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