Nursing Diagnosis For Hypothermia
Hypothermia
Normal core body temperature is maintained within a narrow range of 37 °C or 98.6 °F. This vital core temperature plays a major role in the functioning of organs and body systems, including the nervous system, heart, and blood pressure. When core body temperature falls outside its normal range, for instance, lower than 35 °C (95 °F), it can lead to hypothermia, where the body can no longer generate enough heat through metabolic processes such as convection, conduction, radiation, and evaporation. Severe hypothermia may result in complete failure of the heart and respiratory systems, eventually leading to death. Thus it is important to maintain core body temperature within its normal range in order to keep our bodies healthy and functioning properly.
Nursing Diagnosis: Hypothermia
Causes of Related Factors:
- Age-related changes in thermoregulation and environmental exposure
Possibly evidenced by the:
- Reduction in body temperature below the normal range
- Shivering
- Cool skin
- Pallor
- Tachycardia
Defining Characteristics
1. Physical examination of the patient is a critical component of your nursing assessment. The physical examination helps you determine whether or not a patient is experiencing hypothermia, as well as its severity.
In order to assess for hypothermia, first examine the patient’s skin color and temperature; these are two indicators that may lead you to suspect that he or she has this condition:
- Skin color – pale or bluish tones indicate severe hypothermia; however, if only one part of the body appears blue while other areas remain pinkish or normal-colored (mottled), then it could be due to poor circulation rather than low body temperature. In this case, it’s important to look at other factors such as pulse rate and capillary refill time (CFR). If they’re slow enough for you to notice them during your assessment process then they would be considered indicative of moderate-to-severe hypothermia.
2. Capillary refill time (CRT) is a useful and rapid metric in determining the intravascular volume status of ill patients, particularly those with conditions that arise or result from hypovolemia.
Examples of these pathologic states include but are not limited to: hypo and hyperthermia. The CRT can be assessed by the observer feeling for two seconds over each radial pulse at which point it becomes palpable before removing pressure from their fingers. If there is no pulse after two seconds, this indicates poor peripheral perfusion with possible low blood pressure or shock; if there is still no detectable pulse after three seconds, then it indicates severe shock with complete loss of peripheral perfusion
2. The initial cardiac response to hypothermia is tachycardia followed by bradycardia. Patients with a stable cardiac rhythm (including sinus bradycardia) and stable vital signs may undergo passive rewarming with blankets to prevent further heat loss.
3. Cyanosis of the nail beds is a sign that your body isn’t getting enough oxygen. It can occur when you’re in a cold environment and your body tries to conserve heat by sending more blood to your internal organs and away from your extremities.
When you have cyanosis, it’s usually easy for others to see that something is wrong because of how blue/purple your fingers look. Cyanosis can be caused by many different conditions including pneumonia (lung infection), congestive heart failure (when the heart has trouble pumping enough blood), severe asthma attacks or pulmonary embolism (blood clot in the lung).
4. Piloerection is an involuntary response to cold. It occurs when the sympathetic nervous system stimulates hair follicles, causing them to stand on end and expose the skin’s surface area.
This increases the insulating effects of your coat of fur by trapping air between each individual strand of hair, creating a warm pocket that prevents heat loss through conduction or convection.
The increased blood flow also allows more oxygenated blood to reach your extremities in order to maintain circulation throughout your body (an important function for maintaining core temperature).
Piloerection can also occur as part of an emotional response–for instance, if you’re excited about seeing someone who makes you happy or scared about something bad happening–but it’s most commonly associated with cold temperatures because its protective effect helps keep us alive during times when our bodies have less access to external sources such as blankets or heaters
5. Hypotension is a common symptom of hypothermia. As the core temperature drops, heart rate and cardiac output decrease, causing blood pressure to drop as well.
Hypotension is further exacerbated by fluid shifts and hypovolemia secondary to cold diuresis (Rischall & Rowland-Fisher, 2016). Significant hypotension can be expected once the core temperature reaches 24°C (Rischall & Rowland-Fisher)
Nursing Assessment: Rationale
1. Assess for precipitating situations and risk factors.
Hypothermia is a medical emergency that requires prompt medical treatment and professional nursing diagnosis. As such, nurses must assess for precipitating situations and risk factors to guide the appropriate medical care. In particular, age-related deteriorating vital body functions can increase the risk of hypothermia; therefore these issues should be considered when assessing the situation. With appropriate medical treatment determined, nurses must then provide essential care with accuracy and precision to bring the patient’s body temperature back to a medically safe level.
2. Note and monitor the patient’s temperature.
Hypothermia is a medical emergency that can result in life-threatening consequences. Therefore, when a nursing diagnosis for hypothermia, it is important to assess all relevant medical factors to determine the cause and severity of the condition. Vital body functions such as respiration rate and heart rate also need to be noted and monitored in order to ensure prompt medical intervention is given. The temperature should be recorded, with the usability of oral measurement dependent on the alertness of the patient; core temperature may require further monitoring using special medical devices such as a pulmonary artery catheter or bladder catheter.
3. Monitor the patient’s HR, heart rhythm, and BP.
When dealing with a medical emergency such as hypothermia, nurses must make an accurate nursing diagnosis to best support the patient. Therefore, it is essential to monitor vital body functions such as heart rate, heart rhythm and blood pressure when diagnosing and treating hypothermia. As hypothermia progresses, these key indicators begin to drop which increases the risk for medical events like ventricular fibrillation or other dysrhythmias.
4. Evaluate the patient for drug abuse use, including antipsychotics, opioids, and alcohol.
Hypothermia is a medical emergency that requires a comprehensive nursing diagnosis and treatment approach. It is caused by a steep decline in body temperature, resulting in dysfunction of vital body functions. As part of the nursing assessment, it is important to evaluate the patient for drug abuse use, including antipsychotics, opioids, and alcohol. This is because these groups of drugs can contribute to vasodilation and heat loss which may lead to hypothermia. Through appropriate medical or supportive care, nurses can help minimize health risks associated with hypothermia.
5. Assess the patient’s peripheral perfusion at frequent intervals.
In the intensive care unit, hypothermia is an extremely serious medical emergency that requires intensive monitoring of the patient’s peripheral perfusion at frequent intervals. When assessing the patient, nurses must evaluate underlying signs including skin color and temperature to accurately identify the progression of hypothermia and establish a nursing diagnosis. Accurate assessment of peripheral perfusion allows nurses to monitor vital body functions such as temperature and heart rate, whilst continuing treatment rendered for objectified therapeutic goals.
6. Monitor fluid intake and urine output (and/or central venous pressure).
Decreased output may indicate dehydration or poor renal perfusion. Avoid fluid overload to prevent pulmonary edema, pneumonia, and taxing an already compromised cardiac and renal status.
7. Check for electrolytes, arterial blood gases, and oxygen saturation by pulse oximetry.
In intensive care units, it is standard practice to have nursing personnel check for electrolytes, arterial blood gases, and oxygen saturation by pulse oximetry as it is a critical part of the medical emergency procedure. Accurately measuring these vital body functions can help diagnose and manage acidosis that results from hypoventilation and hypoxia. Understanding these issues is integral to a successful nursing diagnosis, enabling an adequate and efficient treatment plan.
8. Evaluate for the presence of frostbite, if the patient has had prolonged exposure to a cold environment.
Intensive care units play a crucial role in the treatment of medical emergencies. For the healthcare team to provide effective intensive care and nursing diagnosis of their patients, they must first recognize any signs of acidosis due to hypoventilation and hypoxia. Checking for electrolytes, arterial blood gases, and oxygen saturation by pulse oximetry are essential tests that should be conducted in order to properly monitor vital body functions. Through these checks, the intensive care team can ascertain whether or not their patient is receiving the necessary intensive care to address any respiratory distress or health problems caused by changes in acidity in the body.
9. It is incredibly important that the patient comprehends their unique circumstances and the appropriate treatment plan and safety precautions they must take to attend to their health.
If a patient is diagnosed with hypothermia, intensive care must be taken. A proper nursing diagnosis must be developed to ensure that medical treatment is provided in the most effective way. It is a medical emergency as vital body functions can be threatened that require intensive monitoring and intensive supportive care until all of their vital signs stabilize. Appropriate safety precautions must also be taken to avoid any possible risk of complications due directly to hypothermia in order to provide the patient with the best possible outcome.
10. The patient should continue to demonstrate functional positioning, as indicated by a lack of contractures.
Nursing diagnosis for hypothermia can be a critical concern for intensive care units due to its potential for dangerous medical emergencies. Recognizing when the patient is displaying symptoms of hypothermia and providing a tailored nursing diagnosis can be of utmost importance in restoring vital body functions. Typical personalized nursing interventions may include intensive monitoring, repositioning of the body periodically, or other treatments that correct the root cause of hypothermia. By ensuring patient safety and protecting his or her health, through timely and tailored nursing diagnosis, intensive care providers can spirit the patient away from danger.
11. Equally important is that the patient shows adequate core temperature within a normal range, has normalized blood pressure, and there are no signs of severe hypothermia in order to resume activities with relative ease.
12. Furthermore, it is crucial for the patient to also exhibit an eagerness to participate in activities as this can help facilitate a speedy recovery.
13. Maintaining core temperature is an essential aspect of nursing interventions as the core temperature needs to remain within the normal range. Failure to do so can lead to hypothermia, causing a decrease in core temperature and resulting in severe health issues.
14. To help regulate temperature, nursing interventions such as regulation of the environment temperature as well as relocating the patient to a warmer setting can be utilized.
15. Additionally, it is important to keep the patient and linens dry at all times and control heat sources according to the patient’s physical response.
16. Keeping the core temperature within its normal range also involves providing extra coverage, such as clothing and blankets.
17. Besides passive warming, giving heated oral fluids for alert patients is recommended although extra heat sources should also be provided accordingly including a warm blanket, warm fluids, heat lamp, radiant warmers, warming pads, or mattresses even submersion in a warm bath should be considered if necessary.
18. Lastly, avoid manually rubbing, scrubbing, or massaging areas that are affected by frostbite due to exacerbating cold injuries which can further dip or decrease core temperature and blood pressure levels.
Desired Goals/Outcomes:
- The patient will maintain core body temperature within acceptable limits
- The patient will verbalize underlying reasons that contribute to signs of hyperthermia
- The patient will be clear of life-threatening consequences such as brain damage, heat fatigue, shallow breathing, or organ failure from overheating
References:
Wasserman DD, Creech JA, Healy M. Cooling Techniques For Hyperthermia. [Updated 2021 Aug 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459311/
Tanen, D. (2021, February). Malignant Hyperthermia. Merck Manual. https://www.merckmanuals.com/home/injuries-and-poisoning/heat-disorders/malignant-hyperthermia
Malignant Hyperthermia Association of the United States. (2018). What evidence-based interventions are recommended to alleviate hyperthermia associated with Malignant Hyperthermia? Malignant Hyperthermia Association of the United States.
https://www.mhaus.org/healthcare-professionals/mhaus-recommendations/what-evidence-based-interventions-are-recommended-to-alleviate-hyperthermia-associated-with-malignant-hyperthermia/
CDC. (2017, September 1). Warning Signs and Symptoms of Heat-Related Illness. Centers for Disease Control and Prevention. https://www.cdc.gov/disasters/extremeheat/warning.html
