HYPOTHERMIA

By: James Rod D. Marinduque and Jeanette T. Dungca

Nursing Nursing Planning Nursing Intervention Rationale Evaluation

Assessment Diagnosis
Objective: Ineffective After 4 hours Independent: After 4 hours of
 Pale, weak thermoregulation: of nursing 1. Note patient’s age  To impart the proper nursing
looking and hypothermia intervention, 2. Determine if present medication intervention, the
cold clammy related to the patient will illness or condition  Causative factors guide the patient will have a
skin excessive have a body appropriate treatment. body temperature
results from exposure
 Blood loss bleeding. temperature within normal
to environmental
estimated more within normal limits as
limits as factors, trauma, or manifested by an
than 500 mL as
evidenced of manifested by infection increase of
3. Note and monitor  For alert patients, oral
profusely an increase of temperature is regarded as
temperature from
bleeding temperature patient’s more reliable than tympanic or 35.3 C to 36.5 C.
 Hypothermia from 35.3 C to temperature. axillary. For hypothermic
   * Temp: 35.3 36.5 C. patients, core temperature can GOAL: MET
   * BP: 130/90 be monitored using a
   * SP02: 94℅ temperature-sensitive
   * BPM: 110 pulmonary artery catheter or
bladder catheter.

4. Regulate the  These methods provide for a

environment more gradual warming of the
temperature or body. Rapid warming can
relocate the patient to induce ventricular fibrillation.
Moisture promotes
a warmer setting. evaporative heat loss.
Keep the patient and
linens dry.
5. Let the patient  The more we understand how
verbalize risk and protective factors
interact, the better prepared we
understanding of will be to develop appropriate
 individual risk factor. interventions.
6. Demonstrate
 Patient is able to monitor and
behaviors for maintain temperature with
monitoring and herself.
maintaining
appropriate body
temperature
7. Provide extra heat
 These measures raise the core
source: temperature and improve
 Heat lamp, circulation. Core warming is
radiant warmer indicated when body
 Warming pads, temperature is below 30 °C
mattress, or (86 °F).
blankets
 Submersion in a
warm bath
 Heated,
moisturized
oxygen
 Warmed
intravenous
fluids or lavage
fluids

Collaborative:
1. Monitor fluid intake  Decreased output may indicate
and urine output dehydration or poor renal
(and/or central perfusion. Avoid fluid
overload to prevent pulmonary
venous pressure).
edema, pneumonia, and taxing
2. Check for electrolytes, an already compromised
arterial blood gases, and cardiac and renal status.
oxygen saturation by
pulse oximetry.
 Acidosis may emerge from
hypoventilation and hypoxia.