Hypothermia

Nursing diagnosis Hypothermia

Domain 11. Safety-protection
Class 6. Thermoregulation
Diagnostic Code: 00006
Nanda label: Hypothermia
Diagnostic focus: Hypothermia

Nursing diagnosis hypothermia is a subcategory of nursing diagnosis that can affect patients who may be overly exposed to cold environments or suffer from low body temperatures, caused by some underlying medical condition. Nurses are responsible for recognizing the signs of hypothermia and providing necessary treatment and interventions to prevent further complications. This article will explain the definition and characteristics of nursing diagnosis hypothermia, at risk populations, associated conditions, suggested alternative NANDA nursing diagnoses, usage tips, and NOC outcomes and NIC interventions.

NANDA Nursing Diagnosis Definition

NANDA (National Advisory Council on Nursing Diagnosis) defines hypothermia as “a state in which core body temperature is below the normal range of 36.5 to 37.5 degrees Celsius (97.7-98.6 degrees Fahrenheit).” It is important for healthcare professionals to recognize signs of hypothermia, as untreated hypothermia can lead to severe health complications, including death.

Defining Characteristics list

Subjective Characteristics:

  • An individual may report feelings of lethargy and confusion.
  • A person may experience changes in mental status.
  • The patient may also feel cold to the touch.
  • In extreme cases, the person may display cerebral anoxia, frostbite, hypoglycemia and shock.

Objective Characteristics:

  • Shivering may be present.
  • Someone may display an abnormal pulse rate, as well as a decrease in blood pressure.
  • Skin may become pale and cool.
  • Respiration could be shallow and slow.
  • An individual may display irritability, difficulty thinking and decreased motor coordination.
  • Decreased urine output could be a sign of developing hypothermia.
  • Individuals may display non-febrile seizure activity as a result of hypothermia.

Related factors

There are certain factors related to hypothermia, such as age, alcohol use, exposure to cold temperatures, metabolic disorders, and certain drugs (such as barbiturates, anesthetics and narcotics) that can increase the risk of hypothermia. In addition, the elderly or people with poor physical stamina are at a higher risk for developing hypothermia.

At-risk population

Some groups of people are more likely to experience hypothermia than others. These include the elderly, children under five years of age, and people with chronic medical issues. Immigrants or refugees, who are unfamiliar with their new environment, particularly those who are unclothed or inadequately dressed, lack of shelter, and the homeless, are all considered at risk population.

Associated Conditions

Hypothermia can cause serious effects on a person’s metabolism, memory and cognition. It can lead to anorexia, apathy, confusion, depression, fatigue, impaired cognition and decision-making, and increased falls. Individuals are also at risk for developing arrhythmias, cardiac arrest, and pulmonary edema. Serious injuries that can occur as a result of hypothermia include brain swelling, organ failure, paralysis, and frostbite.

Suggestions of use

Nurses should assess possible underlying causes of hypothermia, such as illness, medication, alcohol and drug use, and environmental exposure. The nurse should also perform physical assessment to determine the core body temperature and to identify other associated signs and symptoms. In addition, nurses should educate patients on prevention and safety measures to avoid hypothermia.

Suggested alternative NANDA Nursing Diagnoses

  • Risk for Impaired Skin Integrity
  • Ineffective Tissue Perfusion
  • Impaired Memory
  • Impaired Swallowing
  • Decreased Cardiac Output
  • Disturbed Sleep Pattern

Usage Tips

It is important for nurses to perform regular, complete assessments on patients at risk for hypothermia to detect any changes in vital signs (pulse or temperature) and observe any abnormal behavior or speech. If hypothermia is suspected, nurses should discontinue any warm baths, hot water bottles and heat packs and provide a dry, warm environment, as well as dry clothing. If the patient is confused, reorient them to help reduce the risk of injury.

NOC Outcomes

Nurses should evaluate patients by monitoring the following NOC outcomes after providing nursing interventions.

  • Temperature Regulation: Maintaining body temperature within normal range.
  • Body Temperature: Controlling core body temperature.
  • Cardiac Output: Maintaining good heart rate and rhythm.
  • Safety: Preventing injury due to frigid environment or decreased body functions.
  • Energy Conservation: Reducing energy expenditure by controlling shivering.
  • Mobility: Moving freely and safely through supportive environment.

Evaluation Objectives and Criteria

Nurses should evaluate the effectiveness of interventions by determining if the patient has met the following criteria:

  • Patient has returned to a stable state (of body temperature and vital signs);
  • Patient can move freely and safely;
  • Patient is able to manage his or her own temperature regulation;
  • Patient can control his or her body temperature without external assistance;
  • Patient can move into a warmer environment safely.

NIC Interventions

Nurses should utilize the following interventions to treat hypothermia:

  • Hydration/Fluids: Administer warm fluids as needed to maintain normal hydration.
  • Physiologic Monitoring: Monitor core body temperature, heart and respiration rate, even when patient is stabilized.
  • Thermoregulation: Apply blankets and heating pads to warm patient’s body.
  • Positioning: Position patient in warm environment and avoid drafts.
  • Nutrition Support: Ensure patient has proper nutrition and balanced diet.
  • Pain Management: Provide medications to control shivering and pain if required.
  • Safety Promotion: Instruct patient and family on methods to prevent hypothermia.

Nursing Activities

Nurses should take the following steps to care for patients experiencing hypothermia:

  • Observe and monitor patient’s vital signs.
  • Provide hyperthermic management.
  • Initiate rapid rewarming techniques, such as placement of the patient in a warm bath, heating pads, and incubator.
  • Administer supplemental oxygen as needed.
  • Perform electrocardiograms, as needed.
  • Provide emotional support to patient and/or family.
  • Encourage sufficient rest in a comfortable, warm environment.

Conclusion

Nursing diagnosis hypothermia is serious medical condition that can endanger a patient’s life. It is important for nurses to recognize the signs of hypothermia and administer the appropriate interventions. Nurses should use the defining characteristics, alternative NANDA nursing diagnoses, NOC and NIC interventions discussed in this article to provide optimal patient care.

FAQs

  • What causes hypothermia? Possible causes of hypothermia include exposure to cold temperatures, metabolic disorders, alcohol, drug use, and chronic medical issues.
  • Who is at risk for hypothermia? People at risk for hypothermia are the elderly, children, immigrants, and those with chronic medical conditions.
  • What are some of the associated conditions of hypothermia? Some of the associated conditions of hypothermia include anorexia, apathy, confusion, depression, and fatigue.
  • What should nurses do to treat hypothermia? Nurses should provide a dry and warm environment and dry clothing for the patient, administer warm fluids, monitor vital signs, and utilize thermoregulation techniques like blankets and heating pads.
  • What are the NOC and NIC interventions for nursing diagnosis hypothermia? The NOC interventions for nursing diagnosis hypothermia include temperature regulation, body temperature, cardiac output, safety, energy conservation, and mobility. The NIC interventions include hydration/fluids, physiologic monitoring, thermoregulation, positioning, nutrition support, pain management, and safety promotion.