CONTINUING EDUCATION
Guideline Implementation:
Preventing Hypothermia
1.0
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MARIE A. BASHAW, DNP, RN, NEA-BC
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Conflict-of-Interest Disclosures
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Pricing is subject to change.
The behavioral objectives for this program were created by Liz
Cowperthwaite, BA, senior managing editor, and Helen
Starbuck Pashley, MA, BSN, CNOR, clinical editor, with
consultation from Susan Bakewell, MS, RN-BC, director,
Perioperative Education. Ms Cowperthwaite, Ms Starbuck
Pashley, and Ms Bakewell have no declared affiliations that
could be perceived as posing potential conflicts of interest in
the publication of this article.
Purpose/Goal
To provide the learner with knowledge specific to implementing the AORN “Guideline for prevention of unplanned
patient hypothermia.”
Objectives
1. Identify complications that may result from hypothermia.
2. Discuss factors that increase the patient’s risk for unplanned intraoperative hypothermia.
3. Discuss methods for monitoring the patient’s temperature.
4. Discuss considerations for choosing warming interventions.
5. Describe interventions that can be used to help prevent
hypothermia.
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AORN is accredited as a provider of continuing nursing
education by the American Nurses Credentialing Center’s
Commission on Accreditation.
AORN is provider-approved by the California Board of
Registered Nursing, Provider Number CEP 13019. Check
with your state board of nursing for acceptance of this activity
for relicensure.
Marie A. Bashaw, DNP, RN, NEA-BC, has no declared
affiliation that could be perceived as posing a potential conflict
of interest in the publication of this article.
Sponsorship or Commercial Support
No sponsorship or commercial support was received for this
article.
Disclaimer
AORN recognizes these activities as CE for RNs. This
recognition does not imply that AORN or the American
Nurses Credentialing Center approves or endorses products
mentioned in the activity.
http://dx.doi.org/10.1016/j.aorn.2016.01.009
ª AORN, Inc, 2016
304 j AORN Journal
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Guideline Implementation:
Preventing Hypothermia
1.0
www.aornjournal.org/content/cme
MARIE A. BASHAW, DNP, RN, NEA-BC
ABSTRACT
The updated AORN “Guideline for prevention of unplanned patient hypothermia” provides guidance
for identifying factors associated with intraoperative hypothermia, preventing hypothermia, educating
perioperative personnel on this topic, and developing relevant policies and procedures. This article
focuses on key points of the guideline, which addresses performing a preoperative assessment for
factors that may contribute to hypothermia, measuring and monitoring the patient’s temperature in
all phases of perioperative care, and implementing interventions to prevent hypothermia. Perioperative RNs should review the complete guideline for additional information and for guidance when
writing and updating policies and procedures. AORN J 103 (March 2016) 305-310. ª AORN, Inc, 2016.
http://dx.doi.org/10.1016/j.aorn.2016.01.009
Key words: hypothermia, core temperature, temperature monitoring, warming interventions.
U
nplanned hypothermia can be a serious adverse
event for perioperative patients. In addition to
causing discomfort for the patient, hypothermia
may contribute to complications, including myocardial events,
incision-site infection, and slower healing time, among others,
and may result in a longer hospital stay.1-18 The body’s
natural ability to warm itself is disrupted by anesthetic agents.
General anesthesia causes tonic vasoconstriction of the peripheral
vasculature, which causes vasodilation; thus, the patient’s core
temperature can decrease during the surgical procedure.19 Factors
such as the patient’s age, weight, and health conditions can
contribute to unplanned hypothermia.1,5-8,20-25 In addition,
environmental factors specific to the OR, including low room
temperatures, lack of clothing on the patient, administration of
room-temperature IV and irrigation fluids, evaporation of skin
preparation solutions, and air movement, can contribute to heat
loss and a decrease in core body temperature.19,20 Maintaining
normothermia throughout the surgical encounter optimizes the
patient’s chances of avoiding postoperative complications.26
The updated AORN “Guideline for prevention of unplanned
patient hypothermia”27 was published in November 2015.
AORN guideline documents provide guidance based on an
evaluation of the strength and quality of the available
evidence for a specific subject. The guidelines apply to
inpatient and ambulatory settings and are adaptable to all
areas where surgical and other invasive procedures may
be performed.
Topics addressed in the hypothermia guideline include
identifying factors associated with unplanned intraoperative
hypothermia, preventing hypothermia, educating perioperative
personnel on this topic, and developing relevant policies and
procedures. This article elaborates on key takeaways from the
guideline document; however, perioperative RNs should review the complete guideline for additional information and for
guidance when writing and updating policies and procedures.
Key takeaways from the AORN “Guideline for prevention of
unplanned patient hypothermia” include the following:
The perioperative RN should perform a preoperative nursing
assessment to determine the presence of contributing factors
for unplanned hypothermia.
http://dx.doi.org/10.1016/j.aorn.2016.01.009
ª AORN, Inc, 2016
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AORN Journal j 305
Bashaw
The perioperative team should measure and monitor the
patient’s temperature in all phases of perioperative care.
The perioperative team should implement interventions to
prevent unplanned hypothermia (Figure 1).
The following scenario highlights the key takeaways and
other aspects of the AORN guideline. Each key takeaway and
the nurse’s actions are then discussed in detail following
the scenario.
SCENARIO
Mrs C, a 72-year-old woman, arrives in the same day admission department for a scheduled colectomy. The RN circulator, Nurse N, performs the preoperative patient assessment
and identifies that Mrs C has congestive heart disease. She is
frail and thin and weighs 110 lb. Her temperature is 35.5 C
(95.9 F), which is considered mildly hypothermic.1
preoperative room with a full-body, forced-air warming
blanket attached to the hose, according to the manufacturer’s
instructions. The nurse confirms that Mrs C is to undergo an
exploratory laparotomy with colectomy under a general anesthetic. Surgery is scheduled to last 2.5 hours. The patient has
been NPO since midnight. Nurse N completes the hospital’s
required paperwork, which is signed by the patient and
witnessed by another RN.
Nurse N returns to the OR to discuss the findings of the
assessment and the warming mechanisms necessary for this
patient with the rest of the perioperative health care team.
Factors that could contribute to unplanned hypothermia for
this patient include her advanced age,24,25 low body weight
and frailty,5,6,11,20-23,28 and heart failure.11 The patient will be
receiving general anesthesia, and as a result, her core
temperature could decrease by 0.5 C to 1.5 C (0.9 F to
2.7 F) in the first hour after induction.19,20,29 In addition,
the OR temperature is cool, at 18.5 C (65.3 F).
Considerations for determining warming methods for this
patient include a surgical procedure with a large open
abdominal incision, the patient’s supine position on the OR
bed, IV access in the forearm, and warming equipment
print & web 4C=FPO
A multidisciplinary team at the hospital has recently revised
the hypothermia policy and procedures to include implementing full-body, forced-air warming for preoperative
patients who may be at risk for intraoperative hypothermia.
Nurse N begins active warming of the patient in the
March 2016, Vol. 103, No. 3
Figure 1. Key takeaways from the AORN “Guideline for prevention of unplanned patient hypothermia.”
306 j AORN Journal
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March 2016, Vol. 103, No. 3
constraints related to accessing the surgical site. The team
decides to use a combination of warming methods including
using heated, humidified anesthesia gases; warmed IV fluids;
and warmed irrigation fluids. In addition, an upper-body
forced-air warming blanket will replace the full-body blanket
being used in the preoperative holding area to allow access to
the surgical site. The team will also cover the patient with
surgical drapes to prevent heat loss.
The anesthesia professional warms the IV fluids using a
technology designed and cleared by the US Food and Drug
Administration for this purpose.17,30 The irrigation solutions
are warmed to 40 C (104 F), and the temperature is
measured at the point of use with a device cleared by the US
Food and Drug Administration before the fluid is instilled.27
The drape is vented in a manner that allows the air from
the forced-air warming device to flow freely from under
the drape.31,32 Nurse N documents the hypothermia
interventions in the patient’s medical record.
To ensure consistent monitoring, the perioperative team
agrees to use the same temperature-monitoring site
throughout the perioperative period. The anesthesia professional will monitor the patient’s temperature at the tympanic
membrane using a thermistor. The anesthesia professional
calibrates the temperature-monitoring device according to the
manufacturer’s written instructions.17 By the start of the
procedure, Mrs C’s temperature has increased to 36.5 C
(97.7 F). The anesthesia professional monitors the patient’s
temperature every 15 minutes and documents the
temperature in the medical record.
Mrs C undergoes a successful colectomy with no unplanned
hypothermia. Her temperature remains at 36.5 C (97.7 F),
and Nurse N conveys this information in the hand-over
report to the postanesthesia care unit (PACU) nurse at the
completion of the surgery. The PACU nurse continues
warming the patient with a full-body forced-air warming
blanket during the duration of the PACU recovery period
to achieve and then maintain normothermia at 37 C
(98.6 F).
KEY TAKEAWAYS DISCUSSION
The key takeaways from the AORN “Guideline for prevention
of unplanned patient hypothermia” address assessment to
determine the presence of contributing factors for hypothermia, measurement and monitoring of the patient’s temperature in all phases of perioperative care, and implementation of
interventions for prevention of unplanned hypothermia. These
key points do not cover the entire guideline. Rather, they help
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Guideline Implementation: Preventing Hypothermia
the reader focus on important or new information that should
be implemented into perioperative practice.
Preoperative Nursing Assessment
It is essential that the nurse complete a thorough preoperative
assessment to ascertain what factors may be present that may
contribute to unplanned hypothermia.1,5,20,25 During the
preoperative assessment, Nurse N took note of the patient’s
age, low body-surface area, low body weight, and comorbidities, in addition to the type of surgery and length of time
planned for the surgery. Given her low temperature and the
hospital’s policy, preoperative warming was instituted for
Mrs C. Nurse N then returned to the OR to discuss with the
other health care providers the factors that might contribute to
unplanned hypothermia for this patient. The evidence shows
that collaborative practice optimizes patient outcomes.3
The health care team discussed appropriate interventions
to implement to prevent an unplanned hypothermia,
considering any constraints related to the procedure and
positioning.
Temperature Monitoring
Research evidence establishes the importance of monitoring
the patient’s temperature.2,5-7,10,12-18,33-38 Consistency in the
method and site of temperature monitoring should be maintained throughout the perioperative period.2,5,17,39 Nurse N
collaborated with the health care team to implement standardized temperature monitoring for Mrs C. The perioperative
team agreed to take the patient’s temperature at the tympanic
membrane using a thermistor. The anesthesia professional
monitored and recorded the patient’s temperature every 15
minutes to determine that her temperature remained consistent and within normal limits. If her temperature had dropped, the team would have taken additional methods to warm
the patient.
Interventions
The combination of active and passive warming methods used
by Nurse N and the health care team helped maintain Mrs C’s
core temperature, allowing her to have the highest chance of
an optimal outcome from her surgical encounter. Research
evidence suggests that using a combination of active and
passive warming methods may be the best approach to prevent
unplanned hypothermia.40-43 Warming methods implemented
by the health care team included prewarming in the preoperative holding area with a full-body forced-air warming
blanket to normalize the patient’s core temperature. Intraoperatively, the team used active warming methods including
heated, humidified anesthesia gases;44-47 warmed IV and
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Resources for Implementation
Guidelines implementation: Prevention of hypothermia.
AORN, Inc. http://www.aorn.org/guidelines/guideline
-implementation-topics/patient-care/prevention-of-hypothermia.
The AORN Syntegrity solution. http://www.aorn.org/
aorn-org/education/facility-solutions/aorn-syntegrity.
ORNurseLink. http://www.ornurselink.org/home.
Perioperative Competency Verification Tools and Job
Descriptions [USB drive]. Denver, CO: AORN, Inc;
2016. http://www.aorn.org/guidelines/clinical-resources/
publications/perioperative-competency-verification-tools-and
-job-descriptions.
Policy and Procedure Templates [CD-ROM]. 4th ed.
Denver, CO: AORN, Inc; 2015. http://www.aorn.org/
guidelines/clinical-resources/publications/policy-and-procedure
-templates/.
Syntegrity is a registered trademark and ORNurseLink is a
trademark of AORN, Inc, Denver, CO.
Website access verified January 11, 2016.
irrigation fluids; and a forced-air warming blanket, as well as
the passive warming method of surgical draping.27
In addition, the team took actions to minimize the potential
for injury to the patient. Before Nurse N activated the forcedair warming unit, she attached the blanket to the hose according to the manufacturer’s instructions for use, to avoid a
potential thermal burn to the patient.48-50 In the OR, the
team vented the drape to allow the air from the forced-air
warming device to flow freely from under the drape.
Improper venting of a head drape can lead to an oxygenenriched environment under the warming blanket, a potential fire hazard, as well as increase the temperature of the hose
and potentially cause a thermal burn.31,32 The team warmed
the IV and irrigation fluids using technology designed for this
purpose and measured the temperatures before use.17,27,30
Nurse N documented the interventions used and passed on
information about the patient’s temperature to the PACU
nurse in her transfer-of-care report.27
CONCLUSION
Patient safety is paramount in perioperative practice. Prevention
of unplanned hypothermia is among the main patient-safety
concerns for perioperative RNs.51 Perioperative team
members should receive education about hypothermia,
including clinical signs and symptoms of hypothermia and
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March 2016, Vol. 103, No. 3
What Else Is in the Guideline?
Read the AORN “Guideline for prevention of unplanned
patient hypothermia”1 to learn what the evidence says
about the following:
At what core and “near-core” sites can a patient’s temperature be measured? (Recommendation II.a.)
For what length of procedure is temperature monitoring
required? (Recommendation II.d.)
Are warm waterecirculating devices effective in decreasing
the risk of hypothermia? (Recommendation III.e.)
Are conductive/resistive devices (eg, electric heating
pads, carbon-fiber resistant heating blankets) effective
for preventing hypothermia? (Recommendation III.f.)
What elements should be included in a qualityimprovement program related to preventing intraoperative hypothermia? (Recommendation IV.)
1. Guideline for prevention of unplanned patient hypothermia. In:
Guidelines for Perioperative Practice. Denver, CO: AORN, Inc;
2016:531-554.
preventive measures.27 Policies and procedures related to
hypothermia should be kept up to date and should address
components of perioperative assessment for hypothermia,
consistent temperature measurement through all phases of
care, use of warming equipment according to manufacturer’s
instructions, and competency requirements related to
hypothermia prevention.27 Working as a collaborative team,
perioperative nurses and other health care providers in the
preoperative, intraoperative, and postoperative recovery phases
can minimize, if not eliminate, unplanned hypothermia,
resulting in optimal outcomes for their patients.
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Marie A. Bashaw, DNP, RN, NEA-BC, is an assistant
professor at Wright State University, Dayton, Ohio.
Dr Bashaw has no declared affiliation that could be
perceived as posing a potential conflict of interest in the
publication of this article.
www.aornjournal.org
EXAMINATION
Continuing Education:
Guideline Implementation: Preventing
Hypothermia 1.0
www.aornjournal.org/content/cme
PURPOSE/GOAL
To provide the learner with knowledge specific to implementing the AORN “Guideline for prevention
of unplanned patient hypothermia.”
OBJECTIVES
1.
2.
3.
4.
5.
Identify complications that may result from hypothermia.
Discuss factors that increase the patient’s risk for unplanned intraoperative hypothermia.
Discuss methods for monitoring the patient’s temperature.
Discuss considerations for choosing warming interventions.
Describe interventions that can be used to help prevent hypothermia.
The Examination and Learner Evaluation are printed here for your convenience. To receive
continuing education credit, you must complete the online Examination and Learner Evaluation
at http://www.aornjournal.org/content/cme.
QUESTIONS
1. Hypothermia may contribute to
1. patient discomfort.
2. myocardial events.
3. a shorter hospital stay.
4. slower healing.
5. incision-site infection.
a. 1 and 2
b. 2, 3, and 4
c. 1, 2, 4, and 5
d. 1, 2, 3, 4, and 5
2. Environmental factors in the OR that can contribute to
unplanned intraoperative hypothermia include
1. air movement.
2. evaporation of skin-prep solutions.
3. lack of clothing on the patient.
4. low room temperature.
5. room-temperature IV and irrigation fluids.
a. 1 and 2
b. 1, 3, and 5
c. 2, 3, 4, and 5
d. 1, 2, 3, 4, and 5
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3. In the scenario, factors that could contribute to unplanned hypothermia include the patient’s
1. age.
2. heart disease.
3. height.
4. weight.
a. 1 and 4
c. 1, 2, and 4
b. 2 and 3
d. 1, 2, 3, and 4
4. The use of general anesthesia could decrease the patient’s
temperature by _________ in the first hour after
induction.
a. 0.1 C to 0.4 C (0.2 F to 0.7 F)
b. 0.5 C to 1.5 C (0.9 F to 2.7 F)
c. 2.0 C to 3.0 C (3.6 F to 5.4 F)
d. 3.5 C to 5.0 C (6.3 F to 9.0 F)
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Bashaw
5. The surgical team chooses the intraoperative warming
methods for this patient based on
1. the IV access site.
2. the patient’s position.
3. the type of surgical procedure and incision.
4. warming-system access constraints.
a. 3
b. 2 and 4
c. 1, 3, and 4
d. 1, 2, 3, and 4
6. The irrigation solutions are warmed to a temperature of
a. 37 C (98.6 F)
b. 38 C (100.4 F)
c. 40 C (104 F)
d. 41 C (105.8 F)
7. To ensure they are gathering accurate information, the
perioperative team takes the patient’s temperature at 15minute intervals using different measuring devices at
different sites.
a. true
b. false
8. Research evidence suggests that using a combination of
active and passive warming methods may be the best
approach to prevent unplanned hypothermia.
a. true
b. false
312 j AORN Journal
March 2016, Vol. 103, No. 3
9. The active warming methods used by the surgical team in
the scenario included
1. a forced-air warming blanket.
2. heated, humidified anesthesia gases.
3. surgical drapes.
4. warmed IV and irrigation fluids.
a. 3
b. 1 and 2
c. 1, 2, and 4
d. 1, 2, 3, and 4
10. The passive warming methods used by the surgical team
in the scenario included
1. a forced-air warming blanket.
2. heated, humidified anesthesia gases.
3. surgical drapes.
4. warmed IV and irrigation fluids.
a. 3
b. 1 and 2
c. 1, 2, and 4
d. 1, 2, 3, and 4
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LEARNER EVALUATION
Continuing Education:
Guideline Implementation: Preventing
Hypothermia 1.0
www.aornjournal.org/content/cme
T
his evaluation is used to determine the extent to
which this continuing education program met
your learning needs. The evaluation is printed
here for your convenience. To receive continuing education
credit, you must complete the online Examination and Learner
Evaluation at http://www.aornjournal.org/content/cme. Rate the
items as described below.
OBJECTIVES
8.
Will you be able to use the information from this article
in your work setting?
1.
Yes
2.
No
9.
Will you change your practice as a result of reading this
article? (If yes, answer question #9A. If no, answer
question #9B.)
9A.
How will you change your practice? (Select all that
apply)
1. I will provide education to my team regarding why
change is needed.
2. I will work with management to change/implement
a policy and procedure.
3. I will plan an informational meeting with physicians
to seek their input and acceptance of the need for
change.
4. I will implement change and evaluate the effect of
the change at regular intervals until the change is
incorporated as best practice.
5. Other: __________________________________
9B.
If you will not change your practice as a result of
reading this article, why? (Select all that apply)
1. The content of the article is not relevant to my
practice.
2. I do not have enough time to teach others about the
purpose of the needed change.
3. I do not have management support to make a
change.
4. Other: __________________________________
10.
Our accrediting body requires that we verify the time
you needed to complete the 1.0 continuing education
contact hour (60-minute) program: _______________
To what extent were the following objectives of this
continuing education program achieved?
1. Identify complications that may result from hypothermia.
Low
1.
2.
3.
4.
5.
High
2.
Discuss factors that increase the patient’s risk for
unplanned intraoperative hypothermia.
Low
1.
2.
3.
4.
5.
High
3.
Discuss methods for monitoring the patient’s temperature.
Low
1.
2.
3.
4.
5.
High
4.
Discuss considerations for choosing
interventions.
Low
1.
2.
3.
4.
5.
High
5.
warming
Describe interventions that can be used to help prevent
hypothermia.
Low
1.
2.
3.
4.
5.
High
CONTENT
6.
7.
To what extent did this article increase your knowledge
of the subject matter?
Low
1.
2.
3.
4.
5.
High
To what extent were your individual objectives met?
Low
1.
2.
3.
4.
5.
High
www.aornjournal.org
AORN Journal j 313