| Heat produced - heat lost = body temperature | body temperature |
| 2 kinds of temperature | Core and surface temperature |
| Acceptable temperature range | 98.6 to 99.5 degree Fahrenheit
36 to 37 degree Celsius |
| Temperature sites: | 1
2
3
4
5
6
7 |
| Temperature sites: 1 | Oral |
| Temperature sites: 2 | Rectal |
| Temperature sites: 3 | Tympanic membrane |
| Temperature sites: 4 | Temporal artery |
| Temperature sites: 5 | Esophageal |
| Temperature sites: 6 | pulmonary artery |
| Factors that affect heat production: | 1
2
3
4
5 |
| Factors that affect heat production: 1 | Basal metabolic rate |
| Factors that affect heat production: 2 | Thyroxine output |
| Factors that affect heat production: 3 | Muscle activity |
| Factors that affect heat production: 4 | Epinephrine, norepinephrine, and sympathetic stimulation/ stress response |
| Factors that affect heat production: 5 | fever |
| Heat loss: | Radiation
Conduction
Convection
Evaporation |
| Heat loss: Heat is lost when for example, the infant is near cold surfaces. heat is lost from the infant's body to the sides of the crib or incubator and to the outside walls or windows. | Radiation |
| Heat loss: Occurs when the infant comes in contact with cold objects or surfaces such as a scale, a circumcision restraint board, cold hands, or a stethoscope. | Conduction |
| Heat loss: Occurs when drafts come from open doors, air conditioning, or even air currents created by people moving about. | Convection |
| Heat loss: Can occur during birth or bathing from moisture on skin, as a result of wet linens or clothes, and from insensible water loss. | Evaporation |
| 3 main parts of body temp regulator: | 1
2
3 |
| 3 main parts of body temp regulator: 1 | Sensors in the periphery and in the core |
| 3 main parts of body temp regulator: 2 | Integrator in the hypothalamus |
| 3 main parts of body temp regulator: 3 | Effector system that adjusts the production and loss of heat. |
| Age
Diurnal variations (circadian rhythms)
Exercise
Hormones
Stress
Environment | Factors Affecting Body Temperature |
| Alterations in Body Temperature: | Fever (pyrexia): Hyperthermia, febrile, afebrile
1. Intermittent
2. Remittent
3. Relapsing
4. constant
Fever spike
Not true fever: heat exhaustion, heat stroke |
| Nursing Interventions for Clients with Fever | Monitor vital signs
Assess skin color and temperature
Monitor white cbc, hematocrit value, and other pertinent laboratory reports for indications of infection or dehydration.
Remove excess blankets when the client feels warm, but provide extra warmth when the client feels chilled.
Provide adequate nutrition and fluids (e.g., 2.5-3liters/day) to meet the increased metabolic demands and prevent dehydration
Measure intake and output
Reduce physical activity to limit heat production, especially during the flush stage
Administer antipyretics (drugs that reduce the level of fever) as ordered.
Provide oral hygiene to keep the mucous membranes moist
Provide a tepid sponge bath to increase heat loss through conduction
provide dry clothing and bed linens. |
| Decreased body temperature, pulse, and respirations
Sever shivering (initially)
Feelings of cold and chills
Pale, cool, waxy skin
Frostbite (discolored, blistered nose, fingers, toes)
Hypotension
Decreased urinary output
Lack of muscle coordination
Disorientation
Drowsiness progressing to coma | hypothermia |
| Nursing Interventions for Clients with Hypothermia | Provide a warm environment
Provide dry clothing
Apply warm blankets
Keep limbs close to body
Cover the client's scalp with a cap or turban
Supply warm oral or intravenous fluids
Apply warming pads |
| Most common sites for body temperature vital signs: | Oral
Rectal
Axillary
Tympanic membrane
Skin/temporal artery |
| Sites for measuring body temperature: Most frequently used, least disruptive, most convenient,
done for 3 minutes | Oral |
| Sites for measuring body temperature: Most accurate route, but invasive and uncomfortable to patient.
Done for 2-3 minutes | Rectal |
| Sites for measuring body temperature: Safer than oral method, non-invasive, least accurate
Done for 10 minutes | Axillary |
| Sites for measuring body temperature: accessible, less invasive
Within two seconds
up/back for adult and down/back for pedia | Tympanic membrane |
| Sites for measuring body temperature: Most useful for infants and children when a more invasive measurement is not necessary. | Forehead temperature measurement |
| Types of thermometer: | One-piece home electronic thermometer
Institutional mode
Chemical disposable thermometer: Chemical dot thermometers
Temperature-sensitive skin tape.
Infrared (tympanic) thermometer
Infrared Forehead Thermometer Gun
Pacifier thermometer
Temporal artery thermometer |
| Quick quiz: You have delegated vital signs to assistive personnel. The assistant informs you that the patient has just finished a bowl of hot soup. The nurse's most appropriate advice would be to:
a. Take a rectal temperature
b. Take the oral temperature as planned
c. Advise the patient to drink a glass of cold water
d. Wait 30 minutes and take an oral temperature | d |
| Temperature scales: for Celsius from Fahrenheit | Fahrenheit temperature-32 multiplied by 5 and overall divided by 9 |
| Temperature scales: Fahrenheit from Celsius | Celsius temperature multiplied by 9 then divided by 5 and add 32 to the product or answer. |
