AsKep Klien

dengan
Gangguan Suhu
Tubuh
(Hipotermia)
GANGGUAN SUHU
TUBUH
 Hipotermia
 Pengeluaran panas akibat paparan terus menerus
terhadap dingin mempengaruhi kemampuan tubuh
untuk memproduksi panas
 Gejala → gemetar yang tidak terkontrol, hilang
ingatan, depresi dan tidak mampu menilai (suhu
35oC), frekuensi jantung, pernapasan dan tekanan
darah turun (suhu dibawah 34,4oC), jika terus
berlangsung → kulit menjadi sianotik
Risk for Hypothermia?
 Anyone who spends time outside in extremely cold
weather may be at risk for hypothermia. Young
children and older adults are also at increased risk
for accidental hypothermia even at temperatures
that may not be dangerous to others.
 Other risk factors that can make you more
susceptible to hypothermia include taking certain
medications, having diabetes, and possibly even
some thyroid conditions. Mental illness and some
kinds of somatosensory disorders or nerve damage
are often cited as risk factors as well, since people
with these conditions may not be aware of the
sensations from their bodies, or may not take
appropriate action if they do.
Risk for Hypothermia
 Medical conditions can impair your body’s ability to
maintain a normal body temperature or to sense cold
include:
• arthritis
• hypothyroidism
• dehydration
• diabetes
• Parkinson’s disease
• a stroke
• spinal cord injuries
• burns
• malnutrition
 Medications such as some antidepressants can also make
you more susceptible to suffering from hypothermia.
Mekanisme Hipotermia
 Body temperature below the normal range.
 Normal body temperature is around 37 °C (98.6
°F). Hypothermia occurs as the body
temperature falls lower than normal; usually
below 35 °C (95 °F).
 Hypothermia occurs when the body fails to
produce heat during metabolic processes, in
cells that support vital body functions. Most
heat is lost from the skin’s surface through
convection, conduction, radiation, and
evaporation. When the body temperature
drops, the heart, nervous system and other
organs can’t work normally leading to
complete failure of the heart and respiratory
system and eventually to death.
 Hypothermia can be classified as:
 inadvertent (seen postoperatively)
Inadvertent perioperative hypothermia is a common
consequence of anesthesia.
 intentional (for medical purposes)
Intentional hypothermia is an induced state generally
directed at neuroprotection after an at-risk situation
usually after cardiac arrest.
 accidental (exposure related). Accidental
hypothermia usually results from sudden exposure in
an inadequately prepared person such as an
inadequate shelter for a homeless person or
someone exposed in a winter storm or motor vehicle
accident.
Older adults are particularly exposed to accidental
hypothermia due to age-related changes in normal
thermoregulation.
Stage Hypothermia
 HT I: Mild Hypothermia, 95-89.6 degrees
Normal or nearly normal consciousness,
shivering
 HT II: Moderate Hypothermia, 89.6-82.4
degrees
Shivering stops, consciousness becomes
impaired
 HT III: Severe Hypothermia, 82.4-75.2
degrees
Unconscious, may be difficult to detect
vital signs
 HT IV: Apparent Death, 75.2-59 degrees
 HT V: Death from irreversible hypothermia
Complications
People who develop hypothermia because of
exposure to cold weather or cold water are also
vulnerable to other cold-related injuries, including:
• Freezing of body tissues (frostbite)
• Decay and death of tissue resulting from an
interruption in blood flow (gangrene)
Frosbite
 terjadi bila tubuh terpapar pada suhu
dibawah normal
 Mengakibatkan kerusakan sirkulasi dan
jaringan secara permanen
 Sering terjadi di → lobus telinga, ujung
hidung, jari, dan jari kaki, daerah yang
cedera berwarna putih berlilin, dan
keras jika disentuh
ASKEP KLIEN DENGAN
GANGGUAN SUHU TUBUH
 Nursing Assessment
Assessment
Assess for precipitating
situations and risk factors.
Note and monitor patient’s
temperature.
Monitor the patient’s HR, heart Moderate to severe hypothermia increases the risk
rhythm, and BP.
Evaluate the patient for
drug abuse use,
including antipsychotics,
opioids, and alcohol.
Evaluate the patient’s nutrition
and weight.
Rationales
Causative factors guide the appropriate treatment.
Older patients have a decreased metabolic rate
and reduced shivering response; therefore the
effects of cold may not be immediately manifested.
For alert patients, oral temperature is regarded as
more reliable than tympanic or axillary. For
hypothermic patients, core temperature can be
monitored using a temperature-sensitive pulmonary
artery catheter or bladder catheter.
HR and BP drop as hypothermia progresses.
for ventricular fibrillation, along with other
dysrhythmias.
These groups of drugs contribute to vasodilation and
heat loss.
Poor nutrition contributes to decreased energy
reserves and restricts the body’s ability to generate
heat by caloric consumption.

Assess the patient’s peripheral perfusion
at frequent intervals.
Monitor fluid intake and urine output
(and/or central venous pressure).
Check for electrolytes,
arterial blood gases, and oxygen
saturation by pulse oximetry.
Evaluate for the presence of frostbite, if Severe hypothermia generates ice
the patient has had prolonged
exposure to a cold environment.
Assess the patient’s readiness to reach
a toileting facility, both independently
and with assistance.
Hypothermia initially precipitates
peripheral vascular constriction as a
compensatory mechanism to minimize
heat loss from extremities. The patient’s
skin will look pale and cool to
the touch with delayed capillary refill.
As hypothermia advances, vasodilation
transpires, furthering heat loss. The
patient’s skin becomes warm and less
pale. The patient may start to remove
clothing and bed covers.
Decreased output may
indicate dehydration or poor renal
perfusion. Avoid fluid overload to
prevent pulmonary
edema, pneumonia, and taxing an
already compromised cardiac and
renal status.
Acidosis may emerge from
hypoventilation and hypoxia.
crystals to form inside cells. The cells
eventually burst and die.
This allows the nurse to plan for
assistance.
 HIPOTERMIA
 Kriteriamayor → penurunan suhu dibawah
35,50C per rektal, kulit dingin, pucat (sedang),
menggigil (ringan)
 Faktor yang berhubungan → Penuaan,
mengkonsumsi alkohol, kerusakan
hipotalamus, penurunan kecepatan
metabolisme basal, penyakit atau trauma,
ketidakmampuan atau penurunan
kemampuan untuk menggigil tidak aktif,
pakaian yang tidak adekuat, obat-obatan
yang menyebabkan vasodilatasi, terpajan
lingkungan yang dingin atau kedinginan
(dalam waktu lama)
Hypothermia is characterized by the following signs
and symptoms:
 Body temperature below normal range
 Cool, pale skin
 Dizziness
 Hypertension
 Increased HR
 Lack of coordination
 Piloerection
 Shivering
 Slow capillary refill
Goals and Outcomes
The following are the common goals and
expected outcomes for Hypothermia:
 Patient maintains a core body
temperature above 35°C (95°F).
 Patient manages HR and BP within
normal limits; skin is warm.
Nursing Interventions
Interventions
Regulate the environment
temperature or relocate the
patient to a warmer setting.
Keep the patient and linens dry.
Control the heat source
according to the patient’s
physical response.
Give extra covering (passive
warming), such as clothing and
blankets; cover postoperative
patients with heat-retaining
blankets.
Rationales
These methods provide for a
more gradual warming of the
body. Rapid warming can
induce ventricular fibrillation.
Moisture promotes evaporative
heat loss.
Body temperature should be
raised no more than a few
degrees per hour. Vasodilation
occurs as the patient’s core
temperature increases leading
to a decrease in
BP. Hypotension, metabolic
acidosis, and dysrhythmias are
complications of rewarming.
Warm blankets provide a passive
method for rewarming.
Give heated oral fluids for Warm fluids produce a heat
alert patients. source.

•Provide extra heat

source:Heat lamp, radiant
These measures raise the
warmer
core temperature and
•Warming pads, mattress, or
improve circulation. Core
blankets
warming is indicated when
•Submersion in a warm bath
body temperature is below
•Heated, moisturized oxygen
30 °C (86 °F).
•Warmed intravenous fluids or
lavage fluids

Avoid manually rubbing,

Rubbing can further damage
scrubbing, or massaging
frozen tissue.
areas of frostbite.
Explain all procedures and
Repeated explanations are
treatment to the patient and
needed to avoid confusion.
SO.
 Intervensi Hipotermia
1. Pantau tanda-tanda vital terutama suhu
2. Kaji gejala hipotermia misalnya perubahan
warna kulit, menggigil, kelelahan, kelemahan,
apatis, dan bicara yg berguman
3. Berikan pakaian yang hangat, kering, selimut
penghangat, alat-alat pemanas mekanis, suhu
ruangan yang disesuaikan, botol dengan air
hangat, berendam air hangat, dan minum air
hangat, sesuai toleransi.
4. Jangan berikan obat intramuskular atau
subkutan untuk pasien hipotermia
INTERVENSI KEPERAWATAN
UNTUK GANGGUAN SUHU
TUBUH
WARMER BLANKET
 Lihat makalah kelompok
Kompres Panas
 Definisi→ memberikan rasa hangat
(suhu 40-46oC) pada klien dengan
menggunakan cairan atau alat yang
menimbulkan rasa hangat pada bagian
tubuh tertentu yang memerlukannya
 Tujuan → memperlancar sirkulasi darah,
mengurangi rasa sakit , merangsang
peristaltik, memperlancar pengeluaran
getah radang (eksudat)
Indikasi Kompres Panas
1. Klien dengan perut kembung
2. Klien yang kedinginan, bisa dikarenakan
iklim, narkose, atau hipotermi.
3. Klien yang mengalami radang, seperti
radang persendian
4. Klien dengan kekejangan otot.
5. Klien yg mengalami inflamasi (bengkak)
akibat suntik.
6. Klien yang mengalami abses atau
hematoma
Jenis Kompres Panas
1. Kompres panas basah → biasanya
dilakukan untuk mengompres luka
2. Kompres panas kering
Prosedur Kompres Panas
Kering
 Persiapanalat → Buli-buli panas dengan
sarungnya , termos , air panas , tisu,
sarung tangan bersih, thermometer air
dan kain besar secukupnya (jika
diperlukan)
 Prosedur Kerja Kompres Panas
Kering
1. Berikan penjelasan kepada klien
2. Dekatkan alat-alat pada klien
3. Jaga privasi klien dan berikan posisi yg nyaman
4. Bebaskan area yang akan dikompres
5. Cuci tangan dan pasang sarung tangan
6. Pasang pengalas di bawah area yang akan di
kompres
7. Periksa buli-buli dari kebocoran dengan cara
berikut :
▪ Membalikkan mulut/tempat memasukkan air
kemudian lihat apakah terjadi kebocoran/tidak
▪ Dengan meremas dan melihat apakah ada kaluarnya
udara bersamaan dengan tetesan air atau tidak
8. Uji buli-buli panas terlebih dahulu dg cara mengisi
terlebih dahulu air panas dan mengencangkan
sekrupnya (penutup) kemudian membalikan posisi
buli-buli panas berulang kali lalu dikosongkan
kembali
9. Siapkan & ukur air panas yg akan diberikan (± 50-
600C)
10. Isi buli-buli panas kembali dengan air panas ±
setengah bagian, lalu keluarkan udara dengan cara
berikut.
▪ Melatakkan atau meniduri buli-buli panas diatas meja atau
tempat yang datar
▪ Melipat bagian atas buli-buli sampai kelihatan permukaan air
di leher atau mulut buli-buli lalu menutup buli-buli dengan
benar dan rapat.
11. Periksa kembali apakah terjadi kebocoran,
keringkan dan masukkan ke dalam sarungnya.
12. Bawa buli-buli ke dekat klien dan letakkan
13. kaji secara teratur kondisi klien misalnya
kemerahan, ketidaknyamanan, kebocoran dan
sebagainya.
14. Ganti buli-buli panas setelah 20 menit
pemberian
15. Kembalikan klien pada posisinya yang nyaman
16. Buli-buli panas dikosongkan dan dikeringkan
agar dapat dipergunakan kembali
17. Buka sarung tangan dan cuci tangan