Medical Surgical Critical Care Hypothermia & Frostbite #1

Question

The nurse is caring for a client who was admitted to the ICU with hypothermia. The client’s core body temperature is 93ºF. Which interventions does the nurse anticipate to implement? Select all that apply.

Answers

  1. Mechanical ventilation.
    • Rationale:

      This answer is correct because airway is a #1 priority. When the organs shut down, the client has to be put on mechanical ventilation.

  2. Cardiac monitoring with defibrillation.
    • Rationale:

      This answer is correct because arrhythmias both atrial and ventricular begin spontaneously with hypothermia. Hypothermia depresses the client’s central nervous system decreasing metabolism.

  3. Rewarming process starting with trunk and then extremities.
    • Rationale:

      This answer is correct because the trunk has all the vital organs, so rewarming is essential for the trunk first and then the extremities.

  4. Warmed IV fluids with 2 large bore IVs.
    • Rationale:

      This answer is correct because warming IV fluids helps prevent shivering and restores core body temperature to the normal range.

  5. Placing client in a whirlpool.
    • Rationale:

      This answer is not correct because placing a client in a whirlpool is contraindicated. The nurse should use dry warm compresses and not direct hot water, a heating lamp, or a heating pad.

  6. Massage the client's trunk and extremities.
    • Rationale:

      This answer is not correct because massaging the client with hypothermia could trigger a cardiac arrest, so handle the client with extreme care and avoid rubbing or massaging.

Overview

Hypothermia is when the core body temperature is < 95ºF. The nurse needs to handle the client with care. The client’s organs shut down with cardiac arrhythmias, such as Vfib.

Explanation

Learning Outcomes

Hypothermia is when the core body temperature is < 95ºF. The nurse needs to handle the client with care. Nursing interventions are mechanical ventilation, cardiac monitoring with defibrillation, rewarming the client’s trunk and then the extremities, and administering warmed IV fluids with 2 large bore IVs.

Test Taking Tip

Know the treatments to implement for hypothermia clients.

Video Rationale