00254 Risk Of Perioperative Hypothermia

Domain 11: security/protection
Class 6: thermoregulation
Diagnostic Code: 00254
Nanda label: risk of perioperative hypothermia
Diagnostic focus: perioperative hypothermia
Approved 2013 • Revised 2017, 2020 • Evidence level 2.2

NANDA Nursing Diagnosis Definition

Nanda nursing diagnosis « risk of perioperative hypothermia occur from an hour before to 24 hours after surgery and that can compromise health.

Risk factors

  • Anxiety
  • Body mass index below the normal range according to age and sex
  • Ambient temperature <21 ° C/69.8 ° F
  • Improper availability of appropriate heating equipment
  • Uncover wound area

Risk population

  • People> 60 years of age
  • People in environments with laminar flow of air
  • People who receive anesthesia for a period> 2 hours
  • People who suffer a long induction time
  • People who suffer open surgical intervention
  • People who suffer surgical intervention> 2 hours
  • Score> 1 according to the classification of the physical state of the American Society of Anesthesiologists (ASA)
  • People with a high score in the state-end model of liver disease (MELD)
  • People with increased loss of intraoperative blood
  • People with intraoperative diastolic blood pressure <60 mmHg
  • People with intraoperative systolic blood pressure <140 mmHg
  • People with low body area surface
  • Neonates <37 weeks of gestation
  • Women

Associated problems

  • Acute liver failure
  • Anemia
  • Burns
  • Cardiovascular complications
  • Chronic renal failure
  • Combined, regional and general anesthesia
  • Neurological disorder
  • Pharmacological preparations
  • Trauma