The 20-year-old healthy soccer player is brought to the emergency department after collapsing at the end of a summer soccer game. The patient is lethargic and confused about the event. Upon assessment, the nurse notes flushed, dry skin that is warm to the touch. The oral mucosa is dry, as well. Vitals are as follows: temperature 40.7°C, heart rate 122 bpm, respiratory rate 20, and blood pressure 116/64 mm Hg. A rectal thermistor is inserted and aggressive cooling measures are instituted. After 30 minutes in the ice bath, the patient’s rectal temperature is 39.1°C and the ice is partially melted. The nurse notes the rectal thermistor has stopped working; there are no other rectal thermistors in the facility. Which action by the nurse is most appropriate?

Question

The 20-year-old healthy soccer player is brought to the emergency department after collapsing at the end of a summer soccer game. The patient is lethargic and confused about the event. Upon assessment, the nurse notes flushed, dry skin that is warm to the touch. The oral mucosa is dry, as well. Vitals are as follows: temperature 40.7&deg;C, heart rate 122 bpm, respiratory rate 20, and blood pressure 116/64 mm Hg. A rectal thermistor is inserted and aggressive cooling measures are instituted. After 30 minutes in the ice bath, the patient&rsquo;s rectal temperature is 39.1&deg;C and the ice is partially melted. The nurse notes the rectal thermistor has stopped working; there are no other rectal thermistors in the facility. Which action by the nurse is most appropriate?

Accepted Answer

Continue cooling while assessing for signs of shivering. In the absence of core temperature monitoring, assessing for shivering is an acceptable alternative. Once shivering commences, remove the patient from the ice bath. Oral and axillary temperatures are not accurate in this instance. Insertion of a Foley places the patient at risk for a urinary tract infection as well as trauma to the genitourinary tract and is not appropriate.

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