Circumstances where an individual experiencing or at risk of decreased body temperature constantly below 35, 5 º C per-rectal because of the increased vulnerability to external factors.
Situational (personal, environmental)
- related to the heat, rain, wind
- related to clothes that do not fit with the climate
- related to decreased circulation: extreme weight loss
- related to alcohol consumption
- related to dehydration
- related to inactivity
- Temperatures below 35.5 º C per-rectal
- Cold skin
- Pallor (medium)
- Chills (mild)
- Mental disorder / sleepy / restless
- Decrease in pulse and respiration
- Cachexia / malnutrition
- Identifying risk factors for hypothermia.
- Connecting method of maintaining the warmth / heat loss prevention.
- Maintain body temperature within normal limits.
Nursing Interventions - Nursing Care Plan for Hypothermia :
- Teach clients to reduce exposure to the cold environment of the old.
- Explain to family members that neonates, infants and the elderly are more susceptible to heat loss.
- Teach early signs of hypothermia: skin cold, pale, shivering.
- Explain the need to drink 8-10 glasses of water each day
- Explain the need to avoid alcohol in very cold weather.
- Teach for extra wear.