00006 Hypothermia

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00006 Hypothermia

Definition of the NANDA label

Hypothermia is the state in which the body temperature falls below normal limits.

Core body temperature below the normal diurnal range due to failure of thermoregulation.

Defining characteristics

  • Reduction of body temperature below normal limits.
  • Mild chills.
  • Skin coldness.
  • Moderate paleness.
  • Slow capillary filling.
  • Cyanosis of the nail bed.
  • Tachycardia.
  • Hypertension.
  • Piloerection.

Neonates

  • Infant with insufficient energy to maintain sucking – Infant with insufficient weight gain (< 30 g/day) – Irritability
  • Jaundice
  • Metabolic acidosis
  • Pallor
  • Respiratory distress

Related factors

  • Exposure to a cold environment.
  • Illness or trauma.
  • Injury affecting the function of the hypothalamus.
  • Malnutrition.
  • Absence or decrease in the ability to produce chills.
  • Inappropriate clothing for the ambient temperature.
  • Alcohol consumption.
  • Vasodilator drugs.
  • Loss of heat by skin evaporation due to cold environment.
  • Decreased metabolism.
  • Inactivity.
  • Old age.

Neonates

  • Delay in breastfeeding
  • Early bathing of newborn
  • Increase in oxygen demand

At risk population

  • Economically disadvantaged
  • Extremes of age
  • Extremes of weight
  • High-risk out-of-hospital birth
  • Increased body surface area to weight ratio
  • Insufficient supply of subcutaneous fat
  • Unplanned out-of-hospital birth

Associated condition

  • Damage to hypothalamus
  • Immature stratum corneum
  • Increase in pulmonary vascular resistance (PVR)
  • Ineffective vascular control
  • Inefficient nonshivering thermogenesis
  • Pharmaceutical agent
  • Radiation therapy
  • Trauma

NOC

  • Thermoregulation.
  • Thermoregulation: neonate.

NIC

  • Vital signs monitoring.
  • Temperature regulation.
  • Temperature regulation: intraoperative.
  • Treatment of hypothermia.
  • Newborn care
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