Hypothermia

Nursing Diagnosis Definition

The nursing diagnosis for hypothermia is defined as "abnormally low body temperature." This diagnosis is applicable when a patient's core body temperature falls below the normal range of 36-37 degrees Celsius (96.8-98.6 degrees Fahrenheit).

Defining Characteristics

Subjective

• Patient reports feeling cold: Subjective complaint of a cold sensation.
• Patient reports shivering: Subjective expression of shivering.
• Patient reports decreased mental status or confusion: Subjective observation of altered mental status.

Objective

• Core body temperature less than 36 degrees Celsius (96.8 degrees Fahrenheit): Objective measurement of low core body temperature.
• Shivering: Observable shivering in response to cold.
• Pale, cool, or cyanotic skin: Observable changes in skin color associated with hypothermia.
• Decreased pulse rate or blood pressure: Objective signs of decreased cardiovascular function.
• Decreased mental status or confusion: Observable signs of altered mental status.

Related Factors

• Exposure to cold temperatures: Being in a cold environment leading to heat loss.
• Immersion in cold water: Submersion in cold water causing rapid body temperature decrease.
• Insufficient clothing or shelter: Lack of protective clothing or shelter contributing to heat loss.
• Chronic illness or disease: Underlying health conditions impacting thermoregulation.
• Medications that affect thermoregulation: Pharmaceutical agents influencing temperature regulation.
• Alcohol or drug use: Substances affecting the body's ability to regulate temperature.

Risk Population

• Individuals at risk for hypothermia include those who are exposed to cold temperatures, such as outdoor workers or hikers, as well as those who are immersed in cold water, such as swimmers or boaters. Additionally, individuals with chronic illnesses or diseases, those taking medications that affect thermoregulation, and those who use alcohol or drugs are at risk.

Associated Problems

• Hypothermia can lead to a variety of health problems, including:
• Cardiac Arrhythmias: Abnormal heart rhythms may develop due to the impact of low body temperature on the cardiovascular system.
• Respiratory Failure: Severe hypothermia can compromise respiratory function, leading to inadequate oxygen exchange in the lungs.
• Coagulopathies: Abnormal blood clotting may occur, increasing the risk of bleeding or clot-related complications.
• Neurological Damage: Prolonged exposure to low temperatures may result in damage to the nervous system, affecting cognitive and motor functions.
• Death: In extreme cases, untreated or severe hypothermia can be fatal.

Suggestions for Use

• Assess the patient's body temperature and other vital signs: Regularly monitor core body temperature and vital signs.
• Identify any factors that may be contributing to the patient's hypothermia, such as exposure to cold temperatures or chronic illness: Investigate and address potential causes of hypothermia.
• Implement interventions to raise the patient's core body temperature and prevent further heat loss: Utilize warming measures to counteract hypothermia.
• Monitor the patient's response to interventions and adjust as needed: Continuously evaluate the effectiveness of interventions and make necessary modifications.
• Provide education and resources to the patient and their family about preventing hypothermia and recognizing the signs and symptoms: Educate patients and families on preventive measures and symptoms of hypothermia.

Suggested Alternative Diagnoses

• Hypothermia, Accidental: This diagnosis is used when hypothermia occurs unintentionally due to environmental exposure or inadequate protective measures.
• Hypothermia, Intentional: Applies when an individual deliberately induces hypothermia, which may be associated with self-harm or certain therapeutic interventions.
• Hypothermia, Risk For: Indicates a vulnerability to developing hypothermia based on specific risk factors, such as exposure to cold environments or compromised thermoregulatory mechanisms.
• Impaired Thermoregulation: This diagnosis is made when there is a dysfunction in the body's ability to maintain a stable core temperature, leading to an increased risk of hypothermia or hyperthermia.
• Impaired Temperature Regulation: Similar to impaired thermoregulation, this diagnosis encompasses conditions where the body struggles to regulate temperature effectively, contributing to the risk of abnormal body temperature.

Usage Tips

• Be aware of the patient's risk factors and environment, such as cold temperatures or immersion in cold water: Consider contextual factors influencing hypothermia.
• Monitor the patient's vital signs, including body temperature, to detect hypothermia early: Regularly assess vital signs to identify hypothermia promptly.
• Use warming blankets and/or warm fluids to raise the patient's core body temperature: Employ warming measures for effective temperature elevation.
• Consider the use of rewarming methods, such as a warm bath or extracorporeal rewarming, in severe cases of hypothermia: Employ advanced rewarming techniques in critical hypothermic cases.

NOC Results

• Thermoregulation: Continuous monitoring of the patient's temperature will be performed, and interventions will be implemented to maintain a normal body temperature.
• Cardiac Output: Regular monitoring of the patient's cardiac output will be conducted to ensure it is not compromised due to hypothermia.
• Respiratory Status: Ongoing assessment of the patient's respiratory status will be carried out to prevent any compromise due to hypothermia.
• Coagulation: The patient's coagulation status will be continuously monitored to prevent any compromise due to hypothermia.
• Neurological Status: Regular monitoring of the patient's neurological status will be conducted to ensure it is not compromised due to hypothermia.

NIC Interventions

• Warming Therapy: The patient will receive warming therapy, such as warming blankets or warm fluids, to raise their core body temperature effectively.
• Rewarming Methods: If necessary, the patient will receive rewarming methods, such as a warm bath or extracorporeal rewarming, to address severe hypothermia.
• Monitoring and Assessment: The patient's vital signs and response to interventions will be closely monitored and assessed to ensure appropriate management.
• Education and Resources: The patient and their family will be provided with education and resources regarding preventing hypothermia and recognizing the signs and symptoms for proactive health management.