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Nursing 20G - Vital Signs > 6) Nursing Process And Thermoregulation > Flashcards

6) Nursing Process And Thermoregulation Flashcards

1
Q

Why is knowledge of body temperature regulation physiology important for nurses?

A
  • Essential for assessing and evaluating patient’s response to temperature alterations
  • Necessary for intervening safely
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2
Q

What can nurses implement regarding temperature regulation?

A
  • Independent measures to increase or minimize heat loss
  • Measures to promote heat conservation
  • Interventions to increase patient comfort
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3
Q

How do nursing interventions for temperature regulation relate to medical therapies?

A
  • Nursing measures complement the effects of medically ordered therapies
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4
Q

Who can nurses teach temperature regulation measures to?

A
  • Caregivers
  • Parents of children
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5
Q

What sites can be used to measure core body temperature in critical care settings?

A
  • Pulmonary artery
  • Esophagus
  • Nasopharynx
  • Urinary bladder
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6
Q

What sites allow for intermittent temperature measurement?

A
  • Mouth (oral)
  • Rectum
  • Tympanic membrane
  • Axilla
  • Temporal artery
  • Skin (with chemically prepared patches)
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7
Q

What is required for accurate oral, rectal, axillary and skin temperature measurement?

A
  • Effective blood circulation at the measurement site to conduct heat to the probe
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8
Q

Why are tympanic and temporal artery temperatures considered core temperatures?

A
  • They share the same arterial blood supply as the hypothalamus
  • Indicating the body’s central temperature
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9
Q

What is important for obtaining accurate temperature readings?

A
  • Using the correct measuring technique at each site
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10
Q

What is the typical temperature range when measured correctly?

A
  • Between 36.0°C and 38.0°C
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11
Q

How do rectal and axillary temperatures compare to oral temperatures?

A
  • Rectal is usually 0.5°C higher than oral
  • Axillary is usually 0.5°C lower than oral
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12
Q

What task can be delegated to unregulated care providers (UCPs)?

A
  • Measuring temperature
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13
Q

What should the nurse inform the UCP about when delegating temperature measurement?

A
  • Appropriate route and device
  • Patient factors that can affect temperature
  • Precautions for positioning
  • Frequency of measurement
  • Patient’s usual values
  • Abnormalities to report
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14
Q

What equipment is needed for measuring temperature?

A
  • Appropriate thermometer
  • Soft tissue/wipe
  • Alcohol swabs
  • Lubricant (for rectal)
  • Pen and documentation form
  • Disposable gloves
  • Probe cover/sleeve
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15
Q

What is the first step in the procedure for measuring temperature?

A
  • Identify patient using at least two identifiers per employer policy
  • Ensures correct patient and improves safety
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16
Q

What should be assessed before measuring temperature?

A
  • Signs and symptoms of temperature alterations
  • Factors that influence body temperature
  • Allows accurate assessment of variations
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17
Q

What activities should be considered before oral temperature measurement?

A
  • 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
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18
Q

How is the appropriate temperature site and device determined?

A
  • Based on advantages and disadvantages of each site
  • Use disposable thermometer for isolation patients
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19
Q

Why should the measurement route be explained to the patient?

A
  • Patients are curious about measurements
  • Cautions against prematurely removing thermometer
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20
Q

What is the rationale for performing hand hygiene?

A
  • Reduces transmission of microorganisms between patient and nurse
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21
Q

What is the optional first step for oral temperature measurement?

A
  • Put on disposable gloves
  • Using probe cover minimizes need for gloves
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22
Q

What are the next steps to prepare the thermometer?

A
  • Remove from charging unit
  • Attach oral (blue) probe
  • Grasp stem, avoid pressing ejection button
  • Allows measuring temperature without releasing cover
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23
Q

How is the disposable probe cover applied?

A
  • Slide it over probe until it locks in place
  • Soft plastic won’t break in mouth
  • Prevents microorganism transmission between patients
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24
Q

Where should the probe be placed in the patient’s mouth?

A
  • Under tongue in posterior sublingual pocket
  • Lateral to center of lower jaw
  • Sublingual pocket has superficial blood vessels for accurate reading
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25
Q

What instruction should be given to the patient when taking oral temperature?

A
  • Ask patient to hold probe with lips closed
  • Helps maintain proper probe position during reading
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26
Q

How long should the probe remain in place orally?

A
  • Leave in place until audible signal and digital display shows temp
  • Ensures accurate reading by keeping probe in position
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27
Q

What should be done with the used probe cover after taking an oral temperature?

A
  • Push ejection button to discard probe cover in appropriate receptacle
  • Reduces transmission of microorganisms between patients
28
Q

Where should the thermometer stem be returned after use?

A
  • Return stem to storage well of recording unit
  • Proper storage protects probe from damage
  • Returning probe causes digital reading to disappear
29
Q

What should be done if gloves were worn during the procedure?

A
  • Remove and dispose gloves in appropriate receptacle
  • Perform hand hygiene
  • Reduces transmission of microorganisms
30
Q

What is the last step after taking a temperature reading?

A
  • Return thermometer to charger
  • Charging provides battery power
31
Q

What is the first step in preparing for a rectal temperature?

A
  • Draw curtain around bed or close door
  • Provides privacy for the patient
32
Q

What patient position is used for rectal temperature?

A
  • Side-lying or modified left lateral position
  • Upper leg flexed
  • Provides access for rectal probe insertion
33
Q

How should patient privacy be maintained during rectal temperature?

A
  • Move linen to expose only anal area
  • Keep upper body and legs covered
  • Maintains privacy and promotes comfort
34
Q

What instruction should be given to the patient during rectal temperature measurements?

A
  • Remind patient to remain in position until procedure is complete
35
Q

Why should disposable gloves be worn during rectal temperature measurements?

A
  • Maintains standard precautions during exposure to body fluids (e.g. feces)
36
Q

What are the steps to prepare the thermometer?

A
  • Remove from charging unit
  • Attach rectal (red) probe
  • Grasp stem, avoid pressing ejection button
  • Allows measuring temperature without releasing cover
37
Q

How is the disposable probe cover applied?

A
  • Slide it over probe until it locks in place
  • Prevents microorganism transmission between patients
38
Q

How should the thermometer be lubricated?

A
  • 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
39
Q

How should the patient be positioned when putting the thermometer into the anus?

A
  • With non-dominant hand, separate buttocks to expose anus
  • Ask patient to breathe slowly and relax
  • Exposes anus for insertion, relaxes sphincter
40
Q

How should the thermometer be inserted?

A
  • Gently insert 3.5cm into anus toward umbilicus for adult
  • Do not force
  • Ensures exposure to blood vessels in rectal wall
41
Q

What should be done if resistance is felt?

A
  • Withdraw thermometer
  • Prevents trauma to mucosa
42
Q

What is the critical decision point?

A
  • If thermometer cannot be adequately inserted, remove and consider alternative method
43
Q

What should be done to prepare the patient for axillary temperature measurement?

A
  • Draw curtain or close door for privacy
  • Assist patient to supine or sitting position
  • Move clothing away from shoulder/arm to expose axilla
44
Q

How should the probe be positioned in the axilla?

A
  • Raise arm away from torso
  • Inspect for lesions and excessive perspiration
  • Insert probe in center of axilla
  • Lower arm over probe to maintain position
45
Q

What is the critical decision point for axilla temperature measurements?

A
  • Do not use axilla if skin lesions present
  • Local temp may be altered and area painful
  • Wipe off excessive perspiration
46
Q

How long should the probe be held in the axilla?

A
  • Hold probe in place until audible signal sounds and temperature appears on display
  • Ensures accurate reading by keeping probe in position
47
Q

What should be done for the patient’s comfort after a temperature measurment procedure?

A
  • Assist patient to a comfortable position
  • Move linen/gown back over shoulder
  • Restores comfort and promotes privacy
48
Q

What is an important step before leaving the patient?

A
  • Perform hand hygiene
  • Reduces microorganism transmission between patient and nurse
49
Q

How should the patient be positioned for tympanic temperature measurement?

A
  • 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
50
Q

What should be checked before proceeding for a tympanic temperature measurement?

A
  • 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
51
Q

How should the speculum be inserted?

A
  • 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
52
Q

How should the pinna (outer ear) be positioned?

A
  • 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
53
Q

How should the probe be inserted into the ear canal?

A
  • 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
54
Q

What is the proper positioning of the speculum tip?

A
  • Point speculum tip toward patient’s nose
55
Q

What should be done after probe is in place?

A
  • Press scan button on handheld unit
  • Leave probe in place until audible signal and temp appears
  • Ensures accurate reading by detecting infrared energy
56
Q

How should the speculum be removed?

A
  • Carefully remove from auditory canal
  • Prevents rubbing sensitive outer ear lining
57
Q

What if a second reading is needed?

A
  • Replace probe lens cover
  • Wait 2-3 minutes before reinserting probe
  • Allows canal to regain normal temp and lens to stay clear
58
Q

Why discuss temperature findings with the patient?

A
  • Promotes patient participation in care
  • Helps patient understand their health status
59
Q

What should be done if the temperature is within normal range on first assessment?

A
  • Document temperature as baseline
  • Baseline is used to compare future measurements
60
Q

How should the current temperature be evaluated?

A
  • 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
61
Q

What should be done if temperature is 1°C above usual range?

A
  • Assess possible infection sites (e.g. central line, wounds)
  • Check for data suggesting systemic infection
  • Implement appropriate nursing measures
62
Q

What is the intervention for persistent fever?

A
  • Notify healthcare provider
  • Administer prescribed antipyretics and antibiotics
63
Q

What should be done if temperature is 1°C below usual range?

A
  • Remove drafts, wet clothing, damp linens
  • Apply extra blankets
  • Offer warm liquids, unless contraindicated
64
Q

How should temperature be documented?

A
  • Record on vital sign flow sheet
  • Document after specific therapies in nurse’s notes
  • Report abnormal findings to nurse-in-charge or provider
65
Q

What should be assessed in the community setting?

A
  • Assess patient’s environment temperature and ventilation
  • Determine if conditions influence patient’s temperature
66
Q

What education is needed for home thermometer use?

A
  • Educate on mercury hazards if using glass thermometer
  • Encourage replacement with electronic thermometer
67
Q

Should the same site for temperature measurements each time you try to measure there temperature?

A

site should be chosen for each patient. When possible, the same site should be used when measurements must be repeated.

Nursing 20G - Vital Signs (19 decks)

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