LEC 9.1: Overview & Temperature | Vitals

1. Temperature

2. Pulse

3. Respiration

4. BP

5. Pain

6. Oxygen Saturation

Vital Signs

Pain Assessment

Fifth Vital Sign

False (Vital signs should be assessed in a thoughtful way, scientific assessment)

True or False: Vital Signs should be taken in a routine procedure.

1. Upon admission of patient (for baseline data)

2. Client has a change in health status or reports symptoms like feeling faint or hot

3. Before and after surgery, invasive procedure, and/or administration of medication that may affect CV system

4. Before and after any nursing intervention that can affect the vital signs

What times should vital signs be taken?

Body Temperature

Reflects the balance between the heat produced and the heat lost from the body

1. Core Temperature

2. Surface Temperature

2 Types of Body Temperature

Core Temperature

One of the types of body temperature

Temperature of the deep tissues of the body, such as the abdominal cavity and pelvic cavity

Remains relatively constant

Surface Temperature

One of the types of body temperature

Temperature of the skin, SQ tissue, and fat

Rises and falls in response to the environment

Heat Balance

When amount of heat produced by the body = amount of heat loss we are in what?

1. Basal Metabolic Rate

2. Muscle Activity

3. Thyroxine Output

4. Epinephrine and Norepinephrine & Sympathetic Nervous System Stimulation

5. Fever

Factors Affecting the Body’s Heat Production

Basal Metabolic Rate (BMR)

One of the Factors Affecting the Body’s Heat Production

• Rate of energy utilization in the body required to maintain essential body activities, like breathing

• Decreases with age - in general younger clients have a higher __

Muscle Activity

One of the Factors Affecting the Body’s Heat Production

• Including shivering

• Increases the metabolic rate

Thyroxine Output

One of the Factors Affecting the Body’s Heat Production

• When there is increase of this, cellular metabolism increases

Epinephrine and Norepinephrine & Sympathetic Nervous System Stimulation

One of the Factors Affecting the Body’s Heat Production

• Clients experiencing stress

• These chemicals immediately increase cellular metabolism

Fever

One of the Factors Affecting the Body’s Heat Production

• Increases the cellular metabolic rate, thus increasing body temp and heat production

1. Radiation

2. Conduction

3. Convection

4. Evaporation

How is heat lost from the body?

Radiation

Transfer of heat from the surface of one object to the surface of another without contact between the two objects

Infrared Rays

How is radiation mostly in the form of?

Radiation

Example of what type of heat loss:

Even if we don’t touch the stove burner, we feel the heat.

Conduction

Transfer of heat from one molecule to a molecule of lower temperature

Cannot take place without contact between the molecules and normally accounts for minimal heat loss

Conduction

Example of what type of heat loss:

Body immersed in cold water so the amount of heat transferred depends on the temperature difference and amount and difference of contact.

Ironing clothes - heat from iron to the clothes.

Convection

Dispersion of heat by air currents

Body has small amount of warm air adjacent to it, so this warm air rises and is replaced by cooler air, so people always lose a small amount of heat through this.

Convection

Example of what type of heat loss:

Oven heats up and utilizes a fan, which distributes the warm air.

Evaporation

Continuous vaporization of moisture from the respiratory tract and from the mucosa of the mouth and from the skin

Insensible Water Loss

An example of this type of evaporation is sweating.

10%

Insensible heat loss accounts for ___ basal heat loss. When body temperature increases, vaporization accounts for greater heat loss.

Evaporation

Example of what type of heat loss:

Water reaches boiling point, liquid water transforms into water vapor.

Hypothalamus

What part of the brain regulates temperature/acts as the bodies’ “thermostat”?

True

True or False: Skin has more receptors for cold than warm. Therefore, skin sensors detect cold more efficiently than warm.

• Shivering

• Vasoconstriction

Bodies’ response to cold?

• Sweating

• Vasodilation which promotes radiation and evaporation

Bodies’ response to warm?

1. Age

2. Diurnal Variations (Circadian Rhythms)

3. Exercise

4. Hormones

5. Stress

6. Environment

Factors Affecting Body Temperature

Age

Factor Affecting Body Temperature

• As people ___, bodies’ ability to regulate body temperature becomes less efficient leading to increased vulnerability to temperature extremes

Older than 75 years old

Who is at risk of hypothermia?

• Inadequate diet

• Loss of SQ fat

• Lack of activity

• Reduce thermoregulatory efficiency

Why are those older than 75 years old at increased risk of hypothermia?

Diurnal Variations (Circadian Rhythms)

Factor Affecting Body Temperature

• Natural fluctuation in body temp over 24 hours

• Older adults temp may vary less than those of the younger population due to loss of autonomic functioning common in aging

4PM - 6PM

When is the highest temperature reached?

4AM - 6AM

When is the lowest temperature reached?

Exercise

Factor Affecting Body Temperature

• Heart work or engaging in strenuous, may increase body temperature to as high as 38.3-40 degrees celsius

38.3-40 degrees Celsius

How high (in Celsius) may strenuous exercise increase body temperature?

Hormones

Factor Affecting Body Temperature

• Women may usually experience more __ fluctuations than that of men

• Progesterone secretion at ovulation increases body temperature by about 0.3-0.6 degrees celsius above basal temperature

progesterone; 0.3-0.6

For women, ___ secretion at ovulation increases body temperature by about ____ degrees celsius above basal temperature

Stress

Factor Affecting Body Temperature

• Stimulation of the sympathetic nervous system can increase metabolic activity and heat production

• Anxious clients may have an elevated body temperature

False (Stress stimulates the sympathetic nervous system causing an increase in heat.)

True or False: Stress stimulates the parasympathetic nervous system causing an increase in heat.

Environment

Factor Affecting Body Temperature

• Changes in external temp, like humidity can challenge bodies’ ability to maintain core temp

• Extremes in temp of __ can affect regulatory systems of body

36-37.5 degrees Celsius

What is the normal body temp range?

1. Pyrexia

2. Hypothermia

2 Main Alterations in Body Temperature

Pyrexia or Hyperthermia

(One of the Main Alterations in Body Temperature)

• Body temp above usual range

Hyperpyrexia

A very high fever, such as 41 degrees Celsius (105.8 degrees Fahreinheit)

41 degrees Celsius (105.8 degrees Fahreinheit)

What temperature above what is considered hyperpyrexia?

Febrile

Client who has a fever

Afebrile

Client who does not have a fever

1. Intermittent

2. Remittent

3. Relapsing

4. Constant

4 Common Types of Fevers

Intermittent Fever

(One of the 4 Common Types of Fever)

• Body temperature alternates at regular intervals between periods of fever and periods of normal or subnormal temperatures

• Malaria

• Tuberculosis

When can Intermittent Fever occur?

Remittent

(One of the 4 Common Types of Fever)

• A wide range of temperature fluctuations, occurs over a 24-hour period, all of which are above normal

• Colds

• Influenza

When can Remittent Fever occur?

Relapsing Fever

(One of the 4 Common Types of Fever)

• Short febrile periods of a few days are interspersed with periods of 1 or 2 days of normal temperature

Constant Fever

(One of the 4 Common Types of Fever)

• Body temperature fluctuates minimally but always remains above normal

Typhoid Fever

When can Constant Fever occur?

Fever Spike

• Temperature that rises to fever level rapidly following a normal temperature

• Returns to normal within a few hours

Bacterial Blood Infections

When is Fever Spike common?

Heat Exhaustion

Just a result of dehydration and not considered a true fever

Hypothermia

(One of the Main Alterations in Body Temperature)

• Below normal or lower limit of normal

• Caused due to:

  • Excessive Heat Loss

  • Inadequate Heat Production to Counteract Heat Loss

  • Impaired Hypothalamic Thermoregulation

• Excessive Heat Loss

• Inadequate Heat Production to Counteract Heat Loss

• Impaired Hypothalamic Thermoregulation

What can Hypothermia be caused by?

1. Induced/Therapeutic Hypothermia

2. Accidental Hypothermia

Types of Hypothermia

Induced/Therapeutic Hypothermia

(Type of Hypothermia)

• Deliberate lowering of body temp of client to decrease need for oxygen by body tissues

• Certain surgeries, deliberately lowered to slow down metabolic processes, and reduce risk of brain damage and other organ injuries, especially after cardiac arrest, traumatic brain injury, or stroke

• Cooling the body - which reduces the brains demand for oxygen which helps minimize damage caused by a lack of oxygen (ischemia)

Ischemia

What does Induced Hypothermia prevent?

Accidental Hypothermia

(Type of Hypothermia)

• Occurs as a result to exposure to a cold environment, immersion in cold water, or lack of adequate clothing, shelter or heat

• In older adults, can be compounded by a decreased metabolic rate and the use of sedative medications

1. Oral

2. Rectal

3. Axillary

4. Tympanic Membrane

5. Temporal Artery

What are the common sites for measuring body temperature?

Oral

(Common site for measuring body temperature)

• Place probe on either side of frenulum of client

• If client has been drinking something cold, hot, or smoking, nurse must wait 30 minutes before taking temp to ensure mouth temp is not affected by food, fluid or warm smoke

• Advantage: Very accessible, very convenient since just placed at frenulum

• Disadvantage:

  • Sometime can break if bitten, especially if pediatric client

  • Can be inaccurate if client has been ingesting hot or cold or food or been smoking

  • Can injure the mouth, especially those clients who underwent oral surgery

• Very accessible, very convenient since just placed at frenulum

What is the advantage of Oral temperature taking?

1. Sometime can break if bitten, especially if pediatric client

2. Can be inaccurate if client has been ingesting hot or cold or food or been smoking

3. Can injure the mouth, especially those clients who underwent oral surgery

What is the disadvantage of Oral temperature taking?

Rectal

(Common site for measuring body temperature)

• Considered very accurate

• C/I: Clients who are undergoing rectal surgery, diarrhea or diseases of rectum, immunocompromised, clotting disorders, significant hemorrhoids

• Advantage: Reliable measurement

• Disadvantage:

  • Very inconvenient

  • May be very unpleasant

  • Very difficult for clients that can’t turn to sides

  • May injure rectum

  • Presence of stool may interfere the thermometer placement

Reliable measurement

What are the advantages of Rectal temperature taking?

• Very inconvenient

• May be very unpleasant

• Very difficult for clients that can’t turn to sides

• May injure rectum

• Presence of stool may interfere the thermometer placement

What are the disadvantages of Rectal temperature taking?

Axillary

(Common site for measuring body temperature)

• Often preferred site in hospital setting, especially with newborns since accessible and safe

• Lower than rectal temperature - some recommend rechecking an elevated axillary temperature with one taken from another site to confirm the degree of elevation

• Take note if we take temperature for newborns, infants — in NICU can move a lot so may be hard to take axilla temperature

• Advantage: Safe, non-invasice

• Disadvantage:

  • Thermometer may need to be left in place for a long time to obtain an accurate measurement

• May have an alarm system to indicate temperature taking is complete

• Safe

• Non-Invasive

What are the advantages of taking axillary temperature?

• Thermometer may need to be left in place for a long time to obtain an accurate measurement

What are the disadvantages of taking axillary temperature?

Tympanic Membrane

(Common site for measuring body temperature)

• Frequent site — however, proper technique needs to be used

• If probe is too loose, reading may be lower than the true value

• If probe is too tight, it may become very uncomfortable

• No significant difference in measuring right and left ears

• Advantages: Readily accessible, reflects core temperature very fast

• Disadvantages:

  • May be uncomfortable

  • Involves risk of injuring membrane if probe is inserted too far

  • Sometimes right and left measurements differ

  • Presence of cerumen may affect reading — needs to ensure no cerumen buildup is present in the ears

• Readily accessible

• Reflects core temperature very fast

What are the advantages of taking temperature via the Tympanic Membrane?

• May be uncomfortable

• Involves risk of injuring membrane if probe is inserted too far

• Sometimes right and left measurements differ

• Presence of cerumen may affect reading

What are the disadvantages of taking temperature via the Tympanic Membrane?

Temporal Artery

(Common site for measuring body temperature)

• Forehead temperature measurements are useful for infants and children when a more invasive measurement is not necessary

• Advantage: Safe and non-invasive, fast

• Disadvantage:

  • Requires electronic equipment that may be costly or unavailable

  • May cause variation if client has forehead perspiration

• Safe

• Non-invasive

• Fast

What are the advantages of the Temporal Artery thermometer?

• Requires electronic equipment that may be costly or unavailable

• May cause variation if client has forehead perspiration

What are the disadvantages of the Temporal Artery thermometer?

Mercury Thermometer

Thermometer that can be very hazardous due to containing dangerous chemical and glass may break

Electronic Thermometer

(Type of Thermometer)

• Can provide a reading in only 2-60 seconds, depending on the model

• Consists of electronic base, probe, probe cover (disposable)

Chemical Disposable Thermometer

(Type of Thermometer)

• Have liquid crystal dots or bars that change color to indicate temperature

• Some are single-use or reusable, but often single-use

• To read: nurse notes highest reading amongst dots that have changed color

• Can be used rectally, orally, or in axilla

Temperature-Sensitive Tape

(Type of Thermometer)

• Does not indicate the core temperature. Contains liquid crystals that change color according to temperature

• Usually applied on forehead or abdomen

• Temperature digits respond by changing color

• Skin area should be dry

• Reading could depend on the manufacturer

  • Some 15 seconds and color already appears

• Particularly useful at home and for infants whose temperatures are to be monitored

• Not common in Philippines

Infrared Thermometers

(Type of Thermometer)

• Sense body heat in the form of infrared energy given of by a heat source in the ear canal (tympanic membrane)

• Makes no contact with tympanic membrane

Temporal Artery Thermometers

(Type of Thermometer)

• Determine temperature using a scanning infrared thermometer that compares the arterial temperature in the temporal artery of forehead to temperature of the room

• Calculates the heat balance to approximate core temperature of blood in pulmonary artery

• Probe placed in middle of forehead and drawn laterally to the hairline

• If client has perspiration on the forehead, probe is also touched behind the earlobe so thermometer can compensate for evaporative cooling

Noncontact Thermometers

(Type of Thermometer)

• Held about 1 inch from the forehead and use infrared light to estimate temperature in a few seconds

• Accuracy is similar to temporal artery or axillary thermometer measurements

• Very useful, especially with patients considered to have communicable diseases

• Can be used for infants in incubators

1. Electronic

2. Chemical Disposable

3. Temperature-Sensitive Tape

4. Infrared

5. Temporal Artery

6. Noncontact

Types of Thermometers used in the hospital

C = (FAHREINHEIT - 32) x 5/9

How to convert Fahreinheit to Celsius

F = (CELSIUS X 9/5) + 32

How to convert Celsius to Fahreinheit