Introduction

Neonates are important links in the chain of events occurring from conception to adulthood.
Neonatal period is defined as the first 28 days after birth in which major physiological &
metabolic adaptation takes place. The morbidity & mortality in neonates is still alarming
especially in developing countries. In India current neonatal mortality rate is 23 per 1000 live
birth (2018,SRS report). Hence early recognition of problems & appropriate care is very
significant.

Name : B/O Ayesha Begum

Age : 22 days
Religion : Muslim
Address : 92,A.P.C Road,Rajabajar,Machuabazar,kol-700009
Hospital registration No
Date of admission : 15.01.2022
Ward and unit : SNCU
Bed No : 06
Diagnosis : Hypothermia
Date of operation : Not Applicable
Name of operation : Not Applicable

Socio-economic data:
Marital status : Not Applicable
Language : Not Applicable
Educational qualification : Not Applicable
Occupation : Not Applicable
Number of the family member : 6
Role of family member : Not Applicable

Patient's Chief complains :

 cold extremities
 Poor feeding
 Slow & shallow respiration
History of present illness:
 Poor feeding
 Slow respiration
 Cold clammy skin

Past health history:

Past illness history : Nothing Significant

Treatment — Surgical/Medical/Any other : Nothing Significant
Details of previous hospitalization : No
Allergies : Not identified till now

Menstruation (in case of female patient)

Age at monarchy : Not Applicable

Regular/irregular : Not Applicable
LMP : Not Applicable
Menopause : Not Applicable

Details of immunization : Birth dosage of immunization taken

Personal habits : Not Applicable

Current medication being taken : No
Sleeping pattern (regular/irregular/any sleep disorder) :Regular
Any fitness/exercise pattern : Not Applicable

Dairy details (Vegiterian/non-vegiterian/special diet) : Not Applicable

Job/work details (any shieft/sitting or standing) :

Family history:

Key :-------------------------Male

--------------Female

--------------Present Patient

Environmental History :

Drinking Water supply : Corporation supply water

Environmental Sanitation : Unhygenic

Waste/excreta disposal : Dumping

Psychosocial history:
Language : Not Applicable
Details of milestones development : Nothing significant
Social support available or not : No

Physical examination (report only deviation from normal) : Nothing significant

Diagnosis:

● Provisional : Neonatal Hypothermia

● Final : Neonatal Hypothermia

Definition of the disease: Hypothermia is a common alteration of thermoregulatory state of

the neonates. Neonatal hypothermia occurs when the body temperature drops below 36.50C
or 97.70F in the newborn intant (WHO). Normal body temperature is between 36.5 to
37.5C.

Classification: The thermoneutral state of the neonates is considered within the normal range
of 36.50C to 37.50C.

The stages of hypothermia are as follows:

 Cold stress: When the body temperature of the new born baby is between 36
to 36.4(96.80F to 97.60F) then the baby is under cold stress.
 Moderate hypothermia: An infant with temperature of 32 to 35.90C (89.6 -
96.60F) has moderate hypothermia, which is a danger to the baby.
 Severe hypothermia: An infant with a temperature of below 32 o c or 89.6 0
1* is suffering from severe hypothermia, which need urgent skilled care.

A skin temperature change is the initial indicator of cold stress. A decreased core temperature
is a late warning sign indicating that the neonate is already compromised.

Related anatomy & physiology: Human skin consists of three layers: epidermis, dermis, and
subcutaneous fat. All elements of skin are derived from either ectoderm or mesoderm, the
former giving rise to the epidermis and other cutaneous epithelial components.1 A brief
description of fetal skin development is helpful in understanding the structure and function of
newborn skin, and is incorporated into some of the following discussions of the various
compartments and structures.
The subcutaneous fat is an important layer, playing a role in shock absorption, energy
storage, and maintenance of body heat. The individual cells in the subcutaneous fat –
adipocytes – form lobules that are separated by fibrous septa. The fibrous septa contain
neural and vascular elements and connect deeper with the fascia of underlying skeletal
muscle. In contrast, brown adipose tissue (BAT or brown fat) is a distinct type of adipose
tissue, traditionally believed to be present only in newborns, that plays a vital role in neonatal
thermoregulation (discussed in more detail later) through the oxidation of fatty acids.BAT
makes up 2–6% of the neonate’s total body weight and is found primarily in the scapular
region, the mediastinum, around the kidneys and adrenal glands, and in the axilla.The
nonshivering thermogenesis that occurs in this tissue appears to be regulated by the enzyme-
uncoupling protein thermogenin (more recently known as uncoupling protein 1 or UCP-1),
which serves as a protonophore through the mitochondrial membrane, enabling high rates of
cellular respiration and proton conductivity. BAT is believed to be depleted over time,
although recent studies suggest that functionally active BAT is present in at least some adults.
Etiology:

According to book According to patient

Factors Responsible for Neonatal Hypothermia :
 Separation of
 Lack of awareness and attention, about the importance baby from
of warmth for neonates, among health care providers. the mother.
 Inappropriate care of the baby immediately after birth by  Cold
inadequate drying and wrapping. environment
 Separation of baby from the mother. at the place of
 Cold environment at the place of delivery and babycare babycare
areas. areas.
 Change of temperature from womb to cooler
extrauterine environment.
 Inadequate warming procedure before and during transport
of the baby.
 Excessive heat loss by evaporation, conduction,
convection and radiation from wet baby to the cold linen,
cold room and cold air.
 Certain characteristics of neonates, i.e. large body surface
area per unit of body weight, large head, developmental
immaturity of heat regulation center, poor insulation due
to less subcutaneous fat in LBW baby and reduced brown
adipose tissue (BAT) as heat source.
 High risk neonates—LBW baby, birth asphyxia, congenital
malforma tions and mother having anesthetic drugs.
Pathophysioligy : Body temperature reflects the balance between heat production & heat
loss. Heat is generated by cellular metabolism (most prominently in the heart & liver) and
lost by the skin & lungs via the following processes :

 Evaporation : Veporization of water through both insensible losses & sweat.

 Radiation : Emission of infrared electromagnetic energy.
 Conduction : Direct transfer of heat to an adjacent,coller object.
 Convection : Direct transfer of heat to convective air current.

 In response to a cold stress, the hypothalamus attempts to stimulate heat

production through shivering & increased thyroid, catecholamine, & adrenal
activity.
 Sympathetically medited vasoconstriction minimizes heat loss by reducing
blood flow to peripheral tissues, where cooling is gretest.
 Respiration progressively become slow, shallow, irregular, and then absent.
 Blood volume markedly decresses because of extra vacation due to vascular
& a profound ‘cold diuresis’ caused by erroneous signaling to the kindly about
blood volume.
 Cold diuresis is worsened by failure of renal concentrating function. The
hydrostatic effects of immersion also promote shock after water rescue.
 Hypothermia increase myocardial irritability. Thus ventricular fibrillation(VF)
is a frequent problem in severe hypothermia.
Clinical manifestation:

According to book Found in the patient

 Low temperature.
 Limp In case of my patient :
 Poor sucking or feeding.  Low temperature.
 A weak cry.  Poor sucking.
 Slow or shallow respiration.  Slow respiration (34b/m)
 Slow heart rate (<100/min).  Slow heart rate (92b/min).
 Acrocyanosis, cold extremities  Acrocyanosis
due to peripher vasoconstriction.  cold extremities
 Hypoglycemia, metabolic  Hypoglycemia
acidosis due to increase
metabolism.
 Respiratory distress, tachypnea
due to increased pulmona
artery pressure.
 Chronic signs: Weight loss, failure
to thrive.

Investigation :

According to book with normal value Found in the patient

Feel by Feel by touch Interpritation

touch extrimities
trunk
Trunk & extremities both
warm warm Normal
are cold to touch. On
warm cold Cold stress
admission temperature is
cold cold Hypothermia
33.4C
Management :

According to book Found in the patient

Medical :
 Keep the room warm.  In case of my patient :
 Remove cold clothes and replace with  Keep the baby in
warm clothes. radient warmer.
 Re-warm quickly by skin-to-skin contact and/or  Continue breastfeeding
a heating device such as, radiant heater or  Monitor axillary
incubator, thermostatically controlled heated temperature every 1/2
mattress set at 37-38C. hour till it reaches
 Once baby's temperature reaches 34C, the re- 36.5C, then hourly
warming process should be slowed down. for next 4 hours,
 Continue breastfeeding.  Keep in close
 Monitor axillary temperature every 1/2 hour till observation for
it reaches 36.5C, then hourly for next 4 hours, 2 any sign of
hourly for 12 hours thereafter and 3 hourly as a infection.
routine.  Give parents
 Assess for infection. health education
 Give parents health education.
 Management at Home

Surgical : Not Applicable.

Nursing Management :

Assessment Nursing Diagnosis Intervention Evaluation

Subjective : Hypothermia related to • Assessed neonatal The baby maintains
Objective : Temp: disease process as condition. normal core
37.9 C̊ evidence by cold calmy • Monitored vital temperature
skin. sign and as evidence by
recorded. normal
• Provide warmth by vital signs.
keeping under radiant Temp:36.5 C̊
warmer. Heart rate: 155
• Administered Inj. beats/min
Vit-K as per Resp: 48 brths/min
doctors advice.

Subjective : Ineffective breathing • Assessed respiratory Baby maintained

Objective : Resp- pattern due to due to pattern of normal oxygen
66 bts/min. increased pulmona the baby. saturation and
SPO2- 92% artery pressure. • Monitored and respiration.
recorded vital • SPO2- 98%
sign. • Respiration- 48
• Maintained oxygen bts/min.
saturation.
• Monitor SpO2
Assessment Nursing Diagnosis Intervention Evaluation
Subjective : Interrupted Assessed mother’s Mother
Objective : Poor breastfeeding perception and demonstrate
suckling related to knowledge about techniques to
neonate’s present breast feeding. sustain
illness as • Health education lactation,
evidenced by given how to
poor suckling. sustain lactation
until breast feeding
is initiated.
• Encouraged mother
to visit the milk
bank every 3 hrly.
• Demonstrated her
about the use of
breast
pump.
• Encouraged mother
to obtain adequate
rest,
maintain fluid and
nutritional intake.
Subjective : Risk for Hypoglycemia  Assessed Baby maintain normal
Objective : poor related to disease process. nutritional blood glucose level.
suckling status. CBG – 85 mg/dl
 Administer I.V
Fluid @ 10%
Dextrose as
advised.
 Monitored
and recorded
CBG as per
advised
Assessment Nursing Diagnosis Intervention Evaluation
Subjective : Risk for  Monitored There were no
Objective : Temp: infection related and recorded signs of infection.
vital sign
37.9 C̊ to hospitalization
 Hand washing
done before
and
 after every
procedure.
 Aseptic
technique
maintained
 during every
procedure.
 The site
of
invasive
procedure
 had been
assessed for
redness,
 inflammation,
discharge.
 Maintained
personal
hygiene

Subjective : Parental anxiety related  Assessed the Parents looked less

Worried to hospitalization. level of anxious as
anxiety of
Objective : Facial evidence by
the parents.
expression  Encouraged verbalization.
parents to
express
their
concerned
about baby's
prognosis.
 Shared the
feelings of
parents
Assessment Nursing Diagnosis Intervention Evaluation
Subjective : Risk for Impaired Parents were The parents
Objective : Supression parent-neonates assessed about have a
of breast milk Attachment related their perception of mutually
to neonate’s situation and satisfying
physical illness and individual interactions
hospitalization. concerns. with their
• Health education newborn.
given to parents
regarding child
growth and
development.
• Parents are
encouraged and
involved in
activities with the
baby that they
can accomplish
successfully.
Complication :

According to book Found in the patient

In severe cases if not treated early :
 Hypoglycaemia
 Bleeding, DIC  No complication arise
 Acidosis
 Shock
 Hypotension
 Respiratory distress
 Apnoea
 Pulmonary haemorrhage
 Cardiac arrest
 Death

Prognosis :

According to book Found in the patient ( day to day )

 Prognosis is good if treated early & it’s  Prognosis is good

not become complicated.

Conclusion : Hypothermia is considered as silent killer in neonates. It increases the neonatal

morbidity and mortality. Maintenance of warmth of the neonates enhances their survival.
Piere Budin (1900) first drew attention to the high neonatal mortality due to cold. Optimum
thermal environment for neonates was identified in mid 1960s, as they are easily
influenced by the extremes of environmental temperature. Thermal protection of the
newborn babies is considered as one of important essential neonatal care.
References:

 Marlow.R. Dorothy and Redding. A. Barbara (2007), Textbook of Pediatric

Nursing, Elsevier India Private Limited, New Delhi, 235-248

 Hockenberry J. Marilyn, Wilson David, Rodgers C. Cheryl (2018), Wong's Essentials

of Pediatric Nursing, Elsevier India Private Limited, New Delhi, 313-319.

 Pal Panchali, Textbook of Pediatric Nursing, (2016), Textbook of

PediatricNursing, Paras Medical Publisher, New Delhi, 262-268, .

 Datta Parul, , (2009),Pediatric Nursing ,Jaypee Brothers Medical Publisher (P)

Ltd, New Delhi, 237-241