Body temperature below normal range
• Body temperature below normal range
• Cool, pale skin
• Cyanotic nail beds
• Increased blood pressure, heart rate, and capillary reﬁll time
• Exposure to cool environment
• Consumption of alcohol
• Damage to hypothalamus
• Decreased ability to shiver
• Inadequate clothing
• Decreased metabolic rate
• Evaporation from skin in cool
ASSESSMENT FOCUS (Refer to comprehensive assessment parameters.)
• Fluid and electrolytes
• Pharmacological function
• Respiratory function
• Physical regulation
• Tissue integrity
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
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
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-
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-
Manage: Report lack of responses to interventions to physician to
SUGGESTED NIC INTERVENTIONS
Comfort Level; Fluid Management; Hypothermia Treatment;
Temperature Regulation; Vital Signs Monitoring
Good, K. K., et al. (2006, May). Postoperative hypothermia—The chilling
consequences. AORN Journal, 83(5), 1055–1066.