Assessing Health

Vital SignsTemperature

PulseRespiration

Blood pressure

Body Temp• Reflects the balance between heat

production and heat loss.

• Core temp: in the deep tissues of the body (abdominal cavity)(36-37.5°C)

• Surface temp. of the skin

Factors affect heat production• Basal Metabolic Rate (rate of energy utilization

in the body required to maintain essential activities): ↑ in younger persons.

• Muscle activity: shivering ↑ BMR• Thyroxine output: (chemical thermo-genesis)

(stimulation of heat production through cellular metabolism)

Factors affect heat production• Fever: ↑ cellular metabolism• Epinephrine and sympathetic stimulation

Heat Loss• Radiation: b/w 2 surfaces without contact• Conduction: from higher to lower temp

(swimming in cold water)• Convection: dispersion of heat by air currents.• Vaporization: evaporation from respiratory

tract.

Regulation of body temp• Sensors (detect heat/ cold & send signalsto reduce temp or increase heat production) • Integrator in the hypothalamus• Effector system to adjust production and

loss of heat • Sensors detect cold → vasoconstriction,

shivering• Sensors detect warmth → sweating,

peripheral vasodilatation

Factors affecting body temp• Age (thermoregulation control)

(extreme age groups)

• Diurnal variation (early morning-sleep)

• Exercise: increase temp

Factors affecting body temp• Hormones (progesterone ↑ temp)

• Stress ↑ production of adrenaline

• Environment changes.

Alterations in body temp• Average (36-38° C)

• Pyrexia (hyperthermia) (38-41° C) = Fever= Febrile.

• Hyperpyrexia (more than 41° C)

• Hypothermia (below 36° C)

Common types of fever• Intermittent: alteration of temp on

regular intervals • Remittent: wide range of temp

fluctuation than 2 °C/24 hrs.• Relapsing: short febrile periods of a few

days.• Constant:always remains above normal• Fever spike: rapid rise of temp.

S + S OF HYPERTHERMIA• ↑ HR• ↑ Resp rate• Shivering• Cold skin, pallor• Photosensitivity• ↑ thirst• Mild to severe dehydration

Nursing Care of ↑ thermia • Monitor V/S• Assess skin: color and temp.• WBC’s• Remove excessive clothes/blankets• Adequate fluids and nutrition• I & O• Antipyretics as prescribed• Tepid sponges

Hypothermia• Excessive heat loss• In adequate heat production• Impaired hypothalamic control

(regulation)

Clinical S + S of ↓thermia• ↓ temp., pulse and resp.• Severe shivering• Chills• Pale, cool.• Hypotension• ↓ urinary output• Drowsiness progressing to coma

Nursing Care of ↓thermia• Warm environment• Dry clothes• Warm IV fluids• Warm pads

(sponges)

Assessing body temp• Oral (food, fluids, smoking, exercise)

• Rectal (very accurate) (3.5 cm) (C/I in MI, diarrhea, rectal surgery or diseases)

• Axillary (newborn) (inaccurate in fever)• Tympanic (membrane injury)

Types of thermometers• Long tip :oral• Rounded : rectal/

Axillary• Electronic• Chemical

disposable• Infrared • Skin tape

Temp scales• C = (Fahrenheit – 32) x 5/9

• F = (Celsius x 9/5)+ 32

Oral temperature• Accessible and convenient• Easily break down• Inaccurate if hot or cold fluids or

smoke ingestion• Injury post oral surgery

Rectal temp• Reliable and the most accurate

measurement • Inconvenient and unpleasant • Difficult to those clients cannot turn • Could injure rectum post rectal injury• Presence of stool may interfere

accuracy

Axillary temp• Safe and non invasive• Must left long period of time

Tympanic temp• Accessible • Reflects core temp• Very fast

• Uncomfortable and may be invasive to membrane

• Varied repeated measures• Cerumen may affect readings

General guidelines in temp assessment

• Explain procedure• Hand washing• Privacy• Sim’s or lateral position• Protective sheath or lubricant• 2-3 min for an oral (either side of frenulum) or

rectal temp (deep breath and 3.5 cm against rectal wall)

• 6-10 min in axillary (bulb in the center of axilla) temp

• Pull pinna slightly upward and backward, anteriorly to ear drum in tympanic temp.

• Wiping glass thermometer• Read temp• Wash thermometer• Documentation

General guidelines in temp assessment

• Use axillary temp in infants• Tympanic or axillary routs are

preferable in children