6) Nursing Process And Thermoregulation Flashcards
Why is knowledge of body temperature regulation physiology important for nurses?
- Essential for assessing and evaluating patient’s response to temperature alterations
- Necessary for intervening safely
What can nurses implement regarding temperature regulation?
- Independent measures to increase or minimize heat loss
- Measures to promote heat conservation
- Interventions to increase patient comfort
How do nursing interventions for temperature regulation relate to medical therapies?
- Nursing measures complement the effects of medically ordered therapies
Who can nurses teach temperature regulation measures to?
- Caregivers
- Parents of children
What sites can be used to measure core body temperature in critical care settings?
- Pulmonary artery
- Esophagus
- Nasopharynx
- Urinary bladder
What sites allow for intermittent temperature measurement?
- Mouth (oral)
- Rectum
- Tympanic membrane
- Axilla
- Temporal artery
- Skin (with chemically prepared patches)
What is required for accurate oral, rectal, axillary and skin temperature measurement?
- Effective blood circulation at the measurement site to conduct heat to the probe
Why are tympanic and temporal artery temperatures considered core temperatures?
- They share the same arterial blood supply as the hypothalamus
- Indicating the body’s central temperature
What is important for obtaining accurate temperature readings?
- Using the correct measuring technique at each site
What is the typical temperature range when measured correctly?
- Between 36.0°C and 38.0°C
How do rectal and axillary temperatures compare to oral temperatures?
- Rectal is usually 0.5°C higher than oral
- Axillary is usually 0.5°C lower than oral
What task can be delegated to unregulated care providers (UCPs)?
- Measuring temperature
What should the nurse inform the UCP about when delegating temperature measurement?
- Appropriate route and device
- Patient factors that can affect temperature
- Precautions for positioning
- Frequency of measurement
- Patient’s usual values
- Abnormalities to report
What equipment is needed for measuring temperature?
- Appropriate thermometer
- Soft tissue/wipe
- Alcohol swabs
- Lubricant (for rectal)
- Pen and documentation form
- Disposable gloves
- Probe cover/sleeve
What is the first step in the procedure for measuring temperature?
- Identify patient using at least two identifiers per employer policy
- Ensures correct patient and improves safety
What should be assessed before measuring temperature?
- Signs and symptoms of temperature alterations
- Factors that influence body temperature
- Allows accurate assessment of variations
What activities should be considered before oral temperature measurement?
- Wait 2 minutes after smoking
- Wait 5 minutes after chewing gum
- Wait 20 minutes after hot/cold food/drinks
- These activities can affect oral temperature accuracy
How is the appropriate temperature site and device determined?
- Based on advantages and disadvantages of each site
- Use disposable thermometer for isolation patients
Why should the measurement route be explained to the patient?
- Patients are curious about measurements
- Cautions against prematurely removing thermometer
What is the rationale for performing hand hygiene?
- Reduces transmission of microorganisms between patient and nurse
What is the optional first step for oral temperature measurement?
- Put on disposable gloves
- Using probe cover minimizes need for gloves
What are the next steps to prepare the thermometer?
- Remove from charging unit
- Attach oral (blue) probe
- Grasp stem, avoid pressing ejection button
- Allows measuring temperature without releasing cover
How is the disposable probe cover applied?
- Slide it over probe until it locks in place
- Soft plastic won’t break in mouth
- Prevents microorganism transmission between patients
Where should the probe be placed in the patient’s mouth?
- Under tongue in posterior sublingual pocket
- Lateral to center of lower jaw
- Sublingual pocket has superficial blood vessels for accurate reading
What instruction should be given to the patient when taking oral temperature?
- Ask patient to hold probe with lips closed
- Helps maintain proper probe position during reading
How long should the probe remain in place orally?
- Leave in place until audible signal and digital display shows temp
- Ensures accurate reading by keeping probe in position
What should be done with the used probe cover after taking an oral temperature?
- Push ejection button to discard probe cover in appropriate receptacle
- Reduces transmission of microorganisms between patients
Where should the thermometer stem be returned after use?
- Return stem to storage well of recording unit
- Proper storage protects probe from damage
- Returning probe causes digital reading to disappear
What should be done if gloves were worn during the procedure?
- Remove and dispose gloves in appropriate receptacle
- Perform hand hygiene
- Reduces transmission of microorganisms
What is the last step after taking a temperature reading?
- Return thermometer to charger
- Charging provides battery power
What is the first step in preparing for a rectal temperature?
- Draw curtain around bed or close door
- Provides privacy for the patient
What patient position is used for rectal temperature?
- Side-lying or modified left lateral position
- Upper leg flexed
- Provides access for rectal probe insertion
How should patient privacy be maintained during rectal temperature?
- Move linen to expose only anal area
- Keep upper body and legs covered
- Maintains privacy and promotes comfort
What instruction should be given to the patient during rectal temperature measurements?
- Remind patient to remain in position until procedure is complete
Why should disposable gloves be worn during rectal temperature measurements?
- Maintains standard precautions during exposure to body fluids (e.g. feces)
What are the steps to prepare the thermometer?
- Remove from charging unit
- Attach rectal (red) probe
- Grasp stem, avoid pressing ejection button
- Allows measuring temperature without releasing cover
How is the disposable probe cover applied?
- Slide it over probe until it locks in place
- Prevents microorganism transmission between patients
How should the thermometer be lubricated?
- Squeeze lubricant onto tissue
- Dip blunt end, covering 2.5-3.5cm for adult or 1.2-2.5cm for child/infant
- Minimizes trauma to rectal mucosa
- Using tissue avoids contaminating remaining lubricant
How should the patient be positioned when putting the thermometer into the anus?
- With non-dominant hand, separate buttocks to expose anus
- Ask patient to breathe slowly and relax
- Exposes anus for insertion, relaxes sphincter
How should the thermometer be inserted?
- Gently insert 3.5cm into anus toward umbilicus for adult
- Do not force
- Ensures exposure to blood vessels in rectal wall
What should be done if resistance is felt?
- Withdraw thermometer
- Prevents trauma to mucosa
What is the critical decision point?
- If thermometer cannot be adequately inserted, remove and consider alternative method
What should be done to prepare the patient for axillary temperature measurement?
- Draw curtain or close door for privacy
- Assist patient to supine or sitting position
- Move clothing away from shoulder/arm to expose axilla
How should the probe be positioned in the axilla?
- Raise arm away from torso
- Inspect for lesions and excessive perspiration
- Insert probe in center of axilla
- Lower arm over probe to maintain position
What is the critical decision point for axilla temperature measurements?
- Do not use axilla if skin lesions present
- Local temp may be altered and area painful
- Wipe off excessive perspiration
How long should the probe be held in the axilla?
- Hold probe in place until audible signal sounds and temperature appears on display
- Ensures accurate reading by keeping probe in position
What should be done for the patient’s comfort after a temperature measurment procedure?
- Assist patient to a comfortable position
- Move linen/gown back over shoulder
- Restores comfort and promotes privacy
What is an important step before leaving the patient?
- Perform hand hygiene
- Reduces microorganism transmission between patient and nurse
How should the patient be positioned for tympanic temperature measurement?
- Assist patient to comfortable position with head turned to side, away from nurse
- Right-handed caregiver uses patient’s right ear, left-handed uses left ear
- Ensures comfort and exposes ear canal for accurate measurement
What should be checked before proceeding for a tympanic temperature measurement?
- Check for obvious cerumen (earwax) in patient’s ear canal
- Cerumen can impede clear optical pathway
- Switch to other ear or alternative site if needed
How should the speculum be inserted?
- Insert into ear canal according to manufacturer’s instructions
- Correct positioning in relation to ear canal ensures accurate readings
- Operator errors can cause false readings
How should the pinna (outer ear) be positioned?
- For adults and children over 3, pull pinna backward, up and out
- For children under 3, pull pinna down and back
- Straightens the curved ear canal for panoramic view
How should the probe be inserted into the ear canal?
- Fit probe snugly into ear canal and do not move
- Gentle pressure seals canal from ambient temperature
- Prevents altering readings by up to 2.8°C
What is the proper positioning of the speculum tip?
- Point speculum tip toward patient’s nose
What should be done after probe is in place?
- Press scan button on handheld unit
- Leave probe in place until audible signal and temp appears
- Ensures accurate reading by detecting infrared energy
How should the speculum be removed?
- Carefully remove from auditory canal
- Prevents rubbing sensitive outer ear lining
What if a second reading is needed?
- Replace probe lens cover
- Wait 2-3 minutes before reinserting probe
- Allows canal to regain normal temp and lens to stay clear
Why discuss temperature findings with the patient?
- Promotes patient participation in care
- Helps patient understand their health status
What should be done if the temperature is within normal range on first assessment?
- Document temperature as baseline
- Baseline is used to compare future measurements
How should the current temperature be evaluated?
- Compare to patient’s previous baseline
- Compare to acceptable range for patient’s age group
- Normal temp fluctuates in narrow range, comparison reveals abnormalities
- Improper placement/movement of thermometer causes inaccuracies
- Take second measurement to confirm abnormal findings
What should be done if temperature is 1°C above usual range?
- Assess possible infection sites (e.g. central line, wounds)
- Check for data suggesting systemic infection
- Implement appropriate nursing measures
What is the intervention for persistent fever?
- Notify healthcare provider
- Administer prescribed antipyretics and antibiotics
What should be done if temperature is 1°C below usual range?
- Remove drafts, wet clothing, damp linens
- Apply extra blankets
- Offer warm liquids, unless contraindicated
How should temperature be documented?
- Record on vital sign flow sheet
- Document after specific therapies in nurse’s notes
- Report abnormal findings to nurse-in-charge or provider
What should be assessed in the community setting?
- Assess patient’s environment temperature and ventilation
- Determine if conditions influence patient’s temperature
What education is needed for home thermometer use?
- Educate on mercury hazards if using glass thermometer
- Encourage replacement with electronic thermometer
Should the same site for temperature measurements each time you try to measure there temperature?
site should be chosen for each patient. When possible, the same site should be used when measurements must be repeated.
