Hypothermia
(_)Actual (_)
Potential
(_) CNS pathology (_) Decreased ability to shiver (_) Exposure to the cold (_) Impaired physical environment |
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: (_) Other: |
(_) Assess temperature q ___ hours. (_) Asses for possible etiology of (_) Keep room (_) Aply extra (_) Use warming (_) Provide (_) Rewarm patient (_) Teach patient to (_) ________________________ |
__________________________
Patient/Significant other signature
__________________________
RN signature