Hypothermia, Low Body Temperature
Also Consider: Fever
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Hypothermia definition
Rectal temperature less than 95ºF
Causes
Common: exposure to cold, alcohol intoxication
Less common: infection, sepsis, hypothyroidism, neurologic disease, low blood glucose, inactivity
1. Take Vital Signs
Temperature:
Blood Pressure:
Heart Rate:
Respiratory Rate:
Oxygen Saturation:
2. Evaluate Symptoms and Signs
Acute mental status change
Not eating or drinking as much as usual
Fainting, dizziness or lightheadedness when standing up
Acute decline in ADL abilities
Alcohol intoxication
Respiratory: New cough, abnormal lung sounds
Cardiovascular: Chest pain, new irregular pulse, cyanosis, mottling, edema
GI: Nausea, vomiting, diarrhea, abdominal distention or tenderness, rebound tenderness, bowel sounds
GU: New or worsened incontinence, pain with urination
Neurologic changes: consciousness/alertness, orientation, weakness, gait changes (unsteadiness, loss of coordination or balance), slurred or garbled speech
Skin: sweats (diaphoresis), cold/clammy/pale skin; any new skin condition, i.e., bruising (including potential head trauma), rash, infection/cellulitis
Fingerstick glucose (all patients)
3. Take Action using SBAR Report:
Presence of other, significant symptoms or signs of illness
Refer to appropriate Situation-Specific Evaluation for the identified symptoms and signs.
Immediately notify the medical staff & resident representative
Temperature less than 86ºF
Temperature less than 95ºF with
Change in mental status
Symptoms of any infection
Heart rate less than 50
Notify medical staff & resident representative within the next 16 hours.
Temperature less than 95ºF with any other new symptoms
Notify medical staff on the next business day
Temperature repeatedly less than 95ºF without incident or symptoms
SBAR Report
Situation: "Hypothermia with a temperature of ___ associated with:" (acute symptoms) (exposure to cold)
Background:
Reason the patient is in the nursing home (rehab for___, long term care for __).
Recent exposure to cool environment
Abnormal vital signs
History of hypothyroidism
Recent illness, antibiotics, medication changes, surgery, falls
General observation of patient condition
Diet restrictions, fluid restriction, thickened liquids
Blood glucose, if abnormal
Abnormal findings on lung, cardiovascular, abdomen, genitourinary, neurologic or skin observations.
Signs or symptoms of infection, dehydration, head trauma
Assessment: I am concerned about: __________
Recommendations/Requests:
Labs: CBC with manual diff, Lactic Acid, CMP/Chem14, Blood cultures, TSH
INR if patient is on warfarin
Chest X-ray with lateral view if possible
Straight catheterization for urine sample for urinalysis and culture (unless patient is able to collect clean-catch, midstream urine)
Stool culture and C diff testing if diarrhea is present.
Other:
Clarify expectations for care, interventions, and illness course/prognosis. Repeat any telephone orders back to the provider to ensure that they are correct and complete
4. Implement Management Plan
Move the patient to a warm environment
Warm packs under the arms, in the groin, and on the neck and chest
Apply blankets
Monitor vital signs every 4-8 hrs until body temperature remains normal
Offer warm fluids frequently
Oral, IV, or subcutaneous fluids if needed for hydration
Place on Intake & Output monitoring
Monitor meal acceptance
Place on 24-hour report
Obtain lab results (if ordered), and notify medical as needed of significantly abnormal values in lab tests (refer to appropriate Situation)
Update care plan regarding fall risk, pressure ulcer prevention, assistance needed with ADLs, supervision for safety, restorative needs
Review status and plan of care with designated representative
Update advance directives if appropriate
If an incident occurred complete an incident report
2025-04-27
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