Core body temperature below the normal diurnal range in individuals > 28 days of life

Acrocyanosis

Bradycardia

Cyanotic nail beds

Decreased blood glucose level

Decreased ventilation

Hypertension

Hypoglycemia

Hypoxia

Increased metabolic rate

Increased oxygen consumption

Peripheral vasoconstriction

Piloerection

Shivering

Skin cool to touch

Slow capillary refill

Tachycardia

NANDA-I approved*

Situational (Personal, Environmental)

Related to:

Excessive conductive heat transfer*

Excessive convective heat transfer*

Excessive evaporative heat transfer*

Excessive radiative heat transfer*

Exposure to cool environment (e.g., surgical suite)

Low environmental temperature*

Evaporation from skin in cool environment (e.g., during bathing, surgery)

Inadequate clothing*

Inability to pay for shelter or heat

Malnutrition*

Related to decreased circulation secondary to:

Extremes of weight

Alcohol consumption*

Dehydration

Inactivity*

Related to inadequate caregiver knowledge of hypothermia prevention*

Maturational

Related to ineffective temperature regulation secondary to age (e.g., neonate, older adult)

Economically disadvantaged individuals

Individuals at extremes of age

Individuals at extremes of weight

Damage to hypothalamus

Decreased metabolic rate

Pharmaceutical preparations

Radiotherapy

Trauma

AUTHOR"S NOTE

Because more serious hypothermia (temperatures below 95° F or 35° C rectally) can cause severe pathophysiologic consequences, such as decreased cardiovascular and/or respiratory function, the nurse must report low readings to the physician/physician assistant/nurse practitioner. This is a collaborative problem: Risk for Complications of Hypothermia. Nurses most often initiate nurse-prescribed interventions for mild hypothermia (temperatures between 95° F [35° C] and 97° F [36° C] rectally) to prevent more serious hypothermia. Nurses are primarily responsible for identifying and preventing Risk for Hypothermia. See also Ineffective Thermoregulation.

The individual will maintain body temperature WNL evidenced by the following indicators:

• Identifies risk factors for hypothermia
• Reduces risk factors for hypothermia

Level 1 Fundamental Focused Interventions (all nonacute settings)

Assess for Risk Factors

• Refer to Related Factors.

Reduce or Eliminate Causative or Contributing Factors, If Possible

Prolonged Exposure to Cold Environment

• Assess room temperatures at home.
• Teach to keep room temperatures at 70° F to 75° F (21.1° C to 23.9° C) or to layer clothing.
• Explain the importance of wearing a hat, gloves, warm socks, and shoes to prevent heat loss.
• Discourage going outside when temperatures are very cold.
• Acquire an electric blanket, warm blankets, or down comforter and flannel sheets for the bed.
• Teach to wear close-knit undergarments to prevent heat loss.
• Explain that more clothes may be needed in the morning when body metabolism is lowest.

R:Individuals can rewarm themselves even when extremely hypothermic (*Nicoll, 2002).

• Consult with social services to identify the sources of financial assistance, warm clothing, blankets, and shelter.
• Teach the importance of preventing heat loss before body temperature is actually lowered (e.g., warm socks, sweaters, gloves, and hats).

R:Minimizing evaporation, convection, conduction, and radiation can prevent significant heat losses.

Initiate Health Teaching If Indicated

Teach the signs of hypothermia (Zafren & Mechem, 2021).

• (Early)
  • Cool skin
  • Pallor
  • Blanching
  • Redness
  • Slurred speech
  • Confusion
  • Mild hypothermia - Core temperature 32°C to 35°C (90°F to 95°F)
  • Moderate hypothermia - Core temperature 28° C to 32° C (82° F to 90° F)
• (Later)
  • Confusion or sleepiness
  • Slowed, slurred speech or shallow breathing
  • Weak pulse
  • Change in behavior or in the way a person looks
  • Severe shivering or no shivering;
  • Stiffness in the arms or legs
  • Poor control over body movements or slow reactions
  • Severe hypothermia - Core temperature <28° C (82°F)
• Explain the need to drink 8 to 10 glasses of water daily unless instructed to limit fluid intake and to consume frequent, small meals with warm liquids.
• Explain the need to avoid alcohol during periods of very cold weather.

R:Early detection of hypothermia can prevent tissue damage.

• For additional information on preventing hypothermia, refer older adults and their families to www.nia.nih.gov/health/publication/hypothermia#signs
• Low-income home energy assistance program, National Energy Assistance Referral Hotline (NEAR), 1-866-674-6327 (toll-free), www.acf.hhs.gov/programs/ocs/liheap

Pediatric and Geriatric Interventions

For Older Adults:

• Maintain room temperature at 70° F to 74° F (21.1° C to 23.3° C).
• Instruct the adult individual to wear hat, gloves, and socks if necessary to prevent heat loss.
• Explain to family members that older adults are more susceptible to heat loss (see also Ineffective Thermoregulation).

R:Older adults can become hypothermic or hyperthermic in moderately cold or hot environments, compared with younger adults, who require exposure to extreme cold or heat (Miller, 2019).