Hypothermia Nursing Diagnosis and Nursing Care Plan

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Hypothermia Nursing Care Plans Diagnosis and Interventions

Hypothermia NCLEX Review and Nursing Care Plans

Hypothermia is a condition wherein the body’s temperature is compromised and overwhelmed by cold stressors.

Hypothermia is a term derived from two words – hypo (below) and thermē (Greek for heat). It is a state wherein the body’s core temperature falls below the normal limits of 36°C.

There are different classifications of hypothermia, which include:

  • Accidental
  • Intentional
  • Primary
  • Secondary
  • Degree of hypothermia (Severity)

The treatment goals for hypothermia will depend on the subtype and causes. Addressing these on an immediate basis will prevent irreversible damage to the body.

Signs and Symptoms of Hypothermia

The general clinical manifestations of hypothermia are as follows:

  • Shivering
  • Shallow breathing, usually slow
  • Altered mental state – such as confusion, drowsiness, memory loss
  • Slurred or mumbled speech
  • Loss of coordination – e.g. stumbling steps
  • Slow, weak pulse
  • Skin cold to touch
  • Reduced activity observed in infants
  • Mild hypothermia – having a core body temperature between 32-35°C
  • Moderate hypothermia – between 28-32°C
  • Severe hypothermia – < 28°C; unconsciousness without obvious signs of breathing and circulation

Causes of Hypothermia

Causes of hypothermia may include the following:

  1. Accidental – Unanticipated exposure to cold stimulus of an unprepared patient. (e.g. Someone caught in a winter storm; homeless man without proper shelter)
  2. Intentional – An induced state in order to preserve optimum neurologic functions. This is typically done for patients on post-arrest conditions.
  3. Primary – Due to environment factors, without underlying medical condition (e.g. Exposure to cold environment)
  4. Secondary – Low core body temperature arising from a medical condition. Possible etiologies could be due to:
  • Decreased heat production – Endocrine problems such as hypoadrenalism.
  • Increased heat loss – Includes accidental hypothermia. Also includes Vasodilation from either pharmaceutical, pharmacologic, or toxic substances. It could also be from the body’s inability to preserve heat, as in the case of burn patients.
  • Impaired thermoregulation – Associated with failure of the thermoregulation function of the hypothalamus. Other causes could be due to CNS trauma, tumors, Multiple sclerosis.
  • Others – the cause of hypothermia could either be from sepsis, prolonged cardiac arrest. It could also be drug administration induced, such as neuroleptics, anesthesia, beta-blockers.

The risk factors of hypothermia include the following:

  • Extremes of age – the very young and the very old, especially those without appropriate protection or clothing
  • People with mental illness
  • People exposed to the cold outdoors for long periods, especially those with poor judgment (e.g. intoxicated people)

Complications of Hypothermia

Complications of hypothermia are as follows:

Diagnosis of Hypothermia

  • Vital signs – diagnosing hypothermia includes recognizing the presenting signs and symptoms of hypothermia, part of which is recognizing if it is Mild (32-35°C), Moderate (28-32°C) or Severe (< 28°C). Another component for treating hypothermia is recognizing secondary causes through the following diagnostic workup.
  • Laboratory studies
  • Arterial blood gas – use of a gas analyzer is warranted to differentiate false elevated oxygen and carbon dioxide levels in hypothermic patients.
  • Hematocrit levels – 2% increase in hematocrit levels is observed for every 1°C drop in temperature.
  • Serum electrolytes – chronic hypothermia can occasionally cause hypokalemia.
  • Serum glucose levels – chronic hypothermia usually has depressed serum glucose levels.
  • Clotting factors – coagulation factors of the body is compromised in moderate to sever hypothermia.
  • Imaging studies
  • Chest Xray – to find for causes, such as pulmonary edema, that coincide with hypothermia.
  • CT scan – to assess for presence of CNS tumors that may otherwise interfere with the thermoregulation function of the hypothalamus.
  • Other tests such as electrocardiogram (ECG)– the length and height of the QT-interval and characteristic J Osborne waves are associated with hypothermia.

Treatment for Hypothermia

Hypothermia is considered an emergency and is a life-threatening condition. The treatment for hypothermia involves treating the underlying cause.

Pre-hospital Care. The goal of care focuses on preventing further heat loss. Warming measures include:

  • Remove wet clothes
  • Protect the patient against environmental factors that will cause further hypothermia.
  • Rewarm of the patient by utilizing blankets. Heating pads are also useful.
  • Introduce warm fluids, either orally (if awake and alert) or intravenously  (if unconscious).

Emergency department care. The goal of care involves life saving strategies and they are:

  • Oxygen support may be required. Patients with respiratory failure may be intubated and hooked to mechanical ventilators.
  • Monitoring of cardiac rhythm for identification of life-threatening arrythmias.
  • Measurement of core temperature through the esophageal, rectal or bladder for more accurate readings.
  • Rewarming measures like blankets, heat lamps, warm gastric lavage, and warm administration of fluids (could be intravenously, peritoneally, or orally if able)
  • For severe cases, Extracorporeal membrane oxygenation (ECMO) blood rewarming is done.

Further In-patient care. This includes the following:

  • Admission to the Intensive Care Unit (ICU) is done for more thorough and complex monitoring of a hypothermic patient.
  • A complication of hypothermia, acute pulmonary edema should be treated with antibiotics, supplemental oxygen and diuretics as necessary while in the ICU.
  • Frostbite injuries would warrant surgical debridement to avoid gangrene development.   

Hypothermia Nursing Diagnosis

Nursing Care Plan for Hypothermia 1

Nursing Diagnosis: Hypothermia secondary to exposure to cold environment as evidenced by temperature of 29 degrees Celsius, shivering, confusion, shallow breathing, and slow, weak pulse

Desired Outcome: The patient will re-establish a normal core body temperature between 36 degrees Celsius and 37.8 degrees Celsius.

Nursing Interventions for HypothermiaRationales
Provide urgent actions for the hypothermic patient, such as:
Remove wet clothes.
Protect the patient against environmental factors that will cause further hypothermia.
Rewarm of the patient by utilizing blankets. Heating pads are also useful.
Introduce warm fluids, either orally if alert, or intravenously if unconscious.  
To prevent further heat loss and to help the body re-establish a normal core body temperature between 36 degrees Celsius and 37.8 degrees Celsius.
Assess the patient’s vital signs every hour or more frequently if needed. Explain to the patient the need for measurement of core temperature through the esophageal, rectal or bladder for more accurate readings.  To assess and monitor the patient’s vital signs which will provide guidance on further medical treatment for hypothermia.
Provide supplemental oxygen as required.Hypothermic patients’ respiratory system may be affected. This can cause shallow respirations and difficulty of breathing.
Continue with rewarming measures like blankets, heat lamps, warm gastric lavage, and warm administration of fluids until reaching normal body temperature.To prevent further heat loss and to help the body re-establish a normal core body temperature between 36 degrees Celsius and 37.8 degrees Celsius.
If the body temperature drops even lower, consider extracorporeal membrane oxygenation (ECMO) blood rewarming.To treat worsening or severe hypothermia.
Treat respiratory infection accordingly.Hypothermic patients are at risk for infection. Acute pulmonary edema should be treated with antibiotics, supplemental oxygen and diuretics as necessary while in the ICU.

Nursing Care Plan for Hypothermia 2

Nursing Diagnosis: Risk for Ineffective Tissue Perfusion (Peripheral) related to decreased peripheral blood flow to frostbite injuries secondary to severe hypothermia

  Desired Outcome: The patient will be able to achieve optimal tissue perfusion in the affected areas as evidenced by having strong and palpable pulses, regained leg strength, and reduced pain.

Nursing Interventions for HypothermiaRationales
Assess the patient’s vital signs at least every hour, or more frequently if there is a change in them.To assist in creating an accurate diagnosis and monitor effectiveness of medical treatment for hypothermia and frostbite.
Advise the patient to avoid rubbing the frostbite injuries.Rubbing may cause further damage to the frostbite injuries.
Prepare the patient for the surgical procedure as indicated. Preparation involves educating the patient, gaining their consent, and accomplishing a pre-operative checklist.Regional sympathetic block or ganglionectomy can be done surgically to promote vasodilation and improve blood flow. In cases of gangrene and/or ulceration, conservative debridement of necrotic tissue is highly recommended. Amputation may be required to save the rest of the fingers/limb.
Administer vasodilators as prescribed.To help dilate the blood vessels and improve the blood flow to the affected area/s.
Administer analgesics as prescribed.To provide pain relief especially in the affected area.
Ensure adequate hydration.Increased blood viscosity is a contributory factor to clotting. Adequate hydration helps reduce blood viscosity.

Nursing Care Plan for Hypothermia 3

Nursing Diagnosis: Alteration in comfort related to hypothermia as evidenced by crying, irritability, or restlessness

Desired Outcome: Within 4 hours of nursing interventions, the patient will have a stabilized temperature within the normal range and will verbalize feeling more comfortable.

Nursing Interventions for HypothermiaRationales
Remove wet clothing and replace with thick or layered clothes. Adjust the room temperature.To regulate the temperature of the environment and make it more comfortable for the patient.
Place the patient in a well-heated, well-lit room. Consider using heat lamps especially for young patients.To modify environmental stimuli that can help the patient feel more comfortable.
Offer warm drinks and liquids to the patient.To facilitate the body in warming up and to provide comfort.
Elevate the head of the bed if the patient has shallow respirations.Head elevation helps improve the expansion of the lungs, enabling the patient to breathe more effectively.
Offer blankets, heating pads or electric blankets to the patient.To facilitate the body in warming up and to provide comfort.

More Nursing Diagnosis for Hypothermia

Nursing References

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.  Buy on Amazon

Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier.  Buy on Amazon

Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.  Buy on Amazon

Disclaimer:

Please follow your facilities guidelines and policies and procedures.

The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes.

Nursing Stat Facts
Nursing Stat Facts

This information is not intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment.

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