Hypothermia
Hypothermia
(_)Actual (_) Potential
| (_) CNS
pathology (_) Decreased ability to shiver (_) Exposure to the cold (_) Impaired physical environment (_) Other:_____________________________ ____________________________________ ____________________________________ |
| 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
