This nursing care plan and diagnosis with nursing interventions is for the following conditions: Hypothermia, Low Body Temperature, Inablility to Regulate Body Temperature.
What are nursing care plans? How do you develop a nursing care plan? What nursing care plan book do you recommend helping you develop a nursing care plan?
This care plan is listed to give an example of how a Nurse (LPN or RN) may plan to treat a patient with those conditions.
Important Disclosure: Please keep in mind that these care plans are listed for Example/Educational purposes only, and some of these treatments may change over time. Do not treat a patient based on this care plan.
Care Plans are often developed in different formats. The formatting isn’t always important, and care plan formatting may vary among different nursing schools or medical jobs. Some hospitals may have the information displayed in digital format, or use pre-made templates. The most important part of the care plan is the content, as that is the foundation on which you will base your care.
Nursing Care Plan for: Hypothermia, Low Body Temperature, Inability to Regulate Body Temperature.
If you want to view a video tutorial on how to construct a care plan in nursing school, please view the video below. Otherwise, scroll down to view this completed care plan.
Scenario: |
A 56 year old female is being admitted to your ICU unit. The patient is coming to you from the PACU. You received in report from the PACU nurse that the patient had surgery on her right hip for a repair after a fall she sustained from her patio balcony. The surgical dressing is clean, dry, and intact. An abductor pillow is being used and pulses in feet are palpable. The PACU nurse informs you that the patient was going to be transferred to a progressive care unit but the patient has become unstable and need close monitoring that is available in the ICU. The PACU nurse states that the patient has been unable to regulate her own body temperature and her current temperature in 94.4 degrees. A bear hugger blanket is being used. The patient is extremely drowsy and confused and the nurse has been unsuccessful in getting the patient to fully wake up from the anesthesia. Pt HR is 50-55 bpm and BP 80/42. Pt is currently on a Dopamine gtt at 30 mcg/min. RR 12 and O2 Sat 95% on a 50% ventimask.
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Nursing Diagnosis: |
Hypothermia related to surgery as evidence reduction of body temperature of 94.4 degrees, mental confusion, drowsiness, and decreased pulse and respirations. |
Subjective Data: |
The PACU nurse informs you that the patient was going to be transferred to a progressive care unit but the patient has become unstable and need close monitoring that is available in the ICU. PACU nurse states that the patient has been unable to regulate her own body temperature and her current temperature in 94.4. A bear hugger blanket is being used. The patient is extremely drowsy and confused and the nurse has been unsuccessful in getting the patient to fully wake up from the anesthesia. |
Objective Data: |
A 56 year old female is being admitted to your ICU unit. The patient is coming to you from the PACU. Pt HR is 50-55 bpm and BP 80/42. Pt is currently on a Dopamine gtt at 30 mcg/min. RR 12 and O2 Sat 95% on a 50% ventimask.
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Nursing Outcomes: |
-Pt’s temperature will between 98.2-98.6 degrees within 12 hours from arrival to ICU unit.-Pt’s HR will be 60-100 bpm and BP SBP 100-130 within 6 hours from arrival to ICU unit.-Pt will be able to verbalized self, place, and time within 12 hours from arrival to ICU unit. |
Nursing Interventions: |
-The nurse will assess every hour patient’s temperature and report any temperature less than 95 degrees to the doctor for further orders.-The nurse will assess HR and BP every 15 minutes. -The nurse will administer warming intravenous fluids per md order.-The nurse will assess patient’s room temperature every 2 hours and will keep patient’s room temperature between 70-74 degrees.
-The nurse will use the bear hugger warming blanket system per hospital protocol and md order. |