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:
- 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:
- 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:
- Accidental – Unanticipated exposure to cold stimulus of an unprepared patient. (e.g. Someone caught in a winter storm; homeless man without proper shelter)
- Intentional – An induced state in order to preserve optimum neurologic functions. This is typically done for patients on post-arrest conditions.
- Primary – Due to environment factors, without underlying medical condition (e.g. Exposure to cold environment)
- 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:
- Cardiac arrythmias
- Aspiration pneumonia
- Bleeding diathesis
- Bladder atony
- Electrolyte (Hyperkalemia, hypoglycemia), hematocrit, and coagulation abnormalities
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 Hypothermia||Rationales|
|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 Hypothermia||Rationales|
|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 Hypothermia||Rationales|
|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.|
Nursing Care Plan for Hypothermia 4
Nursing Diagnosis: Altered Tissue Perfusion related to hypothermia secondary to frostbite, as evidenced by insensitivity, blisters, severe pain in the affected area, hard or waxy-looking skin, and low body temperature.
- The patient will determine and report any changes in sensation or pain at the affected site.
- The patient will demonstrate an understanding of the plan to heal tissue and prevent injury.
- The patient will identify measures to protect and heal the tissue, including wound care.
- The patient’s wound will decrease in size and will have increased granulation tissue.
|Nursing Interventions for Hypothermia||Rationale|
|Place the patient in a warm, dry place and remove all wet and constrictive clothing.||This will promote thermoregulation and avoid impaired circulation.|
|Assess the location and status of the patient’s affected tissue.||Indications of inflammation and the body’s immune system responding to localized tissue trauma or compromised tissue integrity include redness, swelling, discomfort, burning, and itching.|
|Assess the patient for signs of frostbite if the patient has spent a lot of time in a cold area.||In cells, severe hypothermia causes ice crystals to develop. Eventually, the cells rupture and die.|
|Gently warm the patient’s affected area, Rapid and regulated rewarming can be used. If prompt medical attention cannot be provided, rewarming first aid may be used. This is accomplished by placing the damaged area in a whirlpool heated to 37 to 40 degrees Celsius for 30 to 45 minutes, or until the tips of the injured section flush. The water should be maintained circulating to help with warming.||Exposing the frostbitten area to direct or dry heat can cause further damage. A whirlpool bath is utilized to encourage blood flow to the affected area, remove dead tissue, allow for normal blood flow, and help to avoid infection. The flush could be seen as a sign that the circulatory flow has resumed.|
|Avoid rubbing the patient’s affected area with snow or warm hands.||Doing so could increase the damage on the affected area by forcing ice crystals in the frozen skin through the cell wall.|
|Avoid giving the patient alcohol or any tranquilizers.||Such things will accelerate heat loss from the body.|
|Rush the patient to the hospital if outside as soon as possible, to begin with immediate fluid replacement.||The first step in the treatment is a fluid replacement to increase the blood flow to the tissues that have been frozen.|
|Educated the patient on how to check skin and wounds and how to monitor for signs of infection, complications, and healing.||Early evaluation and action aid in preventing the emergence of significant issues.|
|Teach the patient, significant others, and the family how to properly treat the wound, including handwashing, wound cleaning, changing the dressing, and applying topical treatments.||Accurate information lowers the risk of infection and improves the patient’s capacity to manage therapy independently.|
|Control the heat source to the patient’s physiological reaction.||The rate of increase in body temperature should not exceed a few degrees per hour. Vasodilation happens as the patient’s internal temperature rises, which lowers BP. Rewarming consequences include dysrhythmias, metabolic acidosis, and hypotension.|
|Instruct the patient to avoid manual scraping, rubbing, or massaging frostbitten regions.||Rubbing can worsen tissue damage of frozen tissues.|
|Maintain a strict aseptic technique when dressing the patient’s frostbite wounds.||Frostbite wounds make the patient more prone to infection.|
|Encourage the patient for hourly mobility of the affected digits.||To ensure complete function recovery and avoid contractures.|
|Prepare the patient for procedures like escharotomy or fasciotomy if necessary.||An escharotomy is a procedure that involves cutting through the eschar. This surgery is carried out to stop more tissue damage from occurring and to allow regular blood flow, and motion in the joints. In order to relieve strain on the muscles, nerves, and blood arteries, a fasciotomy is a surgical technique in which an incision is created in the fascia. For the treatment of compartment syndrome, fasciotomy is effective.|
|Advise the patient to avoid smoking.||Because the vasoconstrictive effects of nicotine will further reduce the already deficient blood supply to the damaged tissues.|
|Inform the patient about appropriate hydration, nutrition, and tissue preservation techniques.||To avoid compromised tissue integrity, the patient must be properly informed about their situation.|
Nursing Care Plan for Hypothermia 5
Nursing Diagnosis: Risk for Infection related to hypothermia secondary to sepsis.
- The patient will remain free from infection, as evidenced by normal vital signs and absence of signs and symptoms of infection.
- The patient will maintain or restore defenses.
- The patient will recognize early signs of infection to allow for prompt treatment.
- The patient will know the proper hand washing technique.
|Nursing Interventions for Hypothermia||Rationale|
|Assess the patient for a potential infection source such as burning urination, localized abdominal pain, burns, open wounds or cellulitis, presence of invasive catheters, or lines.||Abdominal and soft tissue infections are the next most frequent causes of sepsis, followed by respiratory and urinary tract infections. The use of intravascular devices is another factor in hospital-acquired sepsis.|
|Instruct the patient to wash the hands properly with antibacterial soap both before and after each care activity.||Cross-contamination is made less likely by hand washing and good hand hygiene. It should be noted that Methicillin-resistant Staphylococcus aureus (MRSA) is most frequently spread by close contact with healthcare professionals who are unable to wash their hands in between patient interactions.|
|Maintain a sterile technique when changing dressings, suctioning, and caring for the site with an invasive line or a urinary catheter.||Medical asepsis stops the spread of microorganisms and lowers the possibility of nosocomial infections.|
|Investigate the patient’s complaints of pain that are out of proportion to the physical symptoms.||A cellulitis region may experience pressure-like pain that needs to be treated right away if necrotizing fasciitis caused by group A beta-hemolytic streptococci (GABHS) is developing.|
|Assess the patient’s wounds daily and give close attention to parenteral nutrition lines. Monitor any localized inflammation, infection, or changes in the character of urine, sputum, or wound drainage.||Where central venous catheters are utilized in both acute and chronic care settings, catheter-related bloodstream infections (CR-BSIs) are on the rise. Clinical symptoms include phlebitis or localized inflammation that may point to a portal of entry, the kind of initial infecting organism, as well as early detection of subsequent infections.|
|Assess the patient’s mouth for white plaques. Look into complaints of burning or itching in the perineum.||Antibiotic use and immune system suppression raise the risk of secondary infections, including yeast thrush.|
|Encourage the patient to use a tissue to cover the mouth and nose when coughing or sneezing. If indicated, place in a private room. If necessary, wear a mask when giving direct care.||The spread of illness by aerosolized droplets is prevented by appropriate conduct, personal protective equipment, and isolation.|
|Encourage the patient to have regular position changes, deep breathing exercises, and coughing techniques.||Having a healthy pulmonary system may lessen respiratory compromise.|
|Avoid using invasive tools and processes when possible. When an infection is present, cut off the lines and equipment, and replace them as necessary.||Minimizes the potential entry points for opportunistic pathogens.|
|Ensure proper disposal of soiled dressings and other items in a double bag.||Reduced contamination and bacterial spread result from proper disposal of contaminated materials.|
|Wear gloves and a gown when treating the patient’s open wounds or anticipating direct contact with secretions or excretions.||Prevents contamination and disease transmission.|
|Isolate and monitor the patient’s visitors as needed.||All infectious patients should be isolated using body substance isolation. Draining wounds may just require hand cleaning, wound isolation, and linen isolation. Patients who have diseases that are airborne could also require airborne and droplet precautions.|
|Monitor the patient’s temperature trends and observe the patient for chills and severe diaphoresis.||Endotoxin action on the hypothalamus and endorphins released by pyrogen cause fever, which is measured between 101°F and 105°F. A serious symptom of hypothermia is a temperature below 96°F, which indicates an advanced state of shock, diminished tissue perfusion, and an inability of the body to develop a febrile response. In the presence of a widespread infection, chills frequently precede temperature increases.|
|Observe the patient if the symptoms are getting worse or not getting better with therapy.||A clinical disease deteriorating or failing to improve with treatment may be due to incorrect or insufficient antibiotic use, an overgrowth of resistant or opportunistic organisms, or both.|
|Collect samples of urine, blood, sputum, wounds, and invasive lines or tubes for sensitivity testing and culture if necessary.||Effective treatment based on drug susceptibility requires the identification of the portal of entry and organism causing the septicemia.|
|Monitor the patient’s laboratory tests including WBC counts with neutrophils and band counts.||Neutrophils typically make up at least 50% of total WBCs, although determining the absolute neutrophil count is more useful for assessing immunological function when the WBC count is noticeably lowered. Similar to how an early increase in band cells shows the body trying to create a defense against the infection, however, a decline shows decompensation.|
Nursing Care Plan for Hypothermia 6
Nursing Diagnosis: Failure to Thrive (Infants) related to hypothermia secondary to preterm birth, as evidenced by inadequate weight gain, poor sucking, height, and weight that is inappropriate for age, and a weak cry.
- The patient will be able to attain the appropriate height and weight.
- The patient will have adequate nutritional support.
|Nursing Interventions for Hypothermia||Rationale|
|Assess the patient’s weight, height, and medical history and determine the results of diagnostic tests.||The result of the initial evaluation will be the baseline for the treatment plan and the requirement for further evaluation.|
|Analyze the patient’s dietary intake.||Following the screening for the risk of malnutrition, patients who were identified as being at nutritional risk should have their nutritional status evaluated. When performing an assessment, nurses and medical professionals can gather more data and conduct a physical exam that is specifically focused on nutrition to establish whether a nutrition problem exists, what the issue is, and how serious it is.|
|Carry the patient close, speak in a reassuring, warm tone, and let the patient participate in age-appropriate play activities.||This will promote sensory stimulation and provide comfort to the infant.|
|Feed the patient slowly and attentively in a calm setting; the infant may need to be cuddled up close and gently rocked throughout the feeding; initially, it may be essential to feed the patient every two to three hours.||This will provide nutritional support. Carrying the patient creates a bond between the infant and the caregiver and promotes warmth by skin-to-skin contact.|
|Provide a peaceful, warm, and comfortable environment for the patient. Providing a warm light is necessary.||The infant can concentrate better on feeding in a peaceful, distraction-free setting, and reduced environmental stimulation will help comfort the patient and assist in temperature regulation.|
|During and after each feeding, burp the patient regularly and then lay the patient on the side with the head slightly raised or held chest to chest.||This will facilitate gastric emptying and reduce the risk of aspiration after feeding.|
|Encourage any family caregivers who may be present to participate in the patient’s feedings.||The infant will build trust and familiarity with the caregiver.|
|Evaluate the patient’s status with the use of a weight and growth chart and advise the caregiver to make a diary of intake.||Regular checking of weight will correlate the food intake and the patient’s weight gain. An inadequate diet reduces energy stores and limits the body’s capacity to produce heat through calorie consumption.|
|Monitor the patient’s elimination patterns.||Bowel movement and urine production return to normal as the patient’s intake of food and liquids is gradually increased.|
|Discuss the potential need for enteral or parenteral nutritional support with the patient’s caregiver.||Patients who are unable to sustain food intake orally may need nutritional supplementation. Enteral tube feedings are recommended if the digestive system is healthy. Parenteral nutrition is advised for patients who cannot tolerate enteral feedings.|
|Assess the willingness of the patient’s caregiver to follow the recommended nutritional guidelines.||Consistency is essential to a successful treatment outcome.|
|Collaborate with other referrals and ensure close follow-up.||Success with feeding and parenting will be increased by collaborative practice with neonatal nutritionists, physical or occupational therapists, home visiting nurses, or lactation specialists.|
More Nursing Diagnosis for Hypothermia
- Risk for Impaired Body Image secondary to amputation of frostbite injury
- Risk for Impaired Elimination
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
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