Hypothermia Risk

Introduction for Nursing Diagnosis

Hypothermia risk is one of the nursing diagnoses developed by the North American Nursing Diagnosis Association (NANDA). Hypothermia is the act of cooling down the body temperature of a patient to level below normal temperature. Hypothermia treatments include a variety of interventions that range from simple prevention measures such as avoiding cold environments to aggressive treatment methods. All of these treatments are intended to protect the patient’s health, prevent hypothermia and reduce the severity of any existing symptoms.

Nursing Diagnosis Definition

Hypothermia Risk, as defined by NANDA, is “vulnerability to abnormally low body temperature.” This nursing diagnosis is applicable to individuals of all ages who may be exposed to extreme temperatures or have certain impairments that increase the risk of hypothermia.

Defining Characteristics

Subjectives:

• Oversensitivity to cold
• Cold skin
• Frequent shivering
• Cold extremities

Objectives:

• Disturbed sleep pattern
• Decreased level of consciousness
• Tachycardia
• Tachypnea

Related Factors

• Inadequate nutrition
• Deficient external insulation
• Inadequate sunlight exposure
• Inability to detect changes in environment
• Limited mental capacity
• Exposure to cold environment

Explanation: These factors either predispose individuals to risks of hypothermia or contribute to impairments that can lead to hypothermia.

Risk Population

• Newborn infants
• Elderly residents of nursing homes
• Undernourished children
• Mentally handicapped individuals
• Homeless persons

Explanation: These populations are more likely to suffer from hypothermia due to physiological, psychological, social and environmental reasons.

Associated Problems

• Respiratory failure
• Hypoglycemia
• Cardiorespiratory arrest
• Loss of consciousness

Explanation: These are some of the conditions associated with hypothermia. These problems can worsen if the patient’s temperature continues to drop.

Suggestions of Use

• Monitoring vital signs
• Encouraging fluid intake
• Using layering techniques for clothes
• Covering larger body parts
• Providing appropriate shelter

Explanation: These interventions can help reduce the patient's risk of hypothermia, as well as prevent further deterioration of existing conditions.

Suggested Alternative Nursing Diagnoses

• Ineffective airway clearance
• Hypothermia
• Impaired gas exchange
• Imbalanced temperature regulation
• Risk for infection, airway

Explanation: These are alternative nursing diagnosis which are closely related to hypothermia risk diagnosis.

Usage Tips

• Diagnose hypothermia risk before assessing interventions.
• Carefully assess physical and environmental factors that can lead to hypothermia.
• Consider the medical, social and psychological factors of the patient.
• Educate the patient and family on ways of preventing hypothermia.
• Develop an individualized treatment plan based on patient needs.

NOC Outcomes

• Temperature Regulation: Ability to maintain an optimal body temperature
• Thermoregulation: Ability to maintain body temperature within normal parameters
• Activity Tolerance: Ability to perform activity without discomfort
• Nutrition: Intake of adequate nutrients to meet metabolic needs
• Self-care: Ability to attend to hygiene, nutrition and other activities of daily living

Explanation: These are the outcomes it is expected to achieve when diagnosing and treating the patient with hypothermia risk.

NIC Interventions

• Assistive Technology: Assistive devices to facilitate performance of activities
• Case Management: Coordination/integration of care to meet patient’s needs
• Environmental Management: Assistive strategies to modify surroundings
• Nutritional Support: Provision of food to meet patient’s requirements
• Thermoregulation: Intervention to regulate thermic balance of the body

Explanation: These are the interventions used in the management of hypothermia risk.

Conclusion

Hypothermia Risk is a nursing diagnosis developed by the North American Nursing Diagnosis Association (NANDA). It is applicable to individuals of all ages who may be exposed to extreme temperatures or have certain impairments that increase the risk of hypothermia. With proper assessment and treatment, a patient can be protected from the negative effects of hypothermia. Nurses must develop an individualized treatment plan based on the patient’s needs in order to provide effective care.

FAQ

• What is hypothermia risk?
• Hypothermia risk is vulnerability to abnormally low body temperature.
• Who is at risk of hypothermia?
• Newborn infants, elderly residents of nursing homes, undernourished children, mentally handicapped individuals, and homeless persons are more likely to suffer from hypothermia.
• What interventions are effective in managing hypothermia risk?
• Interventions such as monitoring vital signs, encouraging fluid intake, using layering techniques for clothes, covering larger body parts, providing appropriate shelter, and assisting with thermoregulation can help reduce the patient’s risk of hypothermia.