Use this guide to create a nursing care plan and nursing interventions for hypothermia.
What is Hypothermia?
Normal body temperature is around 37 °C (98.6 °F). Hypothermia occurs as the body temperature falls lower than normal; usually below 35 °C (95 °F). Hypothermia occurs when the body fails to produce heat during metabolic processes, in cells that support vital body functions. Most heat is lost from the skin’s surface through convection, conduction, radiation, and evaporation. When the body temperature drops, the heart, nervous system, and other organs can’t work normally leading to complete failure of the heart and respiratory system and eventually to death.
Goals and Outcomes
Here are the common goals and expected outcomes for Hypothermia nursing diagnosis.
- The patient will maintain a body temperature within the normal limit (97.7°F to 99.5°F/ 36.5°C to 37.5°C).
- The patient’s cognitive function and vital signs will improve, including heart rate, blood pressure, and respiratory rate.
- The patient will verbalize understanding of the early signs of hypothermia such as shivering, pale or cool skin, fatigue or drowsiness, confusion, and disorientation.
- The patient will identify measures to prevent the recurrence of hypothermia.
- The patient will not experience complications of hypothermia such as cardiac arrest, respiratory failure, and organ damage.
Nursing Assessment and Rationales
Assessment is required in order to distinguish possible problems that may have lead to Hypothermia.
1. Assess for precipitating situations and risk factors.
Causative factors guide the appropriate treatment. Older patients have a decreased metabolic rate and reduced shivering response; therefore the effects of cold may not be immediately manifested.
2. Note and monitor the patient’s temperature.
For alert patients, the oral temperature is regarded as more reliable than tympanic or axillary. For hypothermic patients, the core temperature can be monitored using a temperature-sensitive pulmonary artery catheter or bladder catheter.
3. Monitor the patient’s HR, heart rhythm, and BP.
HR and BP drop as hypothermia progresses. Moderate to severe hypothermia increases the risk for ventricular fibrillation, along with other dysrhythmias.
4. Evaluate the patient for drug abuse use, including antipsychotics, opioids, and alcohol.
These groups of drugs contribute to vasodilation and heat loss.
5. Evaluate the patient’s nutrition and weight.
Poor nutrition contributes to decreased energy reserves and restricts the body’s ability to generate heat by caloric consumption.
6. Assess the patient’s peripheral perfusion at frequent intervals.
Hypothermia initially precipitates peripheral vascular constriction as a compensatory mechanism to minimize heat loss from extremities. The patient’s skin will look pale and cool to the touch with a delayed capillary refill. As hypothermia advances, vasodilation transpires, furthering heat loss. The patient’s skin becomes warm and less pale. The patient may start to remove clothing and bed covers.
7. 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.
8. Check for electrolytes, arterial blood gases, and oxygen saturation by pulse oximetry.
Acidosis may emerge from hypoventilation and hypoxia.
9. Evaluate for the presence of frostbite, if the patient has had prolonged exposure to a cold environment.
Severe hypothermia generates ice crystals to form inside cells. The cells eventually burst and die.
10. Assess the patient’s readiness to reach a toileting facility, both independently and with assistance.
This allows the nurse to plan for assistance.
11. Assess the patient’s typical pattern of urination and occurrence of incontinence.
This information is the source for an individualized toileting program.
Nursing Interventions and Rationales
The following are the therapeutic nursing interventions for Hypothermia:
1. Regulate the environment temperature or relocate the patient to a warmer setting. Keep the patient and linens dry.
These methods provide for a more gradual warming of the body. Rapid warming can induce ventricular fibrillation. Moisture promotes evaporative heat loss.
2. Control the heat source according to the patient’s physical response.
Body temperature should be raised no more than a few degrees per hour. Vasodilation occurs as the patient’s core temperature increases leading to a decrease in BP. Hypotension, metabolic acidosis, and dysrhythmias are complications of rewarming.
3. Give extra covering (passive warming), such as clothing and blankets; cover postoperative patients with heat-retaining blankets.
Warm blankets provide a passive method for rewarming.
4. Provide warmed fluids such as tea or soup for alert patients.
Warm fluids produce a heat source.
5. Provide extra heat source:
- Heat lamp, radiant warmer
- Warming pads, mattresses, or blankets
- Submersion in a warm bath
- Heated, moisturized oxygen
- Warmed intravenous fluids or lavage fluids
These measures raise the core temperature and improve circulation. Core warming is indicated when body temperature is below 30 °C (86 °F).
6. Avoid manually rubbing, scrubbing, or massaging areas of frostbite.
Rubbing can further damage frozen tissue.
7. Administer oxygen as indicated.
Providing oxygenation to patients with hypothermia can help to maintain adequate oxygen levels in the blood, avoid further complications, and support the body’s overall function during the hypothermic state.
8. Explain all procedures and treatments to the patient and SO.
Repeated explanations are needed to avoid confusion.
Recommended nursing diagnosis and nursing care plan books and resources.
Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care
We love this book because of its evidence-based approach to nursing interventions. This care plan handbook uses an easy, three-step system to guide you through client assessment, nursing diagnosis, and care planning. Includes step-by-step instructions showing how to implement care and evaluate outcomes, and help you build skills in diagnostic reasoning and critical thinking.
Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition)
Includes over two hundred care plans that reflect the most recent evidence-based guidelines. New to this edition are ICNP diagnoses, care plans on LGBTQ health issues and on electrolytes and acid-base balance.
NANDA International Nursing Diagnoses: Definitions & Classification, 2021-2023
The definitive guide to nursing diagnoses is reviewed and approved by the NANDA International. In this new version of a pioneering text, all introductory chapters have been rewritten to provide nurses with the essential information they need to comprehend assessment, its relationship to diagnosis and clinical reasoning, and the purpose and application of taxonomic organization at the bedside. A total of 46 new nursing diagnoses and 67 amended nursing diagnostics are presented.
Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales
Quick-reference tool includes all you need to identify the correct diagnoses for efficient patient care planning. The sixteenth edition includes the most recent nursing diagnoses and interventions from NANDA-I 2021-2023 and an alphabetized listing of nursing diagnoses covering more than 400 disorders.
Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care
Identify interventions to plan, individualize, and document care for more than 800 diseases and disorders. Only in the Nursing Diagnosis Manual will you find for each diagnosis…. subjectively and objectively – sample clinical applications, prioritized action/interventions with rationales – a documentation section, and much more!
All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health
Includes over 100 care plans for medical-surgical, maternity/OB, pediatrics, and psychiatric and mental health. Interprofessional “patient problems” focus familiarizes you with how to speak to patients.
Other recommended site resources for this nursing care plan:
- Nursing Care Plans (NCP): Ultimate Guide and Database MUST READ!
Over 150+ nursing care plans for different diseases and conditions. Includes our easy-to-follow guide on how to create nursing care plans from scratch.
- Nursing Diagnosis Guide and List: All You Need to Know to Master Diagnosing
Our comprehensive guide on how to create and write diagnostic labels. Includes detailed nursing care plan guides for common nursing diagnostic labels.