About
Core body temperature is less than 35 decrees Celsius or 95 decrees Fahrenheit because of exposure to cold or inability to maintain body temperature.
Assess
Temperature, arrhythmias, weak pulses/ blood pressure, hypoxemia, drowsiness, disorientation, lethargy, pulmonary edema, slow movement, acid-base disturbances, increased clotting ability, coma.
Complications
Burns from equipment, coma, metabolic acidosis, ventricular dysrhythmias, death
Diagnosis
Hypothermia related to exposure to elements.
Risk for injury related to life-threatening condition.
Goals
- The client will have a temperature within normal range.
- The client will remain free from injury.
Interventions
- Monitor pulse-oximetry, telemetry, vital signs, ABG's, electrolytes, Intake and output, body temperature continuously. May need arterial Line to monitor blood pressures continuously.
- Remove all wet clothes, cold conducting surfaces from patient body.
- May need cardiopulmonary bypass, humidified warmed oxygen, and warmed peritoneal lavage; prepare patient as indicated.
- Administer warmed IV fluids as indicated.
- Apply warming blankets as indicated.
- Administer sodium bicarbonate as metabolic acidosis occurs with rewarming.
- Administer antiarrhythmic medications as indicated.
- Keep record of strict I & O's. Insert indwelling urinary catheter.
- Monitor in critical care setting during re-warming.
- Keep defibrillator near in case of spontaneous stretches of ventricular dysrhythmias.
ليست هناك تعليقات:
إرسال تعليق