Hypothermia:
Definition :
Body temperature below the normal range
Defining Characteristics : body temperature below normal range, cool, pale skin, dizziness, hypertension, increased heart rate, lack of coordination, piloerection, shivering, slow capillary refill
Related Factors : alcohol and drug use, decreased metabolic rate, exposure to cold environment, extreme evaporative heat loss from skin, illness, inability to shiver, inadequate nutrition, poor clothing, medications, trauma
NOC:
- Thermoregulation
- Thermoregulation: neonate
- Body temperature in the normal range
- Pulse and respiratory rate are in the normal range
NIC:
Temperature Regulation
- Monitor temperature at least every 2 hours.
- Plan temperature monitoring continuously.
- Blood pressure monitor, pulse, and respiratory rate.
- Monitor skin color and temperature.
- Monitor signs of hyperthermia and hypothermia.
- Increase intake of fluids and nutrients.
- Cover the patient to prevent loss of body warmth.
- Teach patients how to prevent heat fatigue.
- Discuss the importance of regulating temperature and the possible negative effects of cold.
- Notify about indications of fatigue and emergency handling needed.
- Teach indications of hypothermia and necessary treatment.
- Give antipyretics if necessary.
Vital Sign Monitoring
- Monitor blood pressure, pulse, temperature, and respiratory rate.
- Note blood pressure fluctuations.
- Monitor vital signs when the patient is lying down, sitting or standing.
- Auscultate blood pressure in both arms and compare.
- Monitor BP, pulse, RR, before, during, and after activity.
- Monitor pulse quality.
- Monitor the frequency and rhythm of breathing.
- Monitor lung sounds.
- Monitor abnormal breathing patterns.
- Monitor skin temperature, color and moisture.
- Monitor peripheral cyanosis.
- Monitor for cushing triad (widening pulse pressure, bradycardia, increased systolic).
- Identify the causes of vital sign changes.
