NURSING PATIENT CARE POLICY & PROCEDURE
May 20, 2016
Nursing Manual (Red)
Policy #: 8.12AP
Title: Hypo/Hyperthermia Thermal Blankets for
Adult and Pediatric Patients (Excluding
Neonates) (Adult & Pediatric)
A. To regulate body temperature through actively re-warming hypothermic patients
or to cool hyperthermic patients. The hypo/hyperthermal blankets or wraps
contain passages where heated/cooled water is circulated by a machine. These
blankets are placed under and/or over the patient for warming or cooling. The
provider’s order should indicate the desired body temperature and length of time
the temperature is to be maintained.
B. The decision to use external warming or cooling devices depends on effectiveness
and indications or contraindications of other therapies such as antipyretics, ice
packs, or sponging and the patient’s response to the current body temperature.
C. NOTE: This policy is not for Neonates, please refer to neonatal policies.
A. A provider’s order is required for use of the external warming or cooling blanket.
B. Rectal temperatures are contraindicated in pediatric patients who are pre-term and
patients with anal atresia; recent bowel, rectal or perianal surgery; who are
immunocompromised or have platelet counts less than 50 K/uL.
A. Hypo/Hyperthermal machine with solution (obtained from Central Services [CS])
B. Hyper/Hypothermal blankets (vinyl) bottom and top (if needed) (CS Item Number
4004226) or Hyper/Hypothermia Vest (Large - CS Item Number 4013572,
Small/Medium – CS Item Number 4013571) or Hyper/Hypothermia Leg Wrap
(CS Item Number 4013573)
C. Temperature-sensing bladder catheter or temperature probe (CS Item Number
4004770) and lubricant (if machine is operated in auto mode; optional in manual
D. Bath blanket
E. Adhesive tape (optional)
A. To Prepare the Patient and Initiate Therapy
1. Determine the need for hypo/hyperthermia machine. Review physician’s
order for body temperature desired and length of time the temperature is to
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2. Prepare machine according to specific model directions.
a. CS or Clinical Engineering fills machine with the appropriate
b. If additional solution is needed, call CS to refill machine. DO NOT
use solutions other than those supplied by CS. Solution is available
on tap in Reprocessing.
3. Cardiac monitoring is recommended due to potential for dysrhythmias.
Hyperthermia may cause tachycardia and ventricular dysrhythmias.
Hypothermia may cause bradycardia, heart block and ventricular
4. Assess patient for baseline vital signs including core temperature and
general condition (especially skin integrity including color and edema).
Document on appropriate nursing flowsheets in the clinical record.
5. Set appropriate dial and controls for the desired temperature.
a. Auto: In this mode, the goal temperature is set on the machine and
the temperature in the blanket is adjusted automatically to maintain
this goal temperature. A temperature-sensing bladder catheter or
rectal temperature probe is required in this mode. For cooling
patients, the blanket temperature is low (very cold) to bring down
the patient’s temperature initially. If the patient’s temperature falls
suddenly, assess for probe dislodgement.
b. Manual: In this mode, the temperature of the blanket is
programmed into the machine. The nurse monitors the patient’s
temperature and adjusts the temperature of the blanket on the
machine to achieve the goal temperature in the patient.
6. Place the bottom hypo/hyperthermia blanket on the bed with lead tubes at
the foot of the bed. Cover hypo/hyperthermia blanket with a bath blanket.
Hypo/hyperthermia blanket may be placed on top of patient if needed;
underneath is recommended. DO NOT use pins or other sharp objects,
which could damage the vinyl blanket, bed or linen. Adhesive tape may be
7. Position patient in supine position, if possible, on the bath blanket; cover
patient with a sheet.
a. The greater the area of skin in contact with the blankets, the faster
the desired temperature can be reached.
b. Additional covers may be needed if patient is being warmed,
including a cover for the patient’s head.
c. Protective coverings are placed as indicated, e.g., feet, scrotum,
sacrum, to prevent burns or frostbite.
d. Place patient between two hypo/hyperthermia blankets for faster
cooling/warming. Place the top hypo/hyperthermia blanket over
the patient with tubes toward the foot of the bed.
8. Temperature-sensing needs to be a core temperature measuring device,
which can be a bladder catheter or a rectal temperature probe. Clinicians
should choose the most accurate and reliable method to measure
temperature based on the patient’s clinical condition.
9. If rectal probe is used:
a. Lubricate and insert flexible rectal probe carefully into the rectum
about 3-6 inches for adults.
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i. For children: children 4-5 centimeters
b. Tape in place. Check temperature probe for correct insertion into
the cooling machine.
c. Make sure the correct probe for the hypo/hyperthermia unit is
being used. (Probe can be checked for accuracy by noting room
temperature before inserting probe, about 22 degrees Celsius.)
d. If rectal probe is used, it should be removed from the patient's
rectum every 4-5 hours to be cleaned and reinserted for accuracy
10. Monitor hypo/hyperthermia unit every hour to determine that desired
temperature is maintained and that it is functioning properly. If the
solution level is too low, the pump cannot function and the desired
temperature will not be maintained. (See instructions on specific model in
use.) Contact CS for additional solution.
11. Document use of equipment in the clinical record.
B. Care of Patient with Hyperthermia
1. Assess and document patient's vital signs every 15-30 minutes until the
desired body temperature is reached and at least every hour thereafter, as
indicated by patient condition and according to physician orders.
a. Temperature setting varies depending on patient condition and/or
physician's order. Recommended temperature setting for
hyperthermia treatment is 15.5 degrees Celsius (C) +/- 5 (60
degrees Fahrenheit (F) +/- 5).
b. If the temperature does not decrease, lower the thermal system to
12.3 degrees C (55 degrees F). Reset at 18.3 degrees C (65 degrees
F) when body temperature is normal.
2. Observe nail beds and lips at 15-30 minute intervals until desired body
temperature is reached. Cyanosis indicates peripheral blood vessel
constriction, peripheral blood vessel collapse, respiratory difficulty, or
3. Observe patient for shivering. During the induction phase, be alert for
shivering as it causes increased oxygen consumption, increased metabolic
rate, increased cardiac workload and can raise core temperature. Early
detection of shivering is important and can be accomplished by palpation
of the mandible for vibration. ECG artifact may also be seen due to
muscular contraction. Notify physician if shivering occurs. Physician may
prescribe anti-shivering medication.
4. Observe skin every hour. Signs of frostbite include skin discoloration
(white, redness, blue), hardness, numbness or prickling.
5. Check patient's level of consciousness and respiratory function every hour.
6. Provide reassurance and reorient patient as necessary.
7. Encourage patient to breathe deeply and cough if possible. Watch for signs
of respiratory distress, i.e., cyanosis, moist or irregular respirations,
8. Suction mouth as indicated. Depending on the patient's diagnosis,
expectoration of secretions may become difficult or impossible in the
presence of decreased level of consciousness. For intubated patients,
assess respiratory status and suction as indicated.
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9. Prolonged hyperthermia states cause insensible fluid loss. Patient should
be closely monitored for fluid and electrolyte imbalances. Maintain IV
fluids, give fluids as ordered, and monitor intake and output.
10. Give frequent oral care as needed (refer to UWHC Nursing Patient Care
Policies 13.12, Basic Care Standards-Adult and 13.16, Basic Care
11. Maintain good body alignment.
12. Turn patient at regular intervals (a minimum of every 2 hours and more
frequently as needed). Inspect skin for blanching, redness, excoriation or
pressure areas. Watch for cyanosis and pallor.
13. Document in the clinical record the time treatment was initiated, patient's
response and nursing measures performed. Report hemodynamic
instability, cardiac rhythm changes, and untoward responses immediately
to the physician.
C. Care of Patient with Hypothermia
1. Assess and document patient's vital signs every 15-30 minutes until
desired body temperature is reached and at least every hour after, as
indicated by patient condition.
a. Hypothermia is defined as a core temperature less than 35 degrees
C (95 degrees F). The goal of warming is to achieve a core
temperature above 35 degrees C. Recommended setting to warm
the patient is 10 degrees above the patient's temperature.
b. Limits set on automatic operation will provide the necessary
heating or cooling for maintenance of the desired temperature. This
works only if the temperature probe is used and the unit is set on
2. Place patient on cardiac monitor to observe for cardiac dysrhythmias
according to physician order. The most common ECG abnormality in
hypothermia is generalized progressive depression of myocardial
conduction: PR, QRS, and QT intervals may prolong. Sinus bradycardia,
atrial flutter, atrial fibrillation, and premature ventricular contractions may
occur. Increased ventricular irritability manifested by idioventricular
rhythm and ventricular fibrillation is most common in temperatures less
than 32 degrees C. Asystole may occur at less than 15 degrees C.
3. Observe nail beds and lips at 15-30 minute intervals until desired body
temperature is reached. Cyanosis indicates peripheral blood vessel
constriction, respiratory difficulty or heart failure.
4. Observe patient for shivering. Be alert for shivering as it causes increased
oxygen consumption, increased metabolic rate, increased cardiac
workload and can raise core temperature. Early detection of shivering is
important and can be accomplished by palpation of the mandible for
vibration. ECG artifact may also be seen due to muscular contraction.
Notify physician if shivering occurs.
a. Physician may prescribe anti-shivering medication.
b. Use higher blanket temperatures to prevent shivering.
5. Observe patient carefully for untoward effects of drugs.
a. Hypothermia can modify the effects of medication patient is
receiving and cause side effects.
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b. Intramuscular and subcutaneous drugs are discouraged because of
the reduced blood flow. If bleeding occurs, apply firm pressure to
promote clot formation.
6. Observe skin frequently (a minimum of every two (2) hours and more
frequently as needed) for discoloration (white, redness, blue), hardness,
numbness or prickling. Patients can be burned by the blanket during
warming if the skin is not adequately protected. Particular attention should
be paid to body surfaces closest to blanket, i.e. posterior if blanket
7. Assess patient's level of consciousness and respiratory function every
a. Mild hypothermia (35-32.2 degrees C) is usually quite benign.
Ataxia, slight clumsiness, slowed response to stimuli, and
dysarthria are common. Shivering starts at this stage and
vasoconstriction becomes prominent.
b. With significant hypothermia (32.2-25.6 degrees C), shivering
stops and is replaced by muscular rigidity. Delirium, stupor and
coma may be present. The patient is often arousable and can be
conversant. Temperatures below 30 degrees C are particularly
dangerous. At this stage, the basal metabolic rate is less than 50
c. With severe hypothermia (lower than 25.6 degrees C) there is no
heat conservation. Death may ensue, particularly if hypothermia is
present greater than two (2) hours. Under controlled circumstances
patients have survived with temperatures as low as 16 degrees C
(60.8 degrees F). Purposeful movements and reflexes are absent.
The pupils are unreactive. The standard criteria of brain death do
not apply as the hypothermia itself protects against hypoxic
damage. Prolonged CPR may be required in these patients.
d. For Pediatric patients, definition of hypothermia is:
i. Mild hypothermia is less than 35 degrees C
ii. Moderate hypothermia is 35-32 degrees C, shivering with
increase oxygen consumption and increased sympathetic
iii. Severe hypothermia is 32-28 degrees C, bradycardia,
hypotension and decrease oxygen consumption
iv. Profound hypothermia is less than 28 degrees C, severe
bradycardia, potential for ventricular fibrillation and or
8. Encourage patient to breathe deeply and cough if possible. Suction if
a. Depending on the patient's diagnosis and condition, expectoration
may become difficult or impossible in presence of decreased level
of consciousness. Some patients will be intubated.
b. A warmed inspiratory humidifier is recommended in the intubated
9. Maintain and administer IV fluids as ordered. Evaluate for fluid and
electrolyte imbalances. IV insertion may be difficult due to
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10. Maintain good patient body alignment.
11. Re-warming should NOT occur faster than two (2) degrees Celsius per
hour for adults or one degree Celsius per hour for children or as ordered
by the physician.
a. Rapid re-warming can cause acidosis, shivering, hypovolemic
shock, temperature afterdrop and temperature overshoot.
Temperature afterdrop is a decrease in core temperature after re-
warming is discontinued.
b. As patients re-warm, observe for possible hypotension as the
periphery vessels will dilate from warming.
12. Turn patient at regular intervals (minimum of every two (2) hours, turning
more frequently than every two (2) hours may be needed) and inspect the
skin for blanching, redness, excoriation and pressure areas. Prevent
prolonged or excessive tissue pressure.
a. Patient will warm faster if large amount of skin surface is in
contact with the hypothermia blanket.
b. The area between the patient and the blanket should be kept dry.
c. Patients can be burned if skin is not adequately protected.
13. Document the time treatment was instituted, patient response and nursing
measures performed in the clinical record. Untoward responses are
immediately reported to the physician.
14. Document use of equipment in patient’s clinical record.
D. Discontinuation of Therapy
1. Disconnect hypo/hyperthermia blanket tube connectors from the machine.
2. Remove hypo/hyperthermia blanket from the patient's bed and discard.
3. Return machine to Central Services Reprocessing.
a. Machines are cleaned in CS.
i. Any machine used in isolation is wiped with hospital
disinfectant detergent and returned to CS.
4. Document the time treatment was discontinued, patient response and
general condition as temperature returned to normal. Report any unusual
response or finding to the physician.
5. Return equipment to CS.
6. Discontinue equipment rental in computer system to stop daily use charge
from being posted to the patient's bill.
V. UWHC CROSS REFERENCES
A. Hospital Administrative Policy 13.07, Standard Precautions & Transmission-
based Precautions (Isolation) for Inpatient Settings
B. Nursing Patient Care Policy 8.19, Patient Warming System With Forced Air
Overbody and Underbody Blankets (such as Bair Hugger Patient Warming
C. Nursing Patient Care Policy 13.12, Basic Care Standards (Inpatient Adult)
D. Nursing Patient Care Policy 13.16, Basic Care – Inpatient Pediatrics (Birth-18
years of age)
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A. AACN, Carlson, K. K., Lynn-McHale Wiegand, D. J. (Eds.) (2005). AACN
Procedure Manual for Critical Care. St. Louis, MO: Elsevier Science.
B. Proehl, J. A. (2008). Emergency nursing procedures (4th Ed.). St. Louis, MO:
Elsevier Health Sciences.
C. Hazinski, M. F. (Ed.) (2013). Drowning and Submersion. Nursing Care of the
Critically Ill Child. St Louis, MO: Elsevier/Mosby.
D. Henker, R., & Carlson, K. K. (2007). Fever: applying research to bedside practice.
AACN Advanced Critical Care, 18(1), 76-87.
E. O’Grady, & et al (2008). Guidelines for evaluation of new fever in critically ill
adult patients: 2008 update from the American College of Critical Care Medicine
and the Infectious Diseases Society of America. Critical Care Medicine, 36,
F. Verger, J. T., & Lebet, R. M. (Eds.) (2008). Hypothermia/Hyperthermia Blanket
and Use of Bair Hugger Warming Unit and Warming Cover. AACN Procedure
Manual for Pediatric Acute and Critical Care. St. Louis, MO: Saunders/Elsevier,
VII. REVIEWED BY
Clinical Nurse Specialist, Cardiology
Clinical Nurse Specialist, Emergency Services
Clinical Nurse Specialist, Pediatric Intensive Care Unit (PICU)
Clinical Nurse Specialist, Pediatric Universal Care Unit
Nursing Patient Care Policy and Procedure Committee, May 2016
Beth Houlahan, DNP, RN, CENP
Senior Vice President Patient Care Services, Chief Nursing Officer