Nursing Diagnosis - Hypothermia : Definition, Related Factors, Outcomes and Interventions


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
Expected Outcomes:
  1. Body temperature in the normal range
  2. Pulse and respiratory rate are in the normal range

NIC:
Temperature Regulation
  1. Monitor temperature at least every 2 hours.
  2. Plan temperature monitoring continuously.
  3. Blood pressure monitor, pulse, and respiratory rate.
  4. Monitor skin color and temperature.
  5. Monitor signs of hyperthermia and hypothermia.
  6. Increase intake of fluids and nutrients.
  7. Cover the patient to prevent loss of body warmth.
  8. Teach patients how to prevent heat fatigue.
  9. Discuss the importance of regulating temperature and the possible negative effects of cold.
  10. Notify about indications of fatigue and emergency handling needed.
  11. Teach indications of hypothermia and necessary treatment.
  12. Give antipyretics if necessary.

Vital Sign Monitoring
  1. Monitor blood pressure, pulse, temperature, and respiratory rate.
  2. Note blood pressure fluctuations.
  3. Monitor vital signs when the patient is lying down, sitting or standing.
  4. Auscultate blood pressure in both arms and compare.
  5. Monitor BP, pulse, RR, before, during, and after activity.
  6. Monitor pulse quality.
  7. Monitor the frequency and rhythm of breathing.
  8. Monitor lung sounds.
  9. Monitor abnormal breathing patterns.
  10. Monitor skin temperature, color and moisture.
  11. Monitor peripheral cyanosis.
  12. Monitor for cushing triad (widening pulse pressure, bradycardia, increased systolic).
  13. Identify the causes of vital sign changes.


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