Hypothermia: Heat loss during prolonged exposure to cold overwhelms the body ability to produce heat causing hypothermia. Hypothermia is classified as follows:
Classification of hypothermia
Mild 33 - 36º F 91.4º - 96.8º
Moderate 30 -33º 86.0º - 91. 4º
Severe 27 - 30º 80.6º - 86.0º
Profound < 30º < 80.6º
Frost bits occurs when the body is exposed to subnormal temperature. Ice crystals farming inside the cell result in permanent circulatory and tissue damage. Areas at risk for frost bite are the carlobes, tip of the nose and fingers and toes. The injured area is white, waxy and firm to touch.
Sites for assessing temperature
4. tympanic route
Nursing care of individual with altered body temperature Hyperthermia - Assessment
1. obtain all vital signs
2. observe skin color
observe for shivering are diaphoresis
Non - pharmacological therapy are methods that increase heat loss by evaporation, convection conduction or reduction.
Tepid sponge bathes
Bathing with alcohol - water solution
Allow rest period
Limit physical activity
Reduce external covering on patient' s body to promote heat
loss through reduction and conduction.
Provide fluids (atleast 3 litres per day) to replace fluids loss.
Encourage oral hygiene because oral mucous membranes dry easily from dehydration.
Provide measures to stimulate appetite and offer well balanced meals.
Provide supplemental oxygen therapy as ordered to improve oxygen delivery to body cells.
Control environmental temperature without inducing
shivering. Eg. Cooling fans
Prevention is the key for patient' s at risk for hypothermia and frostbite.
Educate patient who are at risk for hypothermia (Eg. the very young, the very old, persons debilitated by trauma, stroke, diabetes, drug or alcohol intoxication, sepsis, mentally ill, alcohol intoxication, malnutrition).
Prevent a further decrease in body temperature.
Remove wet clothes, provide dry ones and wrap the client in blanket.
If the patient is conscious offer warm liquids such as milk or soups
Place the patient in a warm room
When the patient reaches emergency treatment, patients are closely monitored for cardiac irregularities and electrolyte imbalances.