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:_____________________________ ____________________________________ ____________________________________

**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:________________
________________________
________________________
________________________

__________________________
Patient/Significant other signature

__________________________
RN signature

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