Hypothermia is a potentially life-threatening condition where the body loses heat faster than it can produce it, causing a dangerously low body temperature (below 95°F/35°C). This nursing diagnosis focuses on identifying and treating hypothermia symptoms, preventing complications, and restoring normal body temperature.
Causes (Related to)
Hypothermia can affect patients in various ways, with several factors contributing to its severity and progression:
- Environmental exposure to cold temperatures
- Prolonged immersion in cold water
- Trauma or shock
- Medical conditions such as:
- Risk factors including:
- Advanced age or very young age
- Malnutrition
- Alcohol or drug use
- Homelessness
- Certain medications
Signs and Symptoms (As evidenced by)
Hypothermia presents with distinctive signs and symptoms that nurses must recognize for proper diagnosis and treatment.
Subjective: (Patient reports)
- Feeling cold
- Shivering
- Confusion
- Drowsiness
- Weakness
- Slurred speech
- Memory loss
- Poor judgment
Objective: (Nurse assesses)
- Core body temperature below 95°F (35°C)
- Pale or cyanotic skin
- Cold skin to touch
- Decreased heart rate
- Decreased respiratory rate
- Decreased level of consciousness
- Muscle rigidity
- Poor coordination
- Dilated pupils
Expected Outcomes
The following outcomes indicate successful management of hypothermia:
- The patient will maintain core body temperature within normal range
- The patient will show improved tissue perfusion
- The patient will demonstrate stable vital signs
- The patient will maintain adequate oxygenation
- The patient will show no signs of frostbite or tissue damage
- The patient will return to baseline mental status
- The patient will demonstrate an understanding of hypothermia prevention
Nursing Assessment
Monitor Core Temperature
- Use appropriate temperature monitoring devices
- Check temperature frequently as ordered
- Document temperature trends
- Monitor for rewarming complications
Assess Cardiovascular Status
- Monitor heart rate and rhythm
- Check blood pressure
- Assess peripheral pulses
- Monitor ECG if indicated
- Check for signs of shock
Evaluate Neurological Status
- Assess the level of consciousness
- Check pupillary response
- Monitor orientation
- Evaluate motor function
- Document mental status changes
Check Skin Integrity
- Assess for frostbite
- Monitor skin color and temperature
- Check peripheral circulation
- Document any tissue damage
- Assess for pressure points
Monitor Respiratory Status
- Check respiratory rate and pattern
- Assess oxygen saturation
- Listen to breath sounds
- Monitor for respiratory depression
- Document any changes
Nursing Care Plans
Nursing Care Plan 1: Hypothermia
Nursing Diagnosis Statement:
Hypothermia related to environmental exposure and inadequate thermoregulation as evidenced by core body temperature of 94°F (34.4°C) and cold, pale skin.
Related Factors:
- Environmental exposure
- Inadequate clothing/shelter
- Impaired thermoregulation
- Trauma or shock
Nursing Interventions and Rationales:
- Remove wet clothing and apply warm blankets
Rationale: Eliminates cold exposure and promotes heat retention - Initiate active external warming measures
Rationale: Increases body temperature gradually and safely - Monitor core temperature continuously
Rationale: Tracks rewarming progress and prevents complications
Desired Outcomes:
- Core body temperature will return to the normal range
- The patient will maintain stable vital signs
- The patient will show no signs of rewarming complications
Nursing Care Plan 2: Decreased Cardiac Output
Nursing Diagnosis Statement:
Decreased Cardiac Output related to hypothermia-induced bradycardia as evidenced by weak peripheral pulses and decreased blood pressure.
Related Factors:
- Cold-induced vasoconstriction
- Bradycardia
- Decreased cardiac contractility
- Altered peripheral resistance
Nursing Interventions and Rationales:
- Monitor cardiac rhythm continuously
Rationale: Detects arrhythmias early - Assess peripheral circulation frequently
Rationale: Evaluates tissue perfusion status - Administer warm IV fluids as ordered
Rationale: Supports circulation and assists in rewarming
Desired Outcomes:
- The patient will maintain a stable cardiac rhythm
- The patient will show improved peripheral circulation
- The patient will demonstrate adequate tissue perfusion
Nursing Care Plan 3: Impaired Gas Exchange
Nursing Diagnosis Statement:
Impaired Gas Exchange related to decreased respiratory rate and altered oxygen consumption as evidenced by decreased oxygen saturation and shallow breathing.
Related Factors:
- Decreased respiratory drive
- Altered metabolism
- Respiratory muscle dysfunction
- Increased oxygen demand
Nursing Interventions and Rationales:
- Monitor respiratory rate and depth
Rationale: Identifies respiratory compromise early - Administer oxygen as ordered
Rationale: Supports adequate oxygenation - Position patient appropriately
Rationale: Optimizes ventilation and perfusion
Desired Outcomes:
- The patient will maintain oxygen saturation >95%
- The patient will demonstrate a normal respiratory pattern
- The patient will show no signs of respiratory distress
Nursing Care Plan 4: Acute Confusion
Nursing Diagnosis Statement:
Acute Confusion related to hypothermia-induced cerebral hypoperfusion as evidenced by disorientation and altered level of consciousness.
Related Factors:
- Decreased cerebral blood flow
- Metabolic changes
- Hypoxia
- Altered consciousness
Nursing Interventions and Rationales:
- Assess mental status frequently
Rationale: Monitors neurological function - Provide orientation cues
Rationale: Supports cognitive function - Ensure safe environment
Rationale: Prevents injury during confusion
Desired Outcomes:
- The patient will return to baseline mental status
- The patient will maintain safety
- The patient will demonstrate improved orientation
Nursing Care Plan 5: Risk for Pressure Injury
Nursing Diagnosis Statement:
Risk for Pressure Injury related to decreased peripheral circulation and altered mobility as evidenced by cold, pale extremities and decreased movement.
Related Factors:
- Impaired circulation
- Decreased sensation
- Limited mobility
- Altered tissue perfusion
Nursing Interventions and Rationales:
- Perform frequent skin assessments
Rationale: Identifies tissue damage early - Implement pressure relief measures
Rationale: Prevents tissue breakdown - Monitor skin temperature and color
Rationale: Evaluates circulation status
Desired Outcomes:
- The patient will maintain skin integrity
- The patient will show no signs of pressure injury
- The patient will demonstrate improved peripheral circulation
References
- Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2023). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.
- Evered A. Hypothermia: risk factors and guidelines for nursing care. Nurs Times. 2003 Dec 9-15;99(49):40-3. PMID: 14705345.
- Harding, M. M., Kwong, J., & Hagler, D. (2022). Lewis’s Medical-Surgical Nursing: Assessment and Management of Clinical Problems, Single Volume. Elsevier.
- Herdman, T. H., Kamitsuru, S., & Lopes, C. (2024). NANDA International Nursing Diagnoses – Definitions and Classification, 2024-2026.
- Ignatavicius, D. D., Rebar, C., & Heimgartner, N. M. (2023). Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care. Elsevier.
- McCullough L, Arora S. Diagnosis and treatment of hypothermia. Am Fam Physician. 2004 Dec 15;70(12):2325-32. PMID: 15617296.
- Moore K. Hypothermia in trauma. J Trauma Nurs. 2008 Apr-Jun;15(2):62-4; quiz 65-6. doi: 10.1097/01.JTN.0000327329.68029.b8. PMID: 18690136.
- Silvestri, L. A. (2023). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.
