Nursing care of the patient with hypothermia

Set of activities performed by the nurse in warming and monitoring a patient whose core body temperature is below 35°C.

Objective:

To apply physical means and administer medication to get the patient’s temperature to rise to its normal value.

Equipment:

– Clinical thermometer. – Blanket. – Electric blanket. – Bed linen. – Hot water bottle. – Heat source.

Material:

– Hot drinks. – Compresses. – Prescribed medication. – Nursing records.

Procedure:

– Perform hand washing. – Prepare the material. – Preserve the patient’s privacy. – Inform the patient. – Ask the patient and family to cooperate. – Remove the patient from the cold and place him/her in a warm environment. If necessary, increase the room temperature. – Keep the patient’s bed linen clean and dry, as well as any dressings, bandages or diapers he/she may be wearing. – Monitor the patient’s temperature. – Assess the presence of symptoms associated with hypothermia such as fatigue, weakness, confusion, apathy, impaired coordination, shivering, cyanosis, etc. – Assess the level of consciousness. – Assess the patient’s thermoregulation. – Determine the factors that led to the hypothermic episode.

– Apply physical means: blanket, electric blanket, heat source, warm compresses, hot water bottle. – Maintain adequate fluid intake to avoid dehydration and thus heat loss. Provide hot beverages that do not contain caffeine. – Administer prescribed medication, which may be to infuse intravenous fluids at a temperature of 37-40 degrees. – Monitor the skin and take extreme measures to prevent pressure ulcers. – Monitor temperature, heart rate, respiratory rate, blood pressure and urine output as frequently as assessed by the nurse. – Collect the material. – Perform hand washing. – Record in nursing documentation: status of thermoregulation, procedures performed, date and time, constants, incidents and patient response.

Observations:

– Physical media should not be applied directly to the skin; place bed linen between them and the patient. – Monitor exposure time to physical means to avoid burns.