NANDA Nursing Diagnosis: Risk Of Perioperative Hypothermia
Perioperative hypothermia is a serious risk that is experienced by patients during operations and post-operative care. NANDA nursing diagnosis is the standardized language used to record patient’s medical data, and should be familiar to health care professionals.
NANDA Nursing Diagnosis Definition
The NANDA International (NANDA-I) nursing diagnosis is defined as “at risk for a decrease in body temperature below the normal range.” the NANDA-I includes this diagnostic label as a risk factor. This diagnostic label means increased risk of hypothermia in the perioperative period.
- Excessive shivering
- Abdominal pain
- Anxiety or fear
- Discoloration of skin
- Weak peripheral pulses
- Gastrointestinal upset
- Slowed cognition
- Decreased core body temperature
- Slow, shallow respirations
- Delayed wound healing
- Dry, pale skin
- Decreased bowel functions
- Muscular rigidity
- Decreased urine output
- Hair loss
- Excessive blood, tissue and fluid losses
- Inadequate warm air temperature
- Cold environment
- Extended anesthesia and surgery
- Post-operative infections
- Insufficient number of staff members during anesthesia and postsurgical recovery period
- Elderly patients
- Patients with insufficient body fat
- Patients undergoing major surgeries
- Patients undergoing cyberknife or cryosurgery
- Patients on drugs such as β-blockers, antidepressants and psychotropic medications
- Respiratory system impairment
- Electrolyte disturbances
- Myocardial injury
- Gastrointestinal ileus
- Delayed responses to medications
- Kidney damage
- Brain damages
Suggestions of Use
- Allow unimpeded use of ultra-warm wet packs
- Provide water and warm blankets
- Administer appropriate nutrients
- Frequent monitoring of temperature
- Keep the air humidified
- Maintain patient warmth through efficient use of overhead heat lamps and/or forced hot-air blankets
Suggested Alternative NANDA Diagnoses
- Impaired Skin Integrity
- Risk for Infection
- Disturbed Sleep Pattern
- Ineffective Thermoregulation
- Risk for Complications of Peripheral Venous Disease/Pressure Ulcers
- Risk for Shock
- Monitor vital signs to detect any fluctuations in temperature.
- Check the skin for signs of discoloration or pallor.
- Increase the patient’s oral intake of liquids and other warm beverages.
- Administer fluids and electrolytes as ordered.
- Assist with positioning and turning to prevent morbidity and pressure points.
- Encourage family members to stay with the patient and talk to help distract them from feeling cold.
- Body Temperature: Patient’s core body temperature remains within appropriate ranges.
- Cardiac Output: Patient maintains an adequate cardiac output to meet metabolic needs.
- Nutrition: Patient receives adequate nutrition for proper thermoregulation.
- Integument integrity: Patient exhibits intact and functional skin.
- Thermoregulation: Patient demonstrates an ability to regulate body temperature.
- Bubble Bath: Soaking the patient in a warm bubble bath.
- External Heat Source: Utilizing lights and forced hot-air blankets to maintain an appropriate core body temperature.
- Oral Hydration: Providing the patient with warm liquids through the oral route.
- Positioning: Repositioning the patient to ensure proper circulation and removal of heat.
- Fluid Replacement Therapy: Providing intravenous fluids to maintain adequate hydration.
- Skin Care: Inspecting and maintaining the patient’s skin integrity.
Conclusion & FAQ
Perioperative hypothermia can have a potentially profound and even fatal effect on a patient, so it is important for nurses to understand NANDA nursing diagnosis and related interventions. Nurses need to be aware of the high-risk factors and take preventive measures to ensure that patients remain within the normal temperature range.
FAQs: 1) What is the definition of NANDA nursing diagnosis? NANDA nursing diagnosis is the standardized language used to record patient’s medical data. 2) What are some risk populations prone to perioperative hypothermia? Elderly patients, newborns, patients with insufficient body fat, patients undergoing major surgeries and patients on specific medications are prone to perioperative hypothermia. 3) What are the possible associated problems due to perioperative hypothermia? Respiratory system impairment, electrolyte disturbances, myocardial injury, gastrointestinal ileus, delayed responses to medication, kidney damage and brain damage.