Hypothermia

Related To: [Check those that apply] (_) CNS pathology (_) Decreased ability to shiver (_) Exposure to the cold (_) Impaired physical environment (_) Other:_____________________________ ____________________________________ ____________________________________ As evidenced by: Major: [Check those that apply] (_) Reduction in body temperature below 35 C (95 F) orally, or 35.5 C (96 F) rectally.

(Must be present) (_) Cool skin (_) Moderate pallor (_) Shivering (mild) Minor: (_) Mental confusion/drowsiness/restlessness Plan and Outcome Nursing Interventions (May be present) (_) Decreased pulse and respirations (_) Cachexia/malnutrition [Check those that apply] [Check those that apply] The patient will: (_) Assess temperature q ___ hours. (_) Maintain normal body temperature. Other: (_) Asses for possible etiology of hypothermia. (_) Keep room temperature between 70-74 F. (_) Aply extra blankets. (_) Use warming blanket per physician's order to maintain normal body temperature. (_) Provide intravenous solutions through a blood warmer per physician's order. (_) Rewarm patient gradually to prevent complications of rapid rewarming. (_) Teach patient to avoid extremes of cold weather and to dress adequately when exposed to cold. (_) Other:________________ ________________________ ________________________ ________________________ 1