Vital Signs: Body Temperature

Flashcard maker : Lily Taylor
Vital Signs (VS)
Assessment of vital or critical functions.
Surface Temperature
*Temperature of skin, varies with environmental conditions
Core Temperature
*Temperature of interior body tissues, remains almost constant (within 1 degree F)
***PRODUCT OF THE PRECISE BALANCE BTW HEAT PRODUCTION AND HEAT LOSS
Why is a baseline important?
1. A change in a vital sign may be caused by a disease,effect of therapies, changes in activity and enviroment
Normal Ranges of Temperature:
Oral/Tympanic Temp: 96.8-100.4 degrees F (36-38 degrees C)
Axillary-typically one degree F lower than oral, less reliable
Rectal**BEST REFLECTS CORE TEMP, one degree F higher than oral
Body temperature
Degree of heat maintained by the body
Heat Production
**Must equal heat loss in order for core temperature to remain normal
**produced as a by product of chemical reactions (metabolism)
**rate of heat production determined by metabolic rate
Factors affecting Heat Production
-activity/age
-hormones
-psychological well being
-nutritional status
-body and environmental temperature
How is heat produced in the body?
Interaction of metabolism, movement of skeletal muscles and non-shivering thermogenesis
Basal Metabolic Rate (BMR)
*Amount of energy used by the body during rest in an awake state
Basal Condition
Npo for 12 hours, no exercising after waking, restful nights sleep, environmental temperature 68-80 degrees F and patient relaxed
BMR Factors
-varies with age, sex & temperature, increased temp=increased BMR
-exercise increases bodys heat production
-thyroid hormone metabolism (hyper increases bmr)
-sympathetic nervous system increases bmr (fight or flight)
Heat loss through 4 process:
1. Radiation
2. Convection
3. Evaporation
4. Conduction
Radiation
Objects facing each other are radiating heat towards one another
Conduction
Transfer of heat from one object to another through direct contact (heating blanket)
Convection
Transfer of heat through currents of air or water (ie fan, open window)
Evaporation
Water converted to vapor and lost through the skin (600 ml per day) ie. sweat in response to temperature elevations/ temperature of surroundings is greater than temp of skin surface
Normal Temperature
Oral 97.3 F (36.3 C) , in practice 98.6/37
Rectal- 98.6
Core- 97 F (36.1 C-38.2C) -100.8F
Factors Effecting Body Temp Age:
-Infants have unstable body temperatures because thermoregulatory mechanisms are immature
-Normal temperature drops as a person ages
-Chronic illnesses and medications may alter body temp
Factors Effecting Body Temp Enviroment:
-Changes in Environment do not effect core temp due to internal regulatory mechanism
-However exposure to extreme heat/cold affect body temperature
**if a core temp is less than 77 degrees F= DEATH
Factors Effecting Body Temp Time of Day/Exercise:
-Body temp fluctuates throughout the day, decreased in am and increased in late afternoon
-could be due to circadian rhythm, muscle activity, digestion
**Exercise elevates temp due to heat production
Factors Effecting Body Temp Stress:
Emotional/Physical stress can increase body temp
-stress increases stimulation of the SNS which increases epinephrine/norepinephrine which increases BMR leading to increased heat production
Factors Effecting Body Temp Hormones:
-Progesterone (female hormones) increases temp by 1 degree F
-Thyroxin: BMR depends on the thyroid hormone Hyper elevates temp and Hypo decreases temp
-Epinephrine/Norepinephrine: increases heat production, increase body temp
Hypothalamus
“Body’s Thermostat”
Anterior-heat loss
Posterior-heat promoting
Skin
-Major role in thermoregulation
-Mainly COLD receptors
-BV that transport heat from core to surface
Shivering Mechanism
-Involuntary motor activity increases body temp via increasing heat production
-impulses sent down spinal column to increase muscle tone and shivering occurs from a feedback mechanism
Sweat Glands
-located beneath dermal layer
-secrete solution (NA & CL)
Behavioral Response
-Can help regulate body temperature:
-To Increase: more clothes, change room temp, increase physical activity
-To Decrease, remove clothes, fan, cooler enviroment
Other Physiologic Process Factors
-smoking
-oxygen administration
-hot/cold drinks (slight change in oral temp, wait 15-30m before taking temp
Hyperthermia
-Core temperature increases above acceptable range
**dry air w/breeze, can only tolerate 105F for few hrs
**humid temp 94F, can only tolerate briefly
**can become acclimated to temp, Africa
-NEED TO COOL A HYPERTHERMIA VICTIM (cold compresses axillary and groin)
Hypothermia
-core body temperature lower than acceptable range
-lower the temp, decreases BMR which decreases heat production & further decrease in BMR occurs
-temp less than 95 F or 35 C (core)
**LESS than 75-77F or 23-24 C=DEATH
CNS Impairment
Any condition interfering with the nervous system control over temp regulation (tumor, severed spinal cord)
Malignant Hyperthermia
Temp 11-131F or 43.8-55C, elevated heart rate, muscle rigidity
What is pyrexia?
Fever, a regulated state in which core temperature is above average
Low Grade Fever
98.8-100.6 F or 37-38C
High Grade Fever
100.6-105.8F or 39-41C
Hyperpyrexia
105.8 F or 41C
Name for types of fever
1. intermittent
2. remittent
3. sustained/constant
4. relapsing fever
Intermittent Fever
temperature spikes, periods of elevation with periods of normal/below normal temps
Remittent
Temp is always elevated but amount of elevation fluctuates >3.6F or 2C
Sustained/Constant
Remains elevated
Relapsing Fever
Elevated temp for 1-2 days then normal for 1-2 days
Afebrile
Without fever
3 Phases of a febrile episdoe
1. Initial phase-attempting to increase core, lay on couch/shiver
2. second phase-set point, skin flushed/warm
3. 3rd/crisis phase-fever breaking,fluid deficit, shiver decrease
*potential for febrile convulsions if temp elevates
Heat Cramps
painful spasms from vigorous exercise leads to altered sodium balance from sweating
Heat Exhaustion
Occurs from exercising in heat, leads to water loss and dehydration
S/S: BP drops, HR elevates, Cool Skin, SOB
Heat Stroke Temp? S/S? Tx?
Temp: 104-109F or 40-42.2C
*exposure to increased environmental temps
S/S hot dry skin, increased HR, low bp, delirium, dizziness
Tx: decrease environmental temp
Frostbite assessment?
Bathe immediately in warm water, if not could develop gangrene and need amputation
Oral/Mouth Temperature
-Most common route/easily accessible
-affected by hot/cold liquids (wait 15-30 min)
-placed in posterior sublingual pocket under tongue to L or R
-electronic type 2-60 s and glass 3-8 min
Rectal Temp
-Most reliable
-Contraindicated w/ pts having diarrhea, rectal sx, obstructions, seizures ect.
-Insert Adult 1.5″, Child 1/2″, use lubricants
-Electronic type: 20-30 s, glass 3-5 min
-Blunt tip to decrease trauma risk
Axillary
-least accurate
-too many factors may alter readings
-used in infants (least traumatic)
-electronic type 20-30s, glass 5 min child and adult 9min
Bladder Temp
*Good reflection on core body temp
*foley catheters used with built in temp probes
Pulmonary artery Temp
-catheter placed via heart into pulmonary artery to monitor pressures
-VERY ACCURATE FOR CORE MEASUREMENT
Tympanic Thermometer Placement
-Child-pull pinna down and back
-Adult-pull pinna up and back
*insert into ear canal, make sure its snug, press scan button and release cover
Celsius Formula
(F-32)5/9
Fahrenheit Formula
(9/5 x C) +32
Normal Rectal Temp
98.6F, 36.7 C
Normal Pulmonary Artery Temp
99.2F, 37.3 C
Normal Oral Temp
98F, 36.7C
Axillary
97F, 36 C
Assessment
-gather data for screening
-determine if there is a problem
-monitor existing problems
-subjective/objective data
Temp Assessments Dx NANDA approved:
-hypo/hyperthermia, ineffective thermoregulation, risk for imbalanced body temp
Implemation
focus on preventing thermoregulation problems and educate patient to manage/prevent these problems
Evaluation
Ongoing process, any revisions or interventions

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