HHC Health & Home Care Clinical Policy And

HHC HEALTH & HOME CARE Section: 14-31
Emergency: Hypothermia __RN
PURPOSE:
To identify patients with hypothermia and prevent further
decrease in core body temperature.
CONSIDERATIONS:
1. Identifiable signs of hypothermia are:
Confusion
Disorientation
Slurred speech
Low blood pressure
Weak pulse
Trembling on one side of body
Does not feel the cold
Hard to arouse
Shallow, weak breathing
Puffy face, waxy, oddly pink at times
Muscle tightening
Difficulty in moving
2. Those most at risk are the elderly, very young, and
already ill individuals.
3. Specific situations and disorders predispose anyone
to accidental hypothermia.
a. Individuals with decreased ability to produce
body heat.
Examples: malnutrition
hypothyroidism
Parkinson's disease
b. Individuals with increased heat loss.
Examples: prolonged exposure to cold
acute ethanol intoxication
c. Individuals with impaired thermoregulation.
Examples: brain damage
central nervous system
depression (drugs)
4. Moderate to severe hypothermia is defined as a
core body temperature of 89.6 degrees F (32
degrees C) to 77 degrees F (25 degrees C); mild
hypothermia is 89.6 - 95 degrees F (32 - 35 degrees
C). Note: Temperature below 34 degrees C cannot
be measured with an ordinary thermometer.
5. Patients in deep hypothermia may not exhibit
detectable signs of life, however, warming
procedure is indicated.
6. Special precautions are required for the moderate to
severe hypothermia victim to minimize cardiac
dysrhythmias.
EQUIPMENT:
Blankets
PROCEDURE:
1. Adhere to Universal Precautions.
2. Observe patient and environment to identify signs of
hypothermia.
3. Take vital signs. Before starting CPR check victim’s
pulse for up to 45 seconds.
4. Initiate cardiopulmonary resuscitation, if indicated.
5. Obtain immediate emergency medical care.
6. Remove cold or wet clothing. Keep patient dry.
7. Never rub the injured area; this aggravates tissue
damage.
8. Wrap patient in blankets, handling gently to
minimize cardiac dysrhythmia.
9. Hot water bottles, heating pads (if the victim is dry)
or other heat sources can help re-warm the body.
Apply heat sources only to the trunk, at the armpits
and groin. Keep a barrier between the heat source
and victim to avoid burning. Do not warm victim too
quickly, rapid re-warming can cause dangerous
heart rhythms. If victim fully conscious may give
hot, nonalcoholic, non-caffeinated liquids.
10. Continue observing patient and warming procedure
until medical assistance is obtained.
AFTER CARE:
1. Document in patient's record:
a. Incident, degree of injury, and environment.
b. Estimated length of time exposed to cold
environment.
c. Treatment provided.
d. Patient's response to treatment.
e. Medical assistance obtained.
f. Communication with patient’s physician.
2. Report patient status to nursing supervisor.
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