00006 Hypothermia

Domain 11: security/protection
Class 6: thermoregulation
Diagnostic Code: 00006
Nanda label: hypothermia
Diagnostic focus: hypothermia
Approved 1986 • Revised 1988, 2013, 2017, 2020 • Evidence level 2.2

NANDA Nursing Diagnosis Definition

Nanda nursing diagnosis « hypothermia » is defined as: central body temperature lower than normal daytime range in individuals of> 28 days of life

Definite characteristics

  • distal cyanosis
  • Bradycardia
  • cyanosis of nail beds
  • Decrease in blood glucose level
  • Decrease in ventilation
  • Hypertension
  • Hypoglycemia
  • Hypoxia
  • Increase in the metabolic rate
  • Increase in oxygen consumption
  • Peripheral vasoconstriction
  • Piloerecion
  • Chills
  • cold skin to touch
  • Slow hair filling
  • Tachycardia

Related factors

  • Alcohol consumption
  • Heat transfer by excessive driving
  • Heat transfer by excessive convection
  • Heat transfer by excessive evaporation
  • Transfer of heat by excessive radiation
  • Inactivity
  • Inappropriate knowledge of the caregiver (a) about the prevention of hypothermia
  • Inappropriate dress
  • Low ambient temperature
  • Malnutrition

Risk population

  • People at economic disadvantage
  • People with extreme ages
  • People in weight

Associated problems

  • Hypothalamus injury
  • Decrease in the metabolic rate
  • Pharmacological preparations
  • Radiation therapy
  • Trauma

Suggestions of use

  • Since severe hypothermia (rectal temperature less than 35 ° C) can cause complications such as myocardial or respiratory alterations, these low readings should communicate to the doctor to establish collaboration interventions. Mild hypothermia (35-36 ° C) must respond to nursing interventions.

Suggested alternative diagnostics

  • Disorganized infant behavior, risk of
  • Body temperature, risk of alteration of
  • ineffective thermoregulation

NOC Results

  • Vital signs: To what extent the temperature, pulse, breathing and blood pressure are within normal values ??
  • Thermoregulation: balance between production, gain and heat loss
  • Thermoregulation: Neonate: Balance between production, gain and loss of heat during the first 28 days of life

Evaluation objectives and criteria

  • Also see the objectives and evaluation criteria for hyperthermia and for the risk of imbalance of body temperature.
  • The patient demonstrates thermoregulation, as stated by the following indicators (specify from L to 5: severe, substantial, moderate, light or none)
    • Reduction of cutaneous temperature
    • Changes in skin coloration
  • The patient demonstrates thermoregulation, as stated by the following indicators (specify from 1 to 5: severely, substantially, moderately, slightly or not compromised):
    • presence of chicken skin when it is cold
    • shocking if it is cold
    • Report thermal comfort

Other examples

The patient and family will be able to:

  • Describe measures to prevent or avoid reduction in body temperature
  • Report the early signs and symptoms of hypothermia
  • Maintain patient’s body temperature at at least 36 ° C (97 ° F)

The baby will be able to:

  • Take a posture to keep heat
  • Maintain blood glucose within normal limits
  • Do not remain in a lethargic state

NIC Interventions

  • Newborn control: measurement and interpretation of the physiological state of the neonate during the first 24 hours after childbirth
  • Newborn care: neonate management during transition to extrauterine life and the subsequent stabilization period
  • Temperature regulation: scope or maintenance of a body temperature within the normal range
  • Temperature regulation: Intraoperative: scope or maintenance of the desired body temperature during surgery
  • Treatment for hypothermia: reheating and surveillance of a patient whose central body temperature is below 35 ° C
  • Surveillance of vital signs: Collection and analysis of cardiovascular and respiratory data, as well as body temperature, to determine and prevent complications

Nursing Activities

  • See also nursing activities for the risk of alteration of body temperature.

Valuations

  • Register basal vital signs
  • Place the patient on a cardiac monitor
  • Use a low range thermometer, if necessary, to obtain an exact temperature
  • Evaluate hypothermia symptoms (such as changes in skin color, shuddering, fatigue, weakness, apathy, problems articulating words)
  • Evaluate medical problems that contribute to hypothermia (diabetes, mixedema)
  • (NIC) Temperature regulation:
    • Establish a continuous surveillance device of the central temperature, as required
    • Monitor the temperature at least every two hours, as required

Patient and family education

  • (NIC) Temperature regulation:
    • Teach the patient, especially the elderly, actions to prevent hypothermia for exposure to cold
    • Teach the hypothermia signs and the corresponding emergency treatment, if necessary

Collaboration activities

  • For severe hypothermia, help with central heating techniques (for example, hemodialysis, peritoneal dialysis, colon irrigation)

Others

  • Provide heat, dry clothes, hot blankets, mechanical heat devices, room temperature setting, hot water bottles, hot water immersion and hot liquids orally, if they are tolerated
  • Do not administer intramuscular medications (IM) or subcutaneous to a hypothermic patient
    • For a patient during surgery:
  • Regulate the room temperature to keep the patient’s heat
  • Cover the head and body parts of the patient that are exposed
  • Watch the blood before administering it
  • Cover the patient with a hot blanket for transport after surgery

At home

  • Check that there is a thermometer at home, that someone can read it and that it is accurate
  • Teach the patient or his family to take the temperature
  • (NIC) Temperature regulation:
    • Teach the patient, especially to older patients, actions to prevent hypothermia caused by exposure to cold
    • Teach the signs of hypothermia and the corresponding emergency treatment, if necessary

Babies and Children

  • Keep the room temperature above 22.2 ° C (72 ° F)
  • Keep baby’s clothes dry; change wet clothes as soon as possible
  • (NIC) Temperature regulation:
    • Control the neonate temperature until it stabilizes
    • Wrap the neonate in a blanket immediately after birth to avoid heat loss
    • Place an elastic hat to prevent the loss of heat from the newborn
    • Place the newborn in an incubator isolette or under the heater, as needed

Older people

  • Maintain the room temperature above 21.l ° C (70 ° F); Older people are prone to heat loss, so the operating room temperature must rise before surgery
  • Advise patients who wear warm clothes if it is not possible to raise the room temperature (even jacket, hat and gloves if necessary)
  • Evaluate carefully if the patient presents confusion, as well as the reduction of the level of consciousness; It is likely that older people do not shiver or complain about feeling cold