Fundamentals: Chapter 29; Temp Flashcards
What are the most frequent measurements obtained by health care providers
temperature, pulse, blood pressure (BP), respiratory rate, and oxygen saturation
What is the term for a patient’s a patient’s usual state of health?
baseline
What is the acceptable temperature range for adults?
36° to 38° C (96.8° to 100.4° F)
What is the acceptable respiratory rate for adults?
12-20 breaths/min
What is the average oral/tempanic temperature for adults?
37° C (98.6° F)
What is the average rectal temperature for adults?
37.5° C (99.5° F)
What is the average axillary temperature for adults?
36.5° C (97.7° F)
What is the average BP for adults?
<120/80 mm Hg
What is the normal pulse rate for adults?
60 to 100 beats/min
What is the average pulse pressure in adults?
30 to 50 mm Hg
Who is responsible for measurement of vital signs?
the nurse caring for the patient (individual stats can be delegated)
What is the term for the difference between the amount of heat produced by body processes and the amount of heat lost to the external environment (Heat produced-heat loss = temp)
body temperature
What is the body core temperature?
temperature of the deep tissues
Why does the body surface temperature vary?
depends on blood flow to the skin and the amount of heat lost to the external environment
List the possible sites for measuring temperature
oral
rectal
axillary
tympanic membrane
temporal artery
esophageal
pulmonary artery
urinary bladder
What is the term for the physiological and behavioral mechanisms regulate the balance between heat lost and heat produced
thermoregulation
Which part of the brain regulates body temperature?
hypothalamus
Which part of the brain senses and regulates heat loss?
anterior hypothalamus
What part of the brain senses and regulates heat production?
posterior hypothalamus
What mechanisms does the body use to control heat loss?
sweating
vasodilation
inhibition of heat production
What mechanisms does the body use to control heat production?
vasoconstriction
shivering
voluntary muscle contraction
What kind of injury/illness can cause serious alterations in body’s ability to temperature control
injury to the hypothalamus or the spinal cord
What is the primary source of energy for the body?
food
Explain how metabolism effects heat loss/production
increased metabolism increases heat production. decreased metabolism reduces heat production
What accounts for the heat produced by the body at absolute rest
basal metabolism
How is the average BMR determined?
body surface area
How do thyroid hormones effect BMR?
promote the breakdown of body glucose and fat, and increase the rate of chemical reactions in almost all cells of the body
Why do men have a higher BMR?
testosterone increases BMR
Where does nonshivering thermogenesis usually occur? Why?
neonatesneonates cannot shiver and a limited amount of vascular brown tissue, present at birth, is metabolized for heat production
What are the 4 types of heat loss?
radiation, conduction, convection, and evaporation
What is the term for the transfer of heat from the surface of one object to the surface of another without direct contact between the two?
radiation
What is the term for the transfer of heat from one object to another with direct contact?
conduction
What is the term for the transfer of heat away by air movement
convection
What is the term for the transfer of heat energy when a liquid is changed to a gas
evaporation
What is the term for visible perspiration primarily occurring on the forehead and upper thorax
diaphoresis
What determines the amount of blood flow and heat loss to the skin?
the degree of vasoconstriction
What are 4 factors that affect a persons ability to control body temperature?
(1) the degree of temperature extreme(2) the person’s ability to sense feeling comfortable or uncomfortable(3) thought processes or emotions(4) the person’s mobility or ability to remove or add clothes
What factors must a nurse be aware of when assessing temperature variations and evaluating deviations from normal?
AgeExerciseHormone levelCircadian RhythmStressEnvironment
What are temperature related conditions that a nurse must be aware of?
FeverHyperthermiaHypothermiaHeat StrokeHeat Exhaustion
What is a newborn’s normal body temperature?
35.5° to 37.5° C (95.9° to 99.5° F).
At what stage in life does temperature regulation become more stable?
puberty
Why are older adults particularly sensitive to temperature extremes?
deterioration in control mechanismsreduced amounts of subcutaneous tissuereduced sweat gland activityreduced metabolism
How does progesterone effect body temperature?
low progesterone lead to a few tenths of a degree increase in body temperature until ovulation occurs
What causes “hot flashes” ?
the instability of the vasomotor controls for vasodilation and vasoconstriction (up to 4° C [7.2° F] increase)
What is the source of a true fever?
an alteration in the hypothalamic set point
How does a pyrogen cause an increase in temperature?
act as antigens, triggering immune system responses
What are the 4 physiological signs of chills?
vasoconstrictionpiloerectionepinephrine secretionshivering
What are the benefits of a fever?
increased WBC productioneduces the concentration of iron in the blood plasma (suppressing the growth of bacteria)stimulating interferon (the natural virus-fighting substance of the body)
How do fever patterns serve a diagnostic purpose?
Fever patterns differ, depending on the causative pyrogen
What are the 4 patterns of a fever?
Sustained: A constant body temperature continuously above 38° C (100.4° F) that has little fluctuationIntermittent: Fever spikes interspersed with usual temperature levels (Temperature returns to acceptable value at least once in 24 hours.)Remittent: Fever spikes and falls without a return to normal temperature levels.Relapsing: Periods of febrile episodes and periods with acceptable temperature values (Febrile episodes and periods of normothermia are often longer than 24 hours.)
What is an important nursing action for patients who are experiencing a fever?
Maintaining optimum fluid volume status
What is the term for a hereditary condition of uncontrolled heat production that occurs when susceptible people receive certain anesthetic drugs
malignant hyperthermia
What is the condition that occurs when prolonged exposure to the sun or a high environmental temperature overwhelms the heat-loss mechanisms of the body?
heatstroke>40° C (104° F)
What is the most important sign of heatstroke?
hot, dry skin
What condition occurs when profuse diaphoresis results in excess water and electrolyte loss?
heat exhaustion
What are the 3 classifications of hypothermia?
Celsius FahrenheitMild 34°-36° 93.2°-96.8°Moderate 30°-34° 86.0°-93.2°Severe <86°
What is a nurses role when a patient is experiencing temperature alterations?
Implement independent measures to increase or minimize heat loss, promote heat conservation, and increase comfort
Where do ICUs usually take a patient’s temperature?
core temperatures of the pulmonary artery, esophagus, and urinary bladder
Why is the tempanic membrane considered a core temperature?
shares the same arterial blood supply as the hypothalamus
What should a nurse do if they find a mercury-in-glass thermometer in a patient’s home?
teach the patient about safer temperature devices and encourage the disposal of mercury products at appropriate neighborhood hazardous disposal locations
What are important instructions to NAPs when delegating temperature taking responsibilities?
• Obtain temperature for select patient with ordered frequency.• Report abnormalities to the nurse for further assessment.
What would an increase in body temperature, flushed skin, skin warm to touch, and tachycardia indicate?
hyperthermia
In regard to caring for a patient with temperature alteration, what influences a nurse’s priorities? What is the main priority?
The severity of a temperature alteration and its effects, together with the patient’s general health statussafety
Which kind of antipyretics reduce a fever by increasing heat loss?
Nonsteroidal antiinflammatory drugs such as acetaminophen, salicylates, indomethacin, and ketorolac
Which kind of antipyretics reduce a fever by interfering with the immune system and mask signs of infection
corticosteroidsNote: Should NOT be used to treat a fever unless the fever is being caused by a pyrogen
What should a nurse keep in mind when using nonpharmacological therapy to increase heat loss (reduce fever)?
use nursing measures to enhance body cooling that do not stimulate shivering
What is the priority treatment for hypothermia?
prevent a further decrease in body temperature
