Nursing Care Plan Presentation

hodgieRN · Oct 30, 2012

The blue nail and lips is awesome btw! They should get a kick out it! After taking her temp, you can emphasize stacking blankets one by one. Maybe mention you're going to hang warmed IV fluids. Say "Hey...it seems cool in here. Let me turn up the thermostat!" We use warming blankets at the hospital, so you could say her temp could benefit from it as you pretend to plug it in and roll her back and forthto get the warming sheet underneath her (and mention it's important not to warm her up too quick). Maybe talk about why hypothermia causes people to look blue (blood pullling away from skin to send it to more vital organs.) At the end, when she warms up, have her throw on red lipstick!

Esme12, ASN, BSN, RN · Oct 30, 2012

Ok...you have chosen hypothermia.......

How is hypothermia related to illness? How is shivering related to the hypothermia? What is hypothermia? What are the causes of hypothermia? What caused your patients hypothermia? What are the treatments for hypothermia? What are some accepted standard re-warming techniques? What does NANDA say about hypothermia?

NANDA-I Definition: Body temperature below normal range

Hypothermia is a temperature at a significantly lower level than normal; usually lower than 35° C (95° F) measured by the tympanic/rectal routes. Hypothermia results when the body cannot produce heat at a rate equal to that lost to the environment through conduction, convection, radiation, or evaporation. Core temperature below 32° C (89.6° F) is severe and life threatening. Hypothermia can be classified as inadvertent (seen postoperatively), intentional (for medical purposes), or accidental (exposure related). Older adults are especially vulnerable to accidental hypothermia because of age-related alterations in normal thermoregulation (Gulanick: Nursing Care Plans, 7th Edition)

What are the defining characteristics? What are the relating factors?

Hypothermia is a medical emergency that occurs when your body loses heat faster than it can produce heat, causing a dangerously low body temperature. Normal body temperature is around 98.6 F (37 C). Hypothermia (hi-po-THUR-me-uh) occurs as your body temperature passes below 95 F (35 C).
When your body temperature drops, your heart, nervous system and other organs can't work correctly. Left untreated, hypothermia can eventually lead to complete failure of your heart and respiratory system and to death.
Hypothermia is most often caused by exposure to cold weather or immersion in a cold body of water. Primary treatments for hypothermia are methods to warm the body back to a normal temperature.(Hypothermia - MayoClinic.com)

Hypothermia

(Medscape: Medscape Access) my favoutite resource/source....it requires registration and it is FREE!

Hypothermia describes a state in which the body's mechanism for temperature regulation is overwhelmed in the face of a cold stressor. Hypothermia is classified as accidental or intentional, primary or secondary, and by the degree of hypothermia.
Accidental hypothermia generally results from unanticipated exposure in an inadequately prepared person; examples include inadequate shelter for a homeless person, someone caught in a winter storm or motor vehicle accident, or an outdoor sport enthusiast caught off guard by the elements. Intentional hypothermia is an induced state generally directed at neuroprotection after an at-risk situation (usually after cardiac arrest, see Therapeutic Hypothermia).^[1]Primary hypothermia is due to environmental exposure, with no underlying medical condition causing disruption of temperature regulation.^[2]Secondary hypothermia is low body temperature resulting from a medical illness lowering the temperature set-point.
Many patients have recovered from severe hypothermia, so early recognition and prompt initiation of optimal treatment is paramount.

Your nursing diagnosis needs work but.....Your ideas are good for presentation but you need accurate information about hypothermia to present to the class/instructor. How about your classmates car broke down during a snowstorm and she was stuck for hours...when she was found she was hypothermic.

Start from there.....

nurseprnRN, BSN, RN · Oct 30, 2012

I think this is a bit backwards-- yes, if you are hypothermic you will shiver to generate heat by the metabolic work done by the shivering muscles. People do shiver if they are generating fevers, too, but they are not, strictly speaking, hypothermic as they're doing it.

But hypothermia itself is not usually caused by an illness. It is most often environmental. Esme's right about the gal whose car broke down in the snow...but the most common hypothermic is either the alcoholic who fell asleep outdoors or the old lady who fell down at home with just her nightie on (or naked getting out of the shower) and was found on the linoleum a day or two later. In the hospital, it's often seen in postop patients who have had their nice warm innards exposed for a long time to an air-conditioned dry OR and pumped full of room-temp fluids or refrigerated blood. Although since hypothermia makes for lousy clotting and other problems, most ORs are now a lot better about giving warmed fluids and warm-air wraps to add (not merely conserve) body heat.

Great idea for cyanotic-looking lips-- suck on a purple popsicle.

jacelynn · Oct 31, 2012

Thanks for the suggestions. I have changed my diagnosis to ineffective thermoregulation, hypothermia RT fluctuating environmental temperature AEB mild shivering, reduction in body temperature below normal range and cyanotic nail beds.

I will be taking my patients vitals for interventions. Her bp will be high along with her respirations and heart rate; her temp will be 92 degrees ( she has mild hypothermia) I'm going to draw a thermostat and be like " let's make sure the thermostat is set at 72* f. I'm always going to explain to her the reason why she needs to eat an adequate amount of carbs and 8-10 glasses of water.... I'm going to have an electric blanket wrapped around her, hat on, blue nails and lips and make her face look pale. that's what I've came up with. Oh I'm going to use either the snow storm story or she fell in a frozen pond while trying to ice skate. Does any of this sound better or worse than my original plan?

mariebailey, MSN, RN · Oct 31, 2012

You asked for creativity suggestions, so here ya go: Hypothermia is associated with symptoms such as disorientation/confusion. You could have the patient trying to unwrap her warm clothing or mumbling incoherently to add to the drama. I think their pulse would be weak and their breathing shallow, depending on when you intervene though.

Esme12, ASN, BSN, RN · Oct 31, 2012

Thanks for the suggestions. I have changed my diagnosis to ineffective thermoregulation, hypothermia RT fluctuating environmental temperature AEB mild shivering, reduction in body temperature below normal range and cyanotic nail beds.
I will be taking my patients vitals for interventions. Her bp will be high along with her respirations and heart rate; her temp will be 92 degrees ( she has mild hypothermia) I'm going to draw a thermostat and be like " let's make sure the thermostat is set at 72* f. I'm always going to explain to her the reason why she needs to eat an adequate amount of carbs and 8-10 glasses of water.... I'm going to have an electric blanket wrapped around her, hat on, blue nails and lips and make her face look pale. that's what I've came up with. Oh I'm going to use either the snow storm story or she fell in a frozen pond while trying to ice skate. Does any of this sound better or worse than my original plan?

But a normal adult can compensate for "fluctuating environmental temperatures". It's the over exposure to the cold for extended periods of time that causes hypothermia. I think you need to look up the standard of care to treat hypothermia. Drinking water will not be on that list unless it is warm. Shivering is the body attempting to rewarm itself and not a symptom of being cold.

Investigate hypothermia and it's standard of treatment and symptoms......92 degrees F will not necessarily cause cyanosis.

runforfun · Oct 31, 2012

Is your care plan written for a real patient or an "imagined" one? If it's for a real patient, look at the history and figure out why their temperature might be low (look to Esme and GrnTea for reasons that might make sense). If the patient is imagined, come up with the most dramatic scenario you can imagine. The patient has been lost in a snowstorm with not coat, and has the most dramatic symptoms associated with hypothermia (get out a patho book and look it up). Really learn about the whys, not just why they are hypothermic, but why hypothermia causes the symptoms it causes, and why specific treatments are chosen. Also think about expected outcomes, and things that could possibly go wrong. It seems like a lot of work for one care plan/nursing diagnosis, but in the long run, all of that knowledge will come in handy, and going through the process will help you to hone your critical thinking skills.

Your creative ideas are great, keep up the good work, and make sure all of the interventions you demonstrate are evidence-based!

jacelynn · Oct 31, 2012

it's a diagnosis presentation. We were given the diagnosis ( ineffective thermoregulation) and had to come up with the rt and AEB parts, implementations, and goals. Our assignment is to just present it to our class so we can become familiar with some nursing diagnosis. I used my mosbys nuring diagnosis guide book to come up with my implementations for hypothermia. And took mine directly out of the book. we're only 3 weeks into school, so our teachers aren't really wanting the whole pathopysiology aspect of it. Thanks for the suggestions and feedback everyone. Time for bed.

Esme12, ASN, BSN, RN · Oct 31, 2012

It is a great project to become familiar with the process.......lateral thinking and looking up "your patients " data/disease/diagnosis is apart of the nursing process that will become apart of your normal. While you are not required to do more......it is always helpful to familiarize yourself with the whys and how's of you patients process....it will help you A LOT in understanding the why and hows of why you are treating someone, but it will also help you critically think to chose the "most correct" answer or place the "most correct answer" in priority order.

I wish you the best on your nursing journey!

nurseprnRN, BSN, RN · Oct 31, 2012

"Ineffective thermoregulation" implies that the patient's shivering is not effective in restoring normothermia. Perhaps the envi is too cold and losses exceed metabolic-driven gains? Remember, you need to ADD heat to this person. Easy ways to do this are to warm IV fluids, give hot sweet liquids as tolerated, high-calorie foods like candy (fat is higher in calories but sugars are more rapidly put to good use), and use active external warming devices like warm packs at hands and feet (most efficient areas for heat transfer between arteries and veins), BAIR Hugger (look it up-- nifty gadget), warmed blankets, and so forth. Protect from further heat losses with a warm blanket around the head and neck, too.

And of course, don't forget to take her temp every half an hour or so while you are doing active rewarming. Believe it or not, research shows the axillary route is more accurate than oral or rectal temp in hypothermia (if you really want to know why, you can come back and ask me), but for your purposes an eardrum temp would be fine.

Perhaps the patient is NOT shivering? If that wasn't specified as part of your scenario, then that would make a lot of sense. Why would someone be unable to shiver effectively? Still under the effects of anesthesia? Out of gas, exhausted, blood sugar is too low to support that much muscle work?

You think this is just a one-and-done exercise, but as Esme points out, it offers you the opportunity to get a really good start on a lot of skills you will need every single day of your student and graduate life (my congratulations to your faculty for this-- you don't know how lucky you are!). Let me point out that hypothermia is very, very common in hospitalized patients, and affects patients in ways most nurses do not know about. I know you don't have a lot of background in physiology yet, but tuck these away somewhere for reference: decreased clotting, altered cognition, decreased coordination and balance, and metabolic acidosis with warming (especially important to watch for in people with chronic lung disease or diabetes). All have important implications for nursing observations and interventions for patient safety.

jacelynn · Nov 1, 2012

Thanks everyone! I made a 100% on my presentation!