Hypothermia

Published on Saturday March 10th , 2007

Hypothermia

(_)Actual (_) Potential

Related To:
[Check those that apply]
(_) CNS pathology
(_) Decreased ability to shiver
(_) Exposure to the cold
(_) Impaired physical environment
(_) Other:_____________________________
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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:________________
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Patient/Significant other signature

 

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RN signature