Hypothermia

Published on Monday October 12th , 2009

Hypothermia

(_)Actual (_)
Potential

Related
To:
[Check
those that apply]
(_) CNS
pathology
(_) Decreased ability to shiver
(_) Exposure to the cold

(_) Impaired physical environment
(_) Other:_____________________________
____________________________________
____________________________________

 

As
evidenced by:
[Check
those that apply]
Major:

(Must be
present)		 (_)
Reduction in body temperature below 35 C (95 F) orally,
or 35.5 C (96 F) rectally.
(_) Cool skin (_) Moderate pallor (_) Shivering (mild)
Minor:

(May be
present)		 (_)
Mental confusion/drowsiness/restlessness
(_) Decreased pulse and respirations (_)
Cachexia/malnutrition

 

Date &

Sign.

 Plan and Outcome
[Check
those that apply]		 Target
Date:		 Nursing Interventions
[Check
those that apply]		 Date
Achieved:
  The
patient will:

(_)
Maintain normal body temperature.

Other:

   (_)
Assess temperature q ___ hours.

(_) Asses for possible etiology of
hypothermia.

(_) Keep room
temperature between 70-74 F.

(_) Aply extra
blankets.

(_) Use warming
blanket per physician’s order to maintain normal body
temperature.

(_) Provide
intravenous solutions through a blood warmer per
physician’s order.

(_) Rewarm patient
gradually to prevent complications of rapid rewarming.

(_) Teach patient to
avoid extremes of cold weather and to dress adequately
when exposed to cold.

(_)
Other:________________
________________________

________________________
________________________

  

 

__________________________
Patient/Significant other signature

 

__________________________
RN signature