A client with hypothermia has just arrived in the emergency department via ambulance. The client is being rewarmed with blankets, and the IV fluids are being changed over to warmed fluids. What additional intervention is a priority?

Question

Quizplus · Accepted Answer

Hypothermia occurs when the core temperature is below 95 F (35 C) and the body is unable to compensate for heat loss. As the core temperature decreases, the cold myocardium becomes extremely irritable and prone to dysrhythmias. The client should be handled gently as spontaneous ventricular fibrillation could develop when moved or touched. Therefore, placing the client on a cardiac monitor is a high priority; the nurse should anticipate defibrillation in these clients. (Option B) Covering the client's head is indicated to prevent heat loss; however, this can be done after the cardiac monitor has been attached. Depending on the severity of the hypothermia, the trunk should be warmed before the extremities to reduce the risk of afterdrop (core temperature drops further). This is due to cold peripheral blood returning to the central circulation. (Option C) A blood draw for laboratory testing is important but should be performed after the cardiac monitor is attached. (Option D) Two large-bore IV catheters are preferred; this can be accomplished after the cardiac monitor has been attached. Educational objective: Cardiac monitoring and gentle handling of the client are a high priority with hypothermia. The cold myocardium is extremely irritable and prone to dysrhythmias. The nurse should anticipate defibrillation in these clients.

A Client with Hypothermia Has Just Arrived in the Emergency