1. HYPOTHERMIA THERMOREGULATION

2. Hypothermia Learning Outcomes 1. Describe the pathophysiology, etiology, clinical manifestations, and direct and indirect causes of hypothermia. 2. Identify risk factors associated with hypothermia. 3. Apply the nursing process in providing culturally competent care across the life span for individuals with hypothermia. 4. Discuss therapies used in the collaborative care of an individual with hypothermia. 5. Identify and employ evidence-based interventions for an individual with hypothermia.

3. Question One The nurse is assessing a three week old infant, and recognizes which finding as an early sign of hypothermia? 1. The infant is shivering. 2. Rectal temperature is 33° celsius. 3. Skin is cool to touch and pale. 4. Rapid and slightly labored respirations.

4. Question 2 What is a priority nursing intervention for a nurse caring for a premature infant born at 32 weeks gestation? 1. Provide a neutral thermal environment. 2. Promote bonding between infant and parents. 3. Teach parents regarding newborn care. 4. Administer immunizations to the newborn.

5. Question 3 While obtaining the admission history for an 80-year-old client admitted to the medical unit, the nurse learns that the client keeps the thermostat in the home at 64° in order to cut the cost of the monthly heating bill. What should the nurse include in the teaching plan for this client? 1. Importance of always keeping the thermostat set on 74°F. 2. Referral to social services for assistance with resources. 3. Assessment for hypothermia. 4. Strategies to reduce the risk of hypothermia

6. Question 4 The nurse is teaching a client who will be undergoing heart open surgery about what to expect when waking up from anesthesia. The nurse explains the client will experience feeling cold, which is induced during surgery. The client asks the nurse why they induce cold. What is the best response by the nurse? 1. “Inducing a cold environment will make the surgery go faster.” 2. “It will decrease the amount of bleeding during surgery.” 3. “It will reduce the demand for tissue oxygenation.” 4. “It will decrease symptoms related to anesthesia.”

7. Hypothermia Overview Key Points Condition in which the core body temperature falls below 36° C Condition in which the core body temperature falls below 36° C Occurs when the heat the body produces is less than the heat lost Occurs when the heat the body produces is less than the heat lost Can be a life-threatening emergency, and can occur in any season and any geographic location Can be a life-threatening emergency, and can occur in any season and any geographic location

8. Hypothermia Pathophysiology and Etiology Hypothermia Pathophysiology and Etiology  Induced Hypothermia − Deliberately lowering body temperature, reducing body’s need for oxygen − Deliberately lowering body temperature, reducing body’s need for oxygen  Accidental − Result of immersion in cold water, exposure − Result of immersion in cold water, exposure  As body’s core temperature falls − Body tries to conserve core temperature at the expense of extremities − Body tries to conserve core temperature at the expense of extremities

9. Hypothermia Pathophysiology and Etiology Routes of Heat Loss Routes of Heat Loss − Internal core to body surface − Internal core to body surface − External surface to environment − External surface to environment Core Temperature – usually higher than skin Core Temperature – usually higher than skin − Continuous transfer, conduction of heat − Continuous transfer, conduction of heat − Greater the difference in temperature the more rapidly heat transfers − Greater the difference in temperature the more rapidly heat transfers − Transfer through increased O2 consumption − Transfer through increased O2 consumption − Depletion of glycogen stores, brown fat − Depletion of glycogen stores, brown fat

10. Hypothermia Pathophysiology and Etiology Induced Hypothermia Induced Hypothermia − Reduced metabolic rates − Reduced metabolic rates − Lower cellular demand for O2 in tissues − Lower cellular demand for O2 in tissues − Used to reduce neurological damage − Used to reduce neurological damage − Sequelae from post-cardiac arrest, lessen anoxia − Sequelae from post-cardiac arrest, lessen anoxia − Initiated with iced saline gastric lavage − Initiated with iced saline gastric lavage  Goal  client temperature of 33°  Goal  client temperature of 33°  Stop all potassium administration during rewarming  Stop all potassium administration during rewarming  Sedation, paralytic medications  Sedation, paralytic medications

11. Hypothermia Pathophysiology and Etiology Accidental Hypothermia Accidental Hypothermia − Exposure to cold environment − Exposure to cold environment − Immersion in cold water − Immersion in cold water − Lack of adequate clothing, shelter, heat − Lack of adequate clothing, shelter, heat − Associated with near drowning − Associated with near drowning − Other causes: − Other causes:  Ingestion of alcohol, drugs, trauma  Ingestion of alcohol, drugs, trauma  Overwhelming sepsis  Overwhelming sepsis

12. NEWBORN Large body surface area in relation to mass Large body surface area in relation to mass Limited insulating subcutaneous fat Limited insulating subcutaneous fat Loses 4 times more heat than adult Loses 4 times more heat than adult Poor thermal stability Poor thermal stability Radiation and convection losses Radiation and convection losses Thermal conduction Thermal conduction − Marked difference between core and skin temperature − Marked difference between core and skin temperature − Cool environment  peripheral vasodilation − Cool environment  peripheral vasodilation

13. NEWBORN, continued Thermogenisis Thermogenisis − Increased metabolic rate − Increased metabolic rate − Muscular activity − Muscular activity − Nonshivering thermogenisis (NST) − Nonshivering thermogenisis (NST)  Skin receptors  Skin receptors  Brown adipose tissue (BAT) – brown fat  Brown adipose tissue (BAT) – brown fat − NST from BAT primary source of heat − NST from BAT primary source of heat Shivering – rare in newborn Shivering – rare in newborn

14. NEWBORN, continued The distribution of brown adipose tissue (brown fat) in the newborn

15. NEWBORN, continued BAT depleted  metabolic response limited BAT depleted  metabolic response limited Keeping newborn warm Keeping newborn warm − Promotes normal oxygen requirements − Promotes normal oxygen requirements − Chilling can cause respiratory distress signs and symptoms − Chilling can cause respiratory distress signs and symptoms − Preterm infant may be unable to increase ventilation − Preterm infant may be unable to increase ventilation − Need extra protection from mild variations − Need extra protection from mild variations

16. Body Temperature Stability Newborn < children < adolescents, adults Newborn < children < adolescents, adults Elderly Elderly − More sensitive than middle-age adults − More sensitive than middle-age adults − Decreased thermoregulatory control − Decreased thermoregulatory control − Loss of subcutaneous fat − Loss of subcutaneous fat − Environmental factors − Environmental factors − Illness − Illness − CNS disorder − CNS disorder

17. FROSTBITE Injury of skin resulting from freezing Injury of skin resulting from freezing − If limited exposure  skin, subcutaneous tissue involvement − If limited exposure  skin, subcutaneous tissue involvement − Increased exposure  deeper structures freeze − Increased exposure  deeper structures freeze − Skin freezes when temperature drops to 21°C-24°C − Skin freezes when temperature drops to 21°C-24°C − Occurs most commonly on exposed and peripheral areas − Occurs most commonly on exposed and peripheral areas

18. FROSTBITE, continued As tissue freezes As tissue freezes − Ice crystals form − Ice crystals form − Small vessels vasoconstrict then vasodilate − Small vessels vasoconstrict then vasodilate Continued exposure  vasoconstriction Continued exposure  vasoconstriction Superficial frostbite Superficial frostbite − Numbness, itching, prickling sensation − Numbness, itching, prickling sensation − Cyanotic, reddened, white − Cyanotic, reddened, white Deeper frostbite  paresthesias and stiffness Deeper frostbite  paresthesias and stiffness

19. FROSTBITE, continued Thawing of tissues Thawing of tissues − Skin white or yellow − Skin white or yellow − Loses elasticity − Loses elasticity − Burning pain − Burning pain − Edema, blisters − Edema, blisters − Necrosis, gangrene − Necrosis, gangrene Rapid thawing may significantly decrease tissue necrosis Rapid thawing may significantly decrease tissue necrosis

20. Risk Factors Older adult Infants, young children Adolescents Damage to hypothalamus Decreased ability to shiver Decreased basal metabolic rate Evaporation from skin in cool environments Exposure to cool environments

21. Risk Factors, continued Acute or chronic illness Acute or chronic illness Inactivity Inactivity Inadequate clothing Inadequate clothing Malnutrition Malnutrition Medications Medications Trauma Trauma Hypothyroidism Hypothyroidism Immaturity of newborn Immaturity of newborn

22. Clinical Manifestations Mild Hypothermia (34°-36°C ) Mild Hypothermia (34°-36°C )  Fatigue  Fatigue  Slurred speech  Slurred speech  Poor coordination and clumsiness  Poor coordination and clumsiness  Confusion and poor judgment  Confusion and poor judgment  Inappropriate behavior  Inappropriate behavior  Shivering  Shivering  Tachycardia and tachypnea  Tachycardia and tachypnea

23. Clinical Manifestations, continued Moderate Hypothermia (30°-34 °C) Moderate Hypothermia (30°-34 °C)  Depressed mental state  Depressed mental state  No shivering  No shivering  Depressed respirations  Depressed respirations  Slow pulse or irregular heart rate  Slow pulse or irregular heart rate  Hypotension  Hypotension  Pale or cyanotic skin  Pale or cyanotic skin  Hallucinations  Hallucinations  Coma  Coma

24. Clinical Manifestations, continued Severe or Profound Hyperthermia (<30°C) Severe or Profound Hyperthermia (<30°C)  Absence of respirations and pulse  Absence of respirations and pulse  Ventricular fibrillation  Ventricular fibrillation  Dilated and unresponsive pupils  Dilated and unresponsive pupils  Coma  Coma

25. Clinical Management Collaboration Primary Prevention Primary Prevention * Reduce Risk Factors * Reduce Risk Factors * Educate regarding avoidance to exposure and extreme temperatures * Educate regarding avoidance to exposure and extreme temperatures * Provide adequate resources * Provide adequate resources - Environmental control and shelter - Environmental control and shelter - Appropriate clothing - Appropriate clothing

26. Clinical Management Collaboration Primary Prevention Primary Prevention - Physical activity - Physical activity - Social services – assess parent’s ability to meet needs, financial constraints, homelessness - Social services – assess parent’s ability to meet needs, financial constraints, homelessness - Free clinics - Free clinics - Manufacturing prescription programs - Manufacturing prescription programs - Schools - Schools

27. Clinical Management Collaboration, continued Secondary Prevention Secondary Prevention - Identify underlying cause - Identify underlying cause - Provide comfort - Provide comfort - Monitor vital signs closely - Monitor vital signs closely - Cardiorespiratory monitor - Cardiorespiratory monitor - Temperature regulation - Temperature regulation - Prevent complications - Prevent complications

28. Clinical Management Collaboration, continued Tertiary Prevention Tertiary Prevention - Remove from cold - Remove from cold - Provide warm environment – dry clothes - Provide warm environment – dry clothes - Warming blankets - Warming blankets - Administer warm oral fluids - Administer warm oral fluids - Keep limbs close to body - Keep limbs close to body

29. Clinical Management Collaboration, continued Tertiary Prevention Tertiary Prevention - Cover scalp with blanket or cap - Cover scalp with blanket or cap - Apply warming pads to axillae, groin, forehead, and nape of neck - Apply warming pads to axillae, groin, forehead, and nape of neck - Supply warm oral or intravenous fluids - Supply warm oral or intravenous fluids - Warm fluid gastric lavage - Warm fluid gastric lavage

30. Clinical Management Collaboration, continued Tertiary Prevention, continued Tertiary Prevention, continued - Rapidly rewarm affected areas in circulating warm water, 104°-105° F (40-40.5°C) for 20 to 30 minutes - Rapidly rewarm affected areas in circulating warm water, 104°-105° F (40-40.5°C) for 20 to 30 minutes - Following rewarming, keep on bedrest with affected areas elevated - Following rewarming, keep on bedrest with affected areas elevated - Avoid rubbing or massaging affected areas - Avoid rubbing or massaging affected areas - Heated humidified oxygen - Heated humidified oxygen - Administer analgesics and anti-inflammatory agents - Administer analgesics and anti-inflammatory agents

31. Clinical Management Collaboration, continued Tertiary Prevention, continued Tertiary Prevention, continued - Debride blisters - Debride blisters - Whirlpool therapy to clean skin and debride necrotic tissue - Whirlpool therapy to clean skin and debride necrotic tissue - Support respiratory and cardiac function - Support respiratory and cardiac function - Reduce handling to decrease risk of cardiac fibrillation - Reduce handling to decrease risk of cardiac fibrillation - Hemodialysis and/or peritoneal dialysis - Hemodialysis and/or peritoneal dialysis

32. Nursing Process ASSESSMENT Body Temperature – below normal range Body Temperature – below normal range Cool skin Cool skin Cyanotic nail beds, slow capillary refill Cyanotic nail beds, slow capillary refill Blood pressure Blood pressure Pallor Pallor Piloerection and shivering Piloerection and shivering Tachycardia Tachycardia

33. Nursing Process DIAGNOSIS Imbalanced Body Temperature, Risk for Imbalanced Body Temperature, Risk for Ineffective Thermoregulation Ineffective Thermoregulation Hypothermia Hypothermia Impaired Skin Integrity, Risk for Impaired Skin Integrity, Risk for

34. Nursing Process PLANNING Prevention is a primary nursing goal: Prevention is a primary nursing goal: - Thermoregulation: Balance among heat production, heat gain, and heat loss - Thermoregulation: Balance among heat production, heat gain, and heat loss - Thermoregulation in Neonate: Balance among heat production, heat gain, and heat loss during the first 28 days of life - Thermoregulation in Neonate: Balance among heat production, heat gain, and heat loss during the first 28 days of life - Vital Signs: Temperature is within normal range - Vital Signs: Temperature is within normal range

35. Nursing Process IMPLEMENTATION All Clients All Clients - Remove from cold, rewarming - Remove from cold, rewarming - Mild hypothermia → warm with blankets - Mild hypothermia → warm with blankets - Severe hypothermia → Hypothermic blanket - Severe hypothermia → Hypothermic blanket - Warm IV fluids - Warm IV fluids - Dry clothing - Dry clothing - Monitor vital signs, urine output - Monitor vital signs, urine output - Assess for cold-related injuries - Assess for cold-related injuries

36. Nursing Process IMLEMENTATION: NEWBORN Newborns Newborns - Transfer to NICU - Transfer to NICU - Critical in very-low-birth-weight infants - Critical in very-low-birth-weight infants - Polyethylene wrapping - Polyethylene wrapping - Head coverings - Head coverings - Swaddling, nesting - Swaddling, nesting - Observe for signs of cold stress - Observe for signs of cold stress

37. Nursing Process IMLEMENTATION : NEWBORN, continued Newborns, continued Newborns, continued ■ Signs of cold stress ■ Signs of cold stress - Increased movement, respirations - Increased movement, respirations - Decreased skin temperature, peripheral perfusion - Decreased skin temperature, peripheral perfusion - Development of hypoglycemia - Development of hypoglycemia Result of metabolic effects of cold stress Result of metabolic effects of cold stress Glucometer values Glucometer values

38. Nursing Process IMLEMENTATION: NEWBORN, continued Newborns, continued Newborns, continued ■ Hypothermia in newborn ■ Hypothermia in newborn - Maintain neutral thermal environment - Maintain neutral thermal environment - Warm newborn slowly - Warm newborn slowly - Increase air temperature 1°C/hour until stable - Increase air temperature 1°C/hour until stable - Monitor skin temperature every 15-30 minutes - Monitor skin temperature every 15-30 minutes - Remove plastic wrap caps, while rewarming - Remove plastic wrap caps, while rewarming - Warm IV fluids before infusing - Warm IV fluids before infusing - Block heat loss - Block heat loss

39. Nursing Process IMLEMENTATION: CHILDREN Teach Parents Teach Parents - Layer children’s clothing, hats in cold climates - Layer children’s clothing, hats in cold climates - Recognizing signs of hypothermia - Recognizing signs of hypothermia - Decrease time of exposure to cold temperatures - Decrease time of exposure to cold temperatures - Know how to treat mild hypothermia - Know how to treat mild hypothermia Teach School-age, Adolescents Teach School-age, Adolescents - Recognize and manage hypothermia in self, others - Recognize and manage hypothermia in self, others - Prevention techniques - Prevention techniques

40. Nursing Process IMLEMENTATION: CHILDREN, continued First Aid First Aid - Move to dry area - Move to dry area - Remove wet clothing - Remove wet clothing - Protect from further environmental exposure - Protect from further environmental exposure - Wrap in dry clothing - Wrap in dry clothing - Encourage to drink warm high calorie liquid - Encourage to drink warm high calorie liquid

41. Nursing Process IMPLEMENTATION: OLDER ADULTS The older adult is less able to maintain internal temperature Similar to treatment at any age Similar to treatment at any age Assess for other risk factors: Assess for other risk factors: - Nutritional status - Nutritional status - Home environment - Home environment - Financial concerns - Financial concerns - Self-care deficits - Self-care deficits

42. Nursing Process EVALUATION No piloerection or shivering No piloerection or shivering Maintain core temperature within normal ranges Maintain core temperature within normal ranges Report thermal comfort Report thermal comfort Describe adaptive measures Describe adaptive measures - Minimize fluctuations in body temperatures - Minimize fluctuations in body temperatures - Report early signs and symptoms - Report early signs and symptoms

43. Learning Activity Break up into small groups (2 to 4 students). Develop a plan of care for preventing hypothermia for one of the following clients: A premature newborn A premature newborn A term newborn A term newborn An elderly man An elderly man A homeless woman living in a city with a cold climate A homeless woman living in a city with a cold climate