CASE STUDY

A 56 year old female is being admitted to your ICU unit. The patient is coming to
you from the PACU. You received in report from the PACU nurse that the patient
had surgery on her right hip for a repair after a fall she sustained from her patio
balcony. The surgical dressing is clean, dry, and intact. An abductor pillow is
being used and pulses in feet are palpable. The PACU nurse informs you that the
patient was going to be transferred to a progressive care unit but the patient
has become unstable and need close monitoring that is available in the ICU. The
PACU nurse states that the patient has been unable to regulate her own body
temperature and her current temperature in 34.67 degrees celsius. A bair
hugger blanket is being used. The patient is extremely drowsy and confused and
the nurse has been unsuccessful in getting the patient to fully wake up from the
anesthesia. Pt HR is 50-55 bpm and BP 80/42. Pt is currently on a Dopamine gtt
at 30 mcg/min. RR 12 and O2 Sat 95% on a 50% ventimask.
ASSESSMENT

SUBJECTIVE DATA

● The PACU nurse informs you that the patient was going to be transferred to
a progressive care unit but the patient has become unstable and need close
monitoring that is available in the ICU.
● PACU nurse states that the patient has been unable to regulate her own
body temperature and her current temperature in 34.67 degrees celsius. A
bair hugger blanket is being used.
● The patient is extremely drowsy and confused and the nurse has been
unsuccessful in getting the patient to fully wake up from the anesthesia.
ASSESSMENT

OBJECTIVE DATA:

● HR is 50-55 bpm
● BP 80/42
● RR 12
● O2 Sat 95%
● 50% ventimask
NURSING DIAGNOSIS

Hypothermia related to surgery as evidenced by reduction of body temperature of

94.4 degrees, mental confusion, drowsiness, and decreased pulse and respirations.
PLANNING

● Pt’s temperature will elevate between 36.8-37 degrees celsius within 12

hours from arrival to ICU unit.
● Pt’s HR will be 60-100 bpm and BP will be normal within 6 hours from
arrival to ICU unit.
● Pt will be able to verbalized self, place, and time within 12 hours from
arrival to ICU unit.
IMPLEMENTATION

● The nurse will assess every hour patient’s temperature and report any temperature
less than 95 degrees to the doctor for further orders.
● The nurse will assess HR and BP every 15 minutes.
● The nurse will administer warming intravenous fluids per md order.
● The nurse will assess patient’s room temperature every 2 hours and will keep
patient’s room temperature between 70-74 degrees.
● The nurse will use the bair hugger warming blanket system per hospital protocol and
md order.
REFERENCE:
https://www.registerednursern.com/nursing-care-plan-diagnosis-
interventions-hypothermia-low-body-temperature-inability-to-
regulate-body-temperature/