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Nursing Care to Prevent Unplanned Hypothermia in the Operating Room Suzanne Prideaux Pacific Lutheran University, Tacoma, Washington Acknowledgements I would like to thank the staff at Providence St. Peter�s Hospital operating room, my preceptor Marjie Caputo, and my clinical instructors at PLU School of Nursing who inspired me to strive for excellence. Evaluation Short Term Goal: Met. Patient did not complain of being cold when asked. Long Term Goal: Undetermined. Objective: Met. Patient was able to maintain normothermia during surgical procedure as evidenced by temperature of 36.6�C. upon admission to recovery. This patient had several risk factors that increased his susceptibility to unplanned hypothermia and when his temperature started to drop during the interoperative phase, we were able to keep his temperature 36�C. or above through our nursing interventions. He was at a higher risk of impaired wound healing because of his diabetes an lack of glycemic control, but according to studies, he would have a 12% lower infection rate because we kept him normothermic (Kurz, 1996). Despite the technology available to prevent unplanned hypothermia, it is an ongoing problem in the perioperative area. Nurses must be proactive in implementing interventions to improve surgical patient outcomes. Case Study 68 yo male admitted for lumbar laminectomy and microdiscectomy for L3-4 disc herniation. HX: htn; diabetes, long-term arthritis of back and joints. He is on medication for hypertension, hyperlipidemia, and diabetes. BP 115/68; P 90; wt 201 lbs; 5 ft 9� Temps: 37 preop; dropped to 36 during surgery and then raised to 36.6 by time went to PACU Blood sugar: 190 preop after insulin Introduction Unplanned hypothermia happens when a surgical patient is given a gas anesthetic with a large amount of body surface area exposed to a cold environment. It is a preventable surgical complication that significantly impacts patient outcomes as exposure to anesthetic gases can drop body temperature by 2�, which can lead to higher wound infection rates, increased need for transfusions, altered drug metabolism, longer recovery time, and possible cardiac events (ASPAN, 1998). Medicare and Medicaid will not pay hospital costs if a surgical complication occurs after an unplanned hypothermic event (PSPH Perioperative Council, 2008). Risk Factors Anesthetic gases which inhibit vasoconstriction and causes dilatation (AORN, 2008) Antihypertensive medication increases vasodilitation, resulting in decreeased heat production and increased heat loss (Scott & Buckland, 2006). Cold surgical environment causes heat to be lost through radiation and convection from the skin and by evaporation from wet skin prep (AORN, 2008). Infusion of cool fluids through an IV or as irrigation decrease body temperature (AORN, 2008). Interventions and Rationales Review chart for patient�s hypothermia risks � allows planning for patient care. Ask the patient if they are cold � helps establish the patient�s thermal comfort level (ASPAN, 1998) Collaborate with anesthesia to ensure temperature regulation equipment is available � allows for preplanning of patient�s needs and supplies needed for intervention. Use prewarmed (37�C.) fluid and/ or take out antibiotic fluids from the refrigerator early in case for surgical site irrigation � used as adjunct therapy to help prevent heat loss (AORN, 2008). Use warm (37�C.) intravenous � unwarmed I.V. fluid can cause the patient to feel cold and discomfort prior to anesthesia; used in adjunct therapy to lessen heat loss (AORN, 2008). Apply forced-air warming gowns to uncovered non-surgical body surfaces � minimizes patient heat loss and is effective at maintaining normothermia (Paulikas, 2008). Keep operating room temperature at 68�F. � allows staff to keep cool under hot lights while minimizing patient heat loss; increases patient comfort level prior to anesthesia (Paulikas, 2008). Apply warm blankets to operating room bed before going to preoperative holding area to get patient and then cover patient after reaching O.R suite � minimizes body heat lost through conduction and radiation. Keep patient�s head and feet covered � helps retain body heat. http://www.arizant.com/us/bairhuggertherapy Goal Short Term Goal: Patient will not complain of being cold before induction of anesthesia. Long Term Goal: Patient will not show signs of impaired wound healing after surgical procedure. Objective: Patient will maintain a core temperature of 36� during the intraoperative phase. Nursing Diagnosis Ineffective thermoregulation r/t exposure to anesthetic gases and cold environment aeb dropping core temperature and inability to shiver. Risk for hypothermia Risk for imbalanced body temperature. Body�s Response to Hypothermia Vasoconstriction reduces blood flow to skin and incision site, which suppresses the phagocytic and macrophage activity during the healing process; decreases blood flow to brain, increases blood pressure, cardiac afterload, and oxygen demand and usage (Odom-Forren, 2006). Blood viscosity is increased which leads to slowed blood flow to organs. Medication metabolism is affected if kidney and liver function decreases (Odom-Forren, 2006). Left shift in the oxygen-hemoglobin dissociation curve causes repression in oxygen delivery system leading to possible tissue hypoxia and metabolic alkalosis (Odom-Forren, 2006). Increased thrombocytopenia and fibrinolysis; decreased clotting cascade, platelet number and function which can lead to an increase in DVT�s, PE�s and decreased perfusion (Odom-Forran, 2006).