A qualitative study of nurse-perceived barriers to body temperature management in postoperative patients

Although evidence-based practices exist for preventing hypothermia in patients during surgery, few studies have focused on this concern in postoperative patients. The aim of this qualitative study was to explore the most challenging issues experienced by surgical ward nurses while managing the body temperature of adult surgical patients. To address this research gap, this study used a qualitative descriptive design to document barriers to body temperature management as reported by a sample of 16 perioperative nurses. The semi-structured, face-to-face interviews were digitally recorded, transcribed verbatim and analysed using inductive content analysis. The main barriers fell into three categories: professional nursing ability limitations, unfavourable working conditions and management of human resources. The eight subcategories were disadvantageous professional views, professional knowledge limitations, low motivation to provide nursing care, non-standard treatment environment, inadequate equipment and care protocols, heavy nursing care loads, inadequate staff training and ineffective staff supervision. These findings highlighted the importance of adequate resources, proper education and evidence-based care protocols in the effective delivery of body temperature management to postoperative patients.

Back to Basics: Unplanned Patient Hypothermia: 1.3 www.aornjournal.org/content/cme

Unplanned perioperative hypothermia is a common occurrence and can negatively affect a patient's postoperative course. Perioperative nurses are responsible for identifying patients at risk for hypothermia and working with the entire surgical team to prevent this complication from occurring. Multiple interventions can be implemented to address hypothermia, including active or passive warming and warm IV and irrigation fluids. This Back to Basics article addresses patient assessment concerns, identifies a variety of evidence-based interventions that can prevent or mitigate perioperative patient temperature changes, and provides basic steps for perioperative RNs to follow to help prevent perioperative hypothermia in their patients.

Quality Improvement Initiative to Prevent Admission Hypothermia in Very-Low-Birth-Weight Newborns

OBJECTIVE

To decrease rates of admission hypothermia (<36 °C) in very-low-birth-weight (VLBW) newborns (<1,500 g).

DESIGN

Quality improvement initiative.

SETTING/LOCAL PROBLEM

Urban, Level IV NICU with 32 patient beds. The number of VLBW newborns admitted with temperatures less than 36 °C was greater than in comparable NICUs in the Vermont Oxford Network.

PARTICIPANTS

Neonates born in 2016 who weighed less than 1,500 g at birth.

INTERVENTION/MEASUREMENTS

Based on the literature and the needs of our unit, our team decided to focus efforts on equipment (chemical mattresses and polyurethane-lined hats for newborns who weighed <1,000 g and polyurethane-lined hats for newborns who weighed <1,500 g), staff education/awareness, and temperature documentation and workflow. Axillary temperature measurements for all neonates who weighed less than 1,500 g were tracked on admission.

RESULTS

The processes involved in this quality improvement initiative were successfully implemented, and use of new equipment began January 1, 2016. In 2016, only 9.6% (n = 7) of VLBW newborns were admitted with temperatures less than 36 °C, compared with 20.2% (n = 19) in 2015 and 32.4% (n = 24) in 2014 (p = .003). Overall, the mean admission temperature for neonates who weighed less than 1,500 g rose from 36.2 °C in 2014 to 36.6 °C in 2016 (p = .001).

CONCLUSION

We reduced the number of VLBW neonates admitted with temperatures less than 36 °C and increased overall admission temperatures for neonates who weighed less than 1,500 g with the addition of polyurethane-lined hats and chemical mattresses.

GUIDANCE FOR PERIOPERATIVE NURSES TO PREVENT PERIOPERATIVE HYPOTHERMIA IN OBSTETRICS

The prevention of perioperative hypothermia is a responsibility of all members of the perioperative team. Nurses are well placed to have a central role in implementing strategies to reduce perioperative heat loss, which is associated with a host of adverse outcomes (National Collaborating Centre for Nursing and Supportive Care 2008).

Hope, hypothermia and human spirit: Refugee Support First Aid and Care Team

Brighid Langtry reflects on her life-changing experiences as a volunteer medic with Refugee Support in 'The Jungle' camp in Calais.

Preventing admission hypothermia in very low birth weight neonates

Neonatal hypothermia, temperature < 36.5°C, is a major contributor to neonatal mortality and morbidity. hypothermia of preterm infants remains a challenge in the NiCU for many reasons. preterm very low birth weight (VlBW) infants, those infants born <1,500 g, are prone to very rapid heat losses through mechanisms of convection, evaporation, conduction, and radiation. this article reviews current research to reduce and prevent mortality and morbidity from hypothermia in preterm VlBW infants by implementing interventions in the delivery room to minimize heat loss and maintain core body temperatures.

[Accidental hypothermia, not just a clinical sign, a social alarm bell]

Accidental hypothermia, even slight, affects the physiological functioning of the body. It requires all the attention of the caregivers, both in terms of prevention among vulnerable people as well as its treatment. Two types of rewarming therapy, one external and passive, the other internal and active, can be envisaged depending on the seriousness of the hypothermia to be treated.

Application of plastic wrap to improve temperatures in infants born less than 30 weeks gestation: a randomized controlled trial

PURPOSE

The primary aim of the study was to evaluate whether the application of a plastic wrap immediately after birth is more effective than the standard care of temperature management for improving admission temperatures to the neonatal intensive care unit (NICU) in infants <30 weeks gestation.

DESIGN

A randomized controlled trial was conducted. Infants in the intervention group were transferred to a prewarmed radiant heater immediately after birth and encased in NeoWrap from the neck down without being dried. The infant's head was dried with a prewarmed towel and a hat added. The control group received usual care for the unit; the infant was transferred to the prewarmed radiant warmer and dried, and warm towels and a hat are then applied.

SAMPLE

A total of 92 infants were analyzed: 49 in the control group and 43 in the intervention group; 48 (52.2 percent) were <27 weeks gestation, and 44 (47.8 percent) were <30 weeks gestation. The infants' temperatures were assessed for two hours following admission.

Improvement in knowledge of nursing staff after an educational intervention about control of newborn temperature

Newborn infants are at risk for hypothermia. Providing an adequate thermal environment is fundamental

OBJECTIVE

To assess nurses knowledge about temperature control in newborns before and after an educational intervention and its effect in the prevalence of hypothermia.

METHODS

Registered nurses working in a NICU received an educational intervention. They answered a pretest and posttest. Prevalence of hypothermia was recorded.

RESULTS

Subjects included 55 nurses (89% females, 11% males). The subjects showed improvement in knowledge (81% correct answers before. 88% after, p < 0.01) Prevalence of hypothermia was similar before and after the intervention.

CONCLUSION

An educational intervention in small group format was successful in improving nurse knowledge about temperature control in newborns. There was no effect in the prevalence of hypothermia. The intervention was aimed to registered nurses but neonatal hypothermia prevention requires interactions by all caregivers, thus educational interventions should be aimed to all personnel involved in neonatal care.

[The treatment of combat casualties today]

Most soldiers are wounded by an explosion and haemorrhaging is the main cause of death. From the first aid provided on the field of combat to repatriation to France, every stage in the treatment of injured soldiers is meticulously organised in order to save as many lives as possible.

[Hypothermia in people in situations of precarity]

Human beings are physiologically warm blooded. Confronted with extreme cold, they become subject to hypothermia. Between a mountain climber and a person living in the street, the functions of resistance to a drop in external temperature are not the same. Studies on this subject remain to be carried out.

Prevention of hypothermia

This article examines normal thermoregulation and the changes in temperature control associated with the ageing process. Factors that influence hypothermia in older people are identified and the article concludes with advice that nurses may give to older people to prevent hypothermia.

[Complications of the hemodialysis procedure in acute renal failure patients: nursing interventions]

This retrospective study has identified both the prevalence of complications during hemodialitic treatment in patients carrying acute renal failure (ARF) in an intensive care unit of a university hospital and the nursing conduct performed during those episodes. We have assessed sixty-five (282 sessions) records of ARF patients who underwent renal replacement therapy and presented complications during hemodialysis sessions. We have noticed that the most prevalent intradialitic complications were: arterial hypotension (35%), hypothermia (29%), and lack of flow in the vascular access (24.1%). The nursing interventions prioritized during episodes of clinical complications involved clinical assessment (66.8%) and evaluation of patients' consciousness level (59.9%). The search for nursing procedures that are suitable to different situations experienced by patients during hemodialysis, as well as the continuing education of the nursing team are actions that may minimize the intercurrence rate.

[Postoperative hypothermia: role of the nurses' aide in ensuring the patient's well-being and comfort]

Non-induced hypothermia is caused by anesthetic techniques, surgical procedures, and the environmental temperature in operating rooms, which affect the body's physiologic thermoregulation mechanisms. Postoperative hypothermia occurs in 93% of surgical patients and is accompanied by shivering in 65% of cases. Non-induced hypothermia affects the patient's postoperative recovery, as it alters metabolic response and reduces the patient's comfort during this period. Within the protocol for controlling postoperative hypothermia, the main objective of the nurses' aide consists of detecting and recording postoperative hypothermia, as well as of correcting the deficit by means of active warming of the body's external surface. These activities not only aid the patient's recovery and reduce complications, but also lower healthcare costs and increase postoperative comfort.

Inadvertent hypothermia: a literature review

While working on my first placement in the operating department recovery room, I was surprised by the frequency of patients coming into recovery with mild hypothermia, having taken their temperature on arrival. In many cases the patient did not arrive with a forced-air warming blanket, or any device other than a cotton blanket. It seemed to me that it would be more efficient, kinder and possibly more cost-effective to takesteps to prevent perioperative hypothermia rather than to treat the consequences.

Nursing management of the patient with hypothermia

This article describes the signs and symptoms of hypothermia and outlines its acute nursing management.

Thermoregulation and heat loss prevention after birth and during neonatal intensive-care unit stabilization of extremely low-birthweight infants

Extremely low-birthweight infants have inefficient thermoregulation due to immaturity and may exhibit cold body temperatures after birth and during their first 12 hours of life. Hypothermia in these infants can lead to increased morbidity and mortality. Anecdotal notes made during our recent study revealed extremely low-birthweight infants' temperatures decreased with caregiver procedures such as umbilical line insertion, intubations, obtaining chest x-rays, manipulating intravenous lines, repositioning, suctioning, and taking vital signs during the first 12 hours of life. Therefore, nursing interventions should be undertaken to prevent heat loss during these caregiver procedures. Nurses can improve the thermal environment for extremely low-birthweight infants by prewarming the delivery room and placing the infant in a plastic bag up to the neck during delivery room stabilization to prevent heat loss.

The effects of intravenous fluids temperature on perioperative hemodynamic situation, post-operative shivering, and recovery in orthopaedic surgery

BACKGROUND

Perioperative hypothermia is physiologically stressful because it elevates blood pressure, heart rate and plasma catecholamine concentration that may increase the risk of cardiac complications, bleeding, wound infection, and post-anaesthesia care unit stay. This study was designed to evaluate the effects of warming intravenous fluids on perioperative hemodynamic situation, post-operative shivering and recovery in orthopaedic surgery patients.

METHODS

Perioperative pulse rate, blood pressure, intraoperative esophageal and skin temperature were measured in sixty patients undergoing orthopaedic surgery that were randomly divided into two groups according to intraoperative IV fluids management. In 30 patients (hypothermia group) all IV fluids infused were at room temperature. In the other 30 patients (normothermia group) all IV fluids were warmed using a dry IV fluid warmer.

RESULTS

The core and skin temperatures of the hypothermia and normothermia groups decreased significantly between the induction of anesthesia and the end of surgery, but the drop was greater in the hypothermia group (P < 0.005). Postoperative mean arterial blood pressure (non-invasive) increased significantly more in the hypothermia group versus normothermia group (p < 0.005). Shivering was observed in 21 of 30 in the hypothermia group and 11 of 30 in the normothermia group (p < 0.005) and recovery time was significantly lower in the normothermia group (36 +/- 5 vs. 26 +/- 3 min, p < 0.005).

CONCLUSION

Intraoperative IV fluid warming reduces perioperative changes to the hemodynamic situation, post-operative shivering, and recovery time.

Damage control surgery for the patient who has experienced multiple traumatic injuries

PATIENTS WHO HAVE EXPERIENCED multiple traumatic injuries present one of the greatest challenges for perioperative teams. IN A TRAUMA PATIENT who is hemorrhaging, increased risk of death arises from a vicious cycle of hypothermia, coagulopathy, and metabolic acidosis known as the triad of death. A STAGED SURGICAL APPROACH predicated on specific priorities for treating multiply injured patients can help save the lives of these patients.

Nursing and medical staff knowledge regarding the monitoring and management of accidental or exposure hypothermia in adult major trauma patients

Recording a patient's vital signs is a basic requirement that in part informs clinical decision-making. Practice suggests that recording a trauma patient's temperature is occasionally overlooked in the emergency department. A staff survey was undertaken to gain an appreciation of knowledge and understanding of the issues that surround accidental or exposure hypothermia in trauma patients. Results demonstrate that nurses and doctors are unsure of how to define hypothermia and are not conversant with simple ways to prevent heat loss or rewarm patients. Complications from hypothermia such as coagulopathy and metabolic acidosis were seldom identified. Issues that limit staff recording temperature include patient access and acuity, lack of knowledge and confidence and access to temperature-measuring devices. These results emphasize the need for regular education. Implications for clinical practice were considered; an algorithm to guide staff on ways to improve the monitoring and management of temperature in trauma patients was developed. Opportunities for ongoing and further research were identified.

[Effect of very early kangaroo care on extrauterine temperature adaptation in newborn infants with hypothermia problems]

Increased morbidity and mortality has been associated with neonates admitted with body temperatures below 36 degrees C. We employed an experimental design in a randomized control trial to compare the effectiveness of using early kangaroo care (KC) for extrauterine temperature adaptation against that of using radiant warmers. Trial subjects included 78 consecutive cesarean newborn infants with hypothermia problems. The KC group received skin-to-skin contact with their mothers in the post-operative room, while infants in the control group received routine care under radiant warmers. The mean temperature of the KC group was slightly higher than that of the control group (36.29 degrees C vs. 36.22 degrees C, p = .044). After four hours, 97.43% of KC group infants had reached normal body temperatures, compared with 82.05% in the radiant warmer group. Results demonstrate the positive effects of KC for extrauterine temperature adaptation in hypothermia infants. In the course of evidence-based practice, KC could be incorporated into the standard care regimen in order to improve hypothermia care.

Convection heating in pediatric general surgery - a comparison of warming alternatives in a mannequin study

BACKGROUND

Numerous methods of patient warming are used to prevent intraoperative hypothermia in children. Commercially available forced air warming blankets are effective, but are single-use items. We tested a custom-designed heat dissipation unit (HDU) against one such commercially available blanket.

METHODS

Air temperatures at various points around a mannequin under simulated operating conditions were recorded using thermistors and thermal imaging. The only variable changed was the heating method: a forced air blanket or a customized HDU with two draping techniques - cotton drapes with and without a plastic 'undersheet'.

RESULTS

The three methods produced similar temperature increases and plateaux across the 11 thermistor points measured. There were no significant differences between temperatures at 1 h. A plastic sheet did not appear to enhance the effectiveness of the HDU in this study. Thermal imaging photography suggested more uniform heating of the mannequin with the HDU arrangements.

CONCLUSIONS

The custom-built HDU compares favorably in our mannequin study with a Bair Hugger forced air warming blanket. As it is reusable, it offers considerable potential savings.

Postoperative hypothermia—The chilling consequences

Unplanned hypothermia is commonly encountered in the perioperative period. Nursing has contributed to the literature on hypothermia with studies on shivering and treatment modalities; however, the direct physiological consequences of postoperative hypothermia have been reported mainly in the medical literature. Research on the physiological effects of postoperative hypothermia offers nurses further evidence to support interventions for temperature correction in patients with hypothermia. Evidence indicates that forced-air warming is the most effective method for warming hypothermic patients. The Roy Adaptation Model is explained as a framework for nursing care of patients with hypothermia. Clinical practice guidelines for unplanned perioperative hypothermia also are provided.

The effect of preoperative warming on patients' postoperative temperatures

Many perioperative clinicians encounter difficulty in preventing hypothermia in surgical patients. One intervention to prevent perioperative hypothermia is the use of forced-air warming. Although forced-air warming is used most frequently in the intraoperative area, prewarming patients with forced-air warming systems before induction of anesthesia may be enough to prevent hypothermia throughout the surgical procedure, allowing patients to arrive in the postanesthesia care unit in a normothermic state. A review of the literature on preoperative forced-air warming is provided, and the effect of prewarming on postoperative patient temperatures is discussed.

Temperature Measurement in the Phase I PACU

Perioperative hypothermia remains a common occurrence in the Phase I PACU. Identification of and appropriate intervention for this complication is of prime importance in the prevention of adverse outcomes. This article provides an overview of perioperative hypothermia and offers a summary of the most common methods used to measure body temperature.

Temperature--the forgotten vital sign

OBJECTIVE

To improve the measurement of core body temperature in the resuscitation room.

METHOD

This work was undertaken in the Emergency Department (ED) of a large District General Hospital. The clinical notes for all admissions to the resuscitation suite during a 2 month period were reviewed to establish the frequency of temperature measurement. Following a simple educational program, performance was re-audited using the same methodology.

RESULTS

Of the first cohort 13.4% had had their temperature recorded. This improved to 71.6%.

CONCLUSIONS

The measurement of body temperature in the resuscitation room is important as hypothermia has profound effects on the cardiovascular, pulmonary, neurological and haemostatic systems. Clinical audit highlights poor current performance and enables improvement of practice through simple education.

Is Postanesthesia Care Unit Length of Stay: Increased in Hypothermic Patients?

Inadvertent hypothermia is one of the most common complications experienced by surgical patients who are transferred to the postanesthesia care unit (PACU). Appropriate pacu length of stay (LOS) is defined as the time required for a patient to achieve a physiologically stable condition after anesthesia administration. In studies measuring appropriate LOS, patients who arrived hypothermic in the PACU had longer stays than those who arrived normothermic. The aims of this study were to determine whether the actual and appropriate LOS in the PACU differs between hypothermic and normothermic patients and to identify differences between subgroups of patients according to age, gender, and type of anesthesia administered.

The effect of wool vs. cotton head covering and length of stay with the mother following delivery on infant temperature

Rectal temperature of 126 term infants was measured on admission to the nursery following variable periods of stay with the mother in the delivery room. Fifty-nine infants who wore woolen hats after delivery had higher rectal temperature than 67 infants whose head was covered by loosely applied cotton diapers (36.5+/-0.5 degrees C vs. 36.3+/-0.5 degrees C, respectively; p=0.03). Among them there were fewer infants who were admitted with rectal temperature 36 degrees C (12 vs. 26, respectively; p=0.03). In multiple regression analyses accounting for head covering with woolen hats, birth weight, gender, delivery room temperature and length of stay with the mother, only birth weight and head covering with woolen hats were significantly associated with rectal temperature at arrival in the nursery (p=0.002 and 0.03, respectively), and only head covering with cotton diapers was significantly associated with rectal temperature 36 degrees C (p=0.03). Our data imply that covering heads of term newborns with simple woolen hats may reduce or prevent heat loss following delivery, and that adequate warming of infants is achieved during prolonged stay with the mother.

Hypothermia: risk factors and guidelines for nursing care

Hypothermia occurs when heat loss from the body exceeds heat gain and the core temperature of the body falls below 35 degrees C. Although death from hypotheRmia is rare, 80 per cent of associated mortalities are in older people. There are many underlying conditions that increase a person's susceptibility to cold and this includes not having the ability to make appropriate environmental adjustments to maintain body temperature. The nursing management of a patient with hypothermia depends upon the severity of the condition. The nurse's primary concern is to treat the symptoms and re-warm the patient appropriately.

Using evidence-based practice to develop a protocol for postoperative surgical intensive care unit patients

Sixty adult postoperative patients from the surgical intensive care unit with core temperatures <35.4 degrees C, as measured by a pulmonary artery catheter, were randomly assigned to one of three treatment options for hypothermia. Results of this study confirmed findings in the literature that forced warm air generated quickest rewarming times. A rewarming protocol for hypothermic patients was developed and implemented. Performance improvement activity demonstrated high compliance rates with nurses using the rewarming protocol.

AANA journal course. Update for nurse anesthetists. A common sense approach to hypothermia

Hypothermia frequently is considered inadvertent in the perioperative setting. The preservation of vital body heat has been an issue since the 1800s. This article provides a select review of the causes of hypothermia and the methods for prevention of hypothermia during the perioperative period. Providing patients with an environment designed to foster normothermia can preclude the costs of longer hospital stays, prevent morbid conditions associated with hypothermia, and provide patients with a more comfortable perioperative experience. Our goal as perioperative healthcare providers is a normothermic perioperative experience for all patients.

Thermal efficiency of prewarmed cotton, reflective, and forced-warm-air inflatable blankets in trauma patients

PURPOSE

To compare the thermal efficiency of 3 methods of heat-loss prevention in trauma patients undergoing resuscitation in the emergency department and the nurses' attitude toward the use of each method.

DESIGN

A quasi-experimental design was used to compare 3 interventions for heat-loss prevention: 3 prewarmed cotton blankets, a reflective blanket with a head covering over 1 prewarmed cotton blanket, and a forced-warm-air inflatable blanket. All patients (n = 298) admitted in trauma-alert status and who were not hypothermic at the time of admission were randomly assigned to 1 of the interventions. Temperatures were recorded every 15 minutes for the first hour, then hourly until the patient was transferred from the emergency department. Nurses were asked to comment on and rate each method for ease of use, convenience, and access to the patient during care.

FINDINGS

Analysis of variance results showed no significant differences in temperature change among the groups. Nurses significantly preferred the prewarmed cotton and reflective blankets to the warm-air inflatable blanket.

CONCLUSIONS

The 3 modes of temperature conservation equally maintained body temperature in trauma patients who were not hypothermic on admission. The nurses surveyed had a preference for not using the more mechanical intervention.