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Assessing Health

Vital Signs Temperature Pulse Respiration Blood pressure. Assessing Health. 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.

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Assessing Health

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  1. Vital Signs Temperature Pulse Respiration Blood pressure Assessing Health

  2. 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

  3. 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)

  4. Factors affect heat production • Fever: ↑ cellular metabolism • Epinephrine and sympathetic stimulation

  5. 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.

  6. Regulation of body temp • Sensors(detect heat/ cold & send signals to reduce temp or increase heat production) • Integratorin the hypothalamus • Effector system to adjust production and loss of heat • Sensors detect cold → vasoconstriction, shivering • Sensors detect warmth → sweating, peripheral vasodilatation

  7. Factors affecting body temp • Age (thermoregulation control) (extreme age groups) • Diurnal variation (early morning-sleep) • Exercise: increase temp

  8. Factors affecting body temp • Hormones (progesterone ↑ temp) • Stress ↑ production of adrenaline • Environment changes.

  9. Alterations in body temp • Average (36-38° C) • Pyrexia (hyperthermia) (38-41° C) = Fever= Febrile. • Hyperpyrexia (more than 41° C) • Hypothermia (below 36° C)

  10. 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:alwaysremains above normal • Fever spike: rapid rise of temp.

  11. S + S OF HYPERTHERMIA • ↑ HR • ↑ Resp rate • Shivering • Cold skin, pallor • Photosensitivity • ↑ thirst • Mild to severe dehydration

  12. 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

  13. Hypothermia • Excessive heat loss • In adequate heat production • Impaired hypothalamic control (regulation)

  14. Clinical S + S of ↓thermia • ↓ temp., pulse and resp. • Severe shivering • Chills • Pale, cool. • Hypotension • ↓ urinary output • Drowsiness progressing to coma

  15. Nursing Care of ↓thermia • Warm environment • Dry clothes • Warm IV fluids • Warm pads (sponges)

  16. 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)

  17. Types of thermometers • Long tip :oral • Rounded : rectal/ Axillary • Electronic • Chemical disposable • Infrared • Skin tape

  18. Temp scales • C = (Fahrenheit – 32) x 5/9 • F = (Celsius x 9/5)+ 32

  19. Accessible and convenient Easily break down Inaccurate if hot or cold fluids or smoke ingestion Injury post oral surgery Oral temperature

  20. 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 Rectal temp

  21. Safe and non invasive Must left long period of time Axillary temp

  22. Accessible Reflects core temp Very fast Uncomfortable and may be invasive to membrane Varied repeated measures Cerumen may affect readings Tympanic temp

  23. 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

  24. Use axillary temp in infants Tympanic or axillary routs are preferable in children General guidelines in temp assessment

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