Hypothermia Nursing Care Plan
Normal body temperature is around 37 °C (98.6 °F). Hypothermia occurs as the body
temperature falls lower than normal; usually below 35 °C (95 °F). Hypothermia occurs when the
body fails to produce heat during metabolic processes, in cells that support vital body functions.
Most heat is lost from the skin’s surface through convection, conduction, radiation, and
evaporation. When the body temperature drops, the heart, nervous system, and other organs
can’t work normally leading to complete failure of the heart and respiratory system and eventually
to death.
Nursing Assessment
Assessment is required in order to distinguish possible problems that may have led to
Hypothermia.
Assessment Rationales
Assess for precipitating situations and risk Causative factors guide the appropriate
factors. treatment. Older patients have a decreased
metabolic rate and reduced shivering
response; therefore the effects of cold may
not be immediately manifested.
Note and monitor the patient's temperature. For alert patients, oral temperature is
regarded as more reliable than tympanic or
axillary. For hypothermic patients, core
temperature can be monitored using a
temperature-sensitive pulmonary artery
catheter or bladder catheter.
Monitor the patient’s HR, heart rhythm, and HR and BP drop as hypothermia progresses.
BP. Moderate to severe hypothermia increases
the risk for ventricular fibrillation, along with
other dysrhythmias.
Normal body temperature is around 37 °C (98.6 °F). Hypothermia occurs as the body
temperature falls lower than normal; usually below 35 °C (95 °F). Hypothermia occurs when the
body fails to produce heat during metabolic processes, in cells that support vital body functions.
Most heat is lost from the skin’s surface through convection, conduction, radiation, and
evaporation. When the body temperature drops, the heart, nervous system, and other organs
can’t work normally leading to complete failure of the heart and respiratory system and eventually
to death.
Nursing Assessment
Assessment is required in order to distinguish possible problems that may have led to
Hypothermia.
Assessment Rationales
Assess for precipitating situations and risk Causative factors guide the appropriate
factors. treatment. Older patients have a decreased
metabolic rate and reduced shivering
response; therefore the effects of cold may
not be immediately manifested.
Note and monitor the patient's temperature. For alert patients, oral temperature is
regarded as more reliable than tympanic or
axillary. For hypothermic patients, core
temperature can be monitored using a
temperature-sensitive pulmonary artery
catheter or bladder catheter.
Monitor the patient’s HR, heart rhythm, and HR and BP drop as hypothermia progresses.
BP. Moderate to severe hypothermia increases
the risk for ventricular fibrillation, along with
other dysrhythmias.
