Actual (_) Date________ Time _______ Potential (_) Date________ Time _______

Diagnosis No:

Patient Label

Nursing Diagnosis: Hypothermia

Related to:
(_) CNS pathology (_) Illness (_) Trauma (_) Aging (_) Medication (vasodilators) (_) Malnutrition (_) Cool/cold environment (_) Inadequate clothing (_) Decreased ability to shiver (_) Epidural anaesthesia (_) Decreased metabolic rate (_) Inactivity (_) Other: __________________________________________ (_) Other: __________________________________________ (_) Other: __________________________________________

As evidenced by:
(_) Body temperature below ____________ degree Celsius (_) Tachycardia, tachypnea, increased BP (mild hypothermia) (_) Mental confusion/restlessness/decrease level of consciousness (_) Decreased pulse, respirations, BP (moderate/severe hypothermia (_) Cachexia (_) Slow capillary refill (_) Cyanotic nail beds (_) Coma (_) Cool skin (_) Shivering (_) Anuria/oliguria (_) Other: __________________________________________ (_) Other: __________________________________________

Patient Plan & Outcome (Goal)

Start Date, Time, Sign & Employee # Patient Plan & Outcome (Goal) The patient will: (_) Maintain vital signs within acceptable ranges (_) Exhibit no complication from hypothermia (_) Be awake, alert, and oriented, with no alteration in abilities (_) Other: Plan & Outcome Target Date Plan & Outcome Met/partially met/not met Date, Time, Sign, Emp. #

As Evidenced By:
(_) Temperature between (_) Heart rate between _______ - _______ _______ - _______ (_) Level of consciousness score greater than _____________ using ______________ scale (_) (_) (_)

(_) Respiration rate between _______ - _______ (_) Blood pressure between _______ - _______ Date: Reason for goal partially met/not met:

__________ _____________________________________________________________________________________ __________ _____________________________________________________________________________________ __________ _____________________________________________________________________________________

Guide: Place a in (_) to indicate the related to and evidenced by information you have gathered from your patient assessment, and to activate a goal and intervention. When a goal has been met sign off in the appropriate column. If the goal has only been partially met or not met at all, sign off in the appropriate column and specify the date and reason in the appropriate box below the table. If an intervention has been discontinued sign it off in the appropriate column. This will clearly indicate that the intervention is no longer relevant.

NURSINGDIAGNOSISHYPOTHERMIA

Page1of3

Patient Label Interventions

Intervention Start Date & Time

NDx: Hypothermia
Interventions (_) Assess vital signs every _________hours and PRN _________hours and PRN _________hours and PRN (_) Monitor neurologic status (coma scale) every _________hours and PRN _________hours and PRN _________hours and PRN (_) Monitor ECG for heart rhythm changes as per physician order (_) Complete focused neurological assessment every __________ hours and PRN (_) Monitor for signs of coagulopathy (_) Monitor and record intake and output every _________hours _________hours _________hours (_) Maintain warm ambient room temperature (_) Keep patient dry, and cover head/neck to reduce heat loss (_) Monitor and assess effects of epidural anaesthesia using Adult Epidural Analgesia Treatment Sheet and report abnormal findings (_) Keep patient covered with blankets whenever possible during procedures, transport, and diagnostic testing (_) For neonates Kangaroo Mother Care/Skin to Skin contact uninterrupted for a least one hour Place baby skin to skin and prone between mothers breasts wearing only a diaper Wrap mother and baby together to improve and maintain babys temperature Mother sits or lies down quietly with minimal sound or movement Fathers can also do Kangaroo Care (_) Early and frequent breastfeeding or expressed breast milk via cup (_) If not breastfeeding then give an appropriate alternative feed as ordered by the physician (_) Assess and monitor neonates blood sugar levels (_) Provide extra heat source: (_) Heat lamp (_) Warming mattress, pads, blanket (_) Submersion in warm bath (_) Other: ____________________________________ (_) Rewarm patient gradually, 1degree Celsius per hour, to prevent the complication of rapid rewarming (hypotension) (_) Minimize factors that contribute to hypothermia (_) For pregnant or laboring women monitor fetal heart and contractions by Electronic Fetal Monitoring, and report findings (_) Intermittent every ____________ hour (_) Continuous (_) Fetal heart rate by Doppler (_) Encourage warm oral intake ______________mls/day ______________mls/day ______________mls/day (_) Use warmed solutions for any lavage procedures (_) Administer warm intravenous fluid/blood via blood warming device as per physician order (_) Administer warm humidified oxygen as per physician order (_) Monitor blood lab work as per physician order, especially coagulation screen (_) Notify physician immediately for any deterioration from baseline monitoring Discontinued Interventions Date, Time, Sign, Emp. #

NURSINGDIAGNOSISHYPOTHERMIA

Page2of3

Patient Label Interventions

Intervention Start Date & Time

NDx: Hypothermia
Interventions Referrals: (_) Dietician (_) Other: _______________________ Patient/family/carer education: Date of referral ________________ Date of referral ________________ Discontinued Interventions Date, Time, Sign, employ #

(_) How to take a temperature accurately in the home (age appropriate) (_) How to prevent and recognize hypothermia (_) When to seek medical advice

(_) For patients in the antenatal or postpartum period emphasize the significance including as relevant but not limited to: (_) Signs of labor (_) Ruptured membranes (_) Vaginal loss or discharge (_) Pain (_) Signs and symptoms of infection (_) Breastfeeding Other education:

(_) Other:

Documentation on HIS

Note: This is a legal document and must be filed in the patient history
References: www.rncentral.com/nursing-library/careplans, Ackley.B, & Ladwig G.B. (2008) Nursing Diagnosis Handbook: An evidenced based guide to planning care 8th Edition, Mosby Elsvier January 2010

NURSINGDIAGNOSISHYPOTHERMIA

Page3of3