulation

• Tissue integrity

EXPECTED OUTCOMES

The patient will

• Maintain body temperature within normal range.

• Have warm and dry skin.

• Maintain heart rate and blood pressure within normal range.

• Not shiver.

• Express feelings of comfort.

• Show no complications associated with hypothermia, such as soft-

tissue injury, fracture, dehydration, and hypovolemic shock, if
warmed too quickly.

• State an understanding of how to prevent further episodes of

hypothermia.

SUGGESTED NOC OUTCOMES

Neurological Status: Autonomic; Thermoregulation; Vital Signs

INTERVENTIONS AND RATIONALES

Determine: Monitor body temperature at least every 4 hr or more

frequently, if indicated, to evaluate effectiveness of interventions.

Record temperature and route to allow accurate data comparison.

Baseline temperatures vary, depending on route used. If temperature

drops below 95   F (35   C), use a low-reading thermometer to obtain

accurate reading.

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Monitor and record neurologic status at least every 4 hr. Falling

body temperature and metabolic rate reduce pulse rate and blood

pressure, which reduces blood perfusion to brain, resulting in disori-

entation, confusion, and unconsciousness.

Monitor and record heart rate and rhythm, blood pressure, and

respiratory rate at least every 4 hr. Blood pressure and pulse

decrease in hypothermia. During rewarming, patient may develop

hypovolemic shock. During warming, ventricular fibrillation and car-

diac arrest may occur, possibly signaled by irregular pulse.

Perform: Provide supportive measures, such as placing patient in

warm bed and covering with warm blankets, removing wet or con-

strictive clothing, and covering metal or plastic surfaces that contact

patient’s body. These measures protect patient from heat loss.

Follow prescribed treatment regimen for hypothermia: As ordered,

administer medications to prevent shivering to avoid overheating.

Monitor and record effectiveness. As ordered, administer analgesic

to relieve pain associated with warming. Monitor and record effec-

tiveness.

Use hyperthermia blanket to warm patient if temperature drops

below 95   F (35   C). Warm patient to 97   F (36.1   C).

As appropriate, administer fluids during rewarming to prevent

hypovolemic shock. If administering large volumes of intravenous

fluids, consider using a fluid warmer to avoid heat loss.

Inform: Discuss precipitating factors with patient, if indicated.

Patient may require community outreach assistance with certain pre-

cipitating factors, including inadequate living conditions, insufficient

finances, and abuse of medications (such as sedatives and alcohol).

Instruct patient in precautionary measures to avoid hypothermia,

such as dressing warmly even when indoors, eating proper diet, and

remaining as active as possible. Precautions help to prevent acciden-

tal hypothermia.

Manage: Report lack of responses to interventions to physician to

prevent complications.

SUGGESTED NIC INTERVENTIONS

Comfort Level; Fluid Management; Hypothermia Treatment;

Temperature Regulation; Vital Signs Monitoring

Reference

Good, K. K., et al. (2006, May). Postoperative hypothermia—The chilling

consequences. AORN Journal, 83(5), 1055–1066.

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