critical thinking activities measurement of body temperature

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Question: CRITICAL THINKING ACTIVITIES A. Measurement of Body Temperature For each of the following situations involving the measurement of body temperature, write C if the technique is correct and I if the technique is incorrect. If the situation is correct, state the principle underlying the technique. If the situation is incorrect, explain what might happen if the

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Chapter 19: Vital signs

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Questions & answers, ■ ■ ■ knowledge check—, knowledge check 19-.

Which age-groups are most susceptible to thermoreg- ulation problems, and why? Answer: Infants and older adults are most susceptible to the effects of environmental temperatures. Infants lose approximately 30% of their body heat through the head, which is proportionally larger with respect to their body than the heads of adults. Older adults have difficulty maintaining body heat because of decreased metabolism, decreased vasomotor control, and loss of subcutaneous tissue.

List five factors that affect body temperature. Answer: Correct answers include developmental level, circadian rhythm, environmental temperature, gender (some students may include hormones), emotions and stress, stimulation of the sympathetic nervous system, and increased production of epinephrine and norepinephrine.

What are the compensatory mechanisms for decreas- ing body temperature? Answer: Peripheral vasodilation, sweating, and inhibition of heat production are mechanisms that decrease body temperature.

What are the compensatory mechanisms for increas- ing body temperature? Answer: Vasoconstriction, release of epinephrine, and shivering are mechanisms that increase body temperature. Piloerection occurs, but it is an important heat-conservation reaction in hairy animals, not in humans.

A healthy, professional tennis player—less than normal
A newborn infant—greater than normal
An adolescent who has just finished running track—greater than normal
A client who has just undergone a painful procedure—greater than normal
A client with a fever—greater than normal
An accident victim who is hemorrhaging—greater than normal
A 90-year-old man—less than normal

Which two gases are exchanged through respiration? Answer: Oxygen (O 2 ) and carbon dioxide (CO 2 ) are the two gases exchanged during respiration.

Which respiratory process involves the movement of air into and out of the lungs? Answer: Pulmonary ventilation (or breathing) involves the movement of air into and out of the lungs.

What is external respiration? Answer: External respiration is the exchange of oxygen (O 2 ) and carbon dioxide (CO 2 ) between blood in the pulmonary vessels and air in the alveoli.

What is the primary stimulus for breathing? Answer: An increased carbon dioxide (CO 2 ) level in the blood is the primary stimulus for breathing.

What mechanical forces allow the lungs to expand? Answer: Lung expansion is allowed by the contraction and downward movement of the diaphragm and expansion of the thoracic space and may also include contraction of thoracic muscles and accessory muscles and movement of the abdomen, which also expand the thorax, lowering airway pressure and allowing air to move into the lungs.

How can you estimate a client’s tidal volume? Answer: Tidal volume can be estimated by observing the depth of the client’s respirations.

What is the range of normal for an adult’s respiratory rate? Answer: A rate of 12 to 20 breaths per minute is normal for adults.

Besides the rate, what other characteristics of a client’s respirations should you observe? Answer: Depth, rhythm, effort, breath sounds, and chest movement should be observed in addition to rate.

What are some common clinical signs associated with poor oxygenation? Answer: Pallor or cyanosis of the nails, lips, or skin; restlessness; apprehension; confusion; dizziness; fatigue; changes in pulse and blood pressure; and decreased level of consciousness are associated with poor oxygenation.

For a client whose BP is 150/80 mm Hg, what is the pulse pressure? Answer: 70 mm Hg

Is that normal? If so, explain. If not, what should the pulse pressure be? Answer: It is not normal; pulse pressure should not be more than one-third of the systolic measure (150), which is ≤ 50 mm Hg.

Which of the Korotkoff sounds would you record as the systolic pressure? Answer: First

Which of the Korotkoff sounds would you record as the diastolic pressure? Answer: Fifth

A nurse is auscultating a BP. He hears the first sound at 170 mm Hg. The sound disappears immediately. At 150 mm Hg, the sound appears again and contin- ues until there is silence at 80 mm Hg. The pressures were taken in the client’s right arm while the client was lying down.

How should the nurse record these pressures? Answer: BP RA, supine, 170/80 mm Hg with an auscultatory gap from 170 to 150 mm Hg

How do you explain what happened? Answer: An auscultatory gap occurred. A gap is most commonly heard in hypertensive clients, whose systolic blood pressure is higher than the adult normal limit of 120 mm Hg.

Which of the clients with the following B Phas hypertension? One with a BP of: 150/80 mm Hg on two separate occasions 180/100 mm Hg on one occasion 138/88 mm Hg on two occasions Answer: 150/80 on two separate occasions

Which of the following client(s) has/have primary hypertension? Client A, who is obese and has a high sodium intake Client B, who is in renal failure Client C, who has hypertension induced by pregnancy Client D, who has a family history of hypertension Answer: Client D, who has a family history of hypertension

Imagine that you are on a committee to make recommendations on the purchase of thermometers. Based on these studies, what recommendations would you make? Suggested response: To ensure accuracy of noninvasive thermometers to use as an addition to the reference-based thermometers, you might institute a pilot project to evaluate the accuracy of the thermometers. This is especially true for the temporal artery thermometers based on conflicting research. For pediatric clients, based on the Hamilton study, you may recommend the ear thermometer.

■ ■ ■ Safe, Effective Nursing

Care—suggested, using evidence to support clinical.

Chapter Key Concept: Perfusion (blood pressure) Competency: Evidence-Based Practice (Thinking, Doing) Background: It is essential to measure blood pressure accurately for appropriate treatment and management (Elliott & Coventry, 2012). Accuracy and reliability of blood pressure measurement are improved by proper patient position, arm position, and timing. Research shows a correlation between increased readings and timing of the measurement, positioning of the patient (standing versus sitting in a chair versus sitting on an examining table) and positioning of the arm at the level of the heart (Jahangir, 2015; Mayo Clinic, 2015; Tomlinson, 2010; Turner, Burns, Chaney, et al., 2008). Scenario: A 70-year-old obese patient with a history of hypertension and peripheral vascular disease is seen at the ambulatory care setting. You are assessing her vital signs to provide data for medication management. Prior to taking the patient’s blood pressure, you obtain an aneroid sphygmomanometer and then request she sit in a chair and extend one arm while supporting the arm at level of the heart. Another nurse states, “You don’t need to do all that.”

Think about it

What factors could influence the accuracy of the blood pressure assessment in this patient? Suggested response: Patient position (arm at heart level with legs uncrossed), smoking, stress, weight, high-sodium diet, age, fitness status, medical condition

What evidence will you give the other nurse for your actions, and how will you locate best evidence to support your response? Suggested response: The correct technique for assessing blood pressure requires that the patient’s arm be comfortably supported at the level of the heart to avoid falsely high (arm below heart level) or low (arm above heart level) blood pressure readings.

What other actions should you institute to maintain accuracy in blood pressure measurement? Suggested response: Position the patient in a sitting position with back supported, legs uncrossed, feet supported on the floor, and arms at heart level. If the patient is supine, ensure the legs are uncrossed. Be sure the patient has rested for at least 5 minutes and is relaxed. This time increases to 30 minutes immediately after the patient has engaged in strenuous activity. Ensure that the correct cuff size is used for the patient. The nurse should use the correct technique for measuring the vital signs.

■ ■ ■ Caring for the

Nguyens—suggested.

Because these are critical-thinking questions, they usually do not have a single right answer. Discuss the questions with your peers—discussion can stimulate critical thinking.

Recall that on Nam Nguyen’s preliminary visit to the Family Medicine Center, his blood pressure (BP) was 162/94 mm Hg. On subsequent visits, his BP was 168/100 and 174/96 mm Hg, and he was continuing to gain weight. Mr. Nguyen was diagnosed with hypertension and prescribed an antihypertension medication to be taken each morning. This morning Mr. Nguyen has come to the clinic for follow-up. The following information is gathered as he checks in for his visit. VS: BP, 168/92 mm Hg; pulse, 80 beats/min; respirations, 20 breaths/min; temperature, 98°F (36°C) Weight: 180 lb (82 kg) Review the preliminary data and the preceding information to answer the following questions: A. What patterns do you see in the data? Suggested response:

There has been little change in blood pressure in spite of a medication being started.

Mr. Nguyen has gained 15 pounds since he began at the clinic.

B. Do you have enough information to draw any conclusions? If not, what other information should you gather? Suggested response: No, you do not have enough information. You will need to determine whether Mr. Nguyen has been taking his medication. You will also need to know whether other factors are affecting his blood pressure. For example, Is he in pain? Is he emotionally upset? What may have caused him to gain weight? When did he last smoke?

C. Identify three alternatives that may explain what is happening with Mr. Nguyen’s vital signs. Suggested responses:

He may not have started his medication.
He may be sporadically taking his medicine.
He may be afraid to start his medicine because of rumors he has heard about the effect of blood pressure medicines.
He may not believe that high blood pressure is dangerous.
He may be acutely ill, and this is affecting his blood pressure.
He may be in extreme pain or emotionally upset.

D. How could you determine which of these alternatives provides the best explanation of what is happening? Suggested response: You have the vital signs and the weight to explain your concerns. However, you will need to further assess Mr. Nguyen to evaluate the alternatives. The data you have gathered (e., whether he in pain, whether he has been taking his medication) will help you to decide which explanation is best.

E. Why is it important to intervene in this situation? Suggested response: Hypertension is a serious disorder associated with increased risk of cardiovascular disease. You must intervene by further evaluating the situation to provide appropriate nursing care.

■ ■ ■ Think Like a Nurse

Suggested—responses.

Because these are critical-thinking questions, they usually do not have a single right answer. Discuss the

questions with your peers—discussion can stimulate critical thinking.

THINK LIKE A NURSE 19-

You notice the following temperature readings in your client’s chart: 0400: 97°F 0800: 97°F 1200: 98°F 1600: 99°F 2000: 100°F

When you assess the client’s temperature at mid- night, it is 101°F. What do you notice about the pattern of the temperature readings? Suggested response: The temperature is gradually but steadily rising. It may indicate inflammation, infection, dehydration, or an increase in room temperature, for instance.

What is important in this scenario? Suggested response: The steady rise in body temperature of almost 4°F rules out circadian rhythm and other normal variations, such as increased activity. A continuously rising temperature indicates a problem.

As a nursing student, what should you do? Suggested response: Notify the primary healthcare provider.

Convert the following temperatures and analyze the readings. What might they mean? a. 38°C Suggested response: Conversion. 101°F Analysis. Above normal range Mean. Could indicate recent vigorous activity or a problem, such as infection or dehydration b. 96°F Suggested response: Conversion. 35°C Analysis. Within normal range, but on the low side c. 37°C Suggested response: Conversion. 98°F Analysis. Within normal range Mean. This number is often referred to as an average normal temperature.

Recall the clients you encountered at the community health fair [Meet Your Patients, in your textbook]. Ms. Sharma is an active 80-year-old woman who works part-time and exercises four times per week. She is complaining of feeling tired. You find that her pulse is irregular and uneven. What other client data do you need to know? How would you go about getting this additional information? Suggested response: You need to know how her heart is functioning— whether her fatigue is caused by inadequate oxygenation secondary to poor cardiac output. A physician would need to order tests, beginning with an ECG. You also need to know whether other causes of fatigue are present. For example, is she sleeping well and eating properly? You could ask her these questions. Also look for pallor, which might indicate anemia and poor oxygenation.

What actions should you consider taking while meet- ing with Ms. Sharma? Suggested response: Check her blood pressure and respirations, in addition to her pulse. Take an apical pulse. As a student, you would also consult your nursing instructor.

What theoretical knowledge (rationale) supports your beliefs and actions? Suggested response: Pulse rate reflects heart functioning. Dysrhythmias may be associated with changes in blood pressure and respirations. The apical pulse is the most accurate, so it would be a check on the accuracy of the radial pulse. It would also be possible to listen to the strength of the heartbeat apically.

Consider the following client situations. What effect would they have on respirations?

A client with four fractured ribs Suggested response: Pain would cause the client to breathe faster but would limit the depth of respirations. This would place the client at risk for development of pneumonia, an infection of the lungs.

A woman who is 9 months pregnant Suggested response: During pregnancy, the uterus expands up into the abdomen to accommodate the growing fetus. As the pregnancy progresses, there is a gradual increase

in upward pressure against the diaphragm. As a result, respirations become shallower in depth. To compensate, the overall diameter of the rib cage increases and the respiratory rate rises rapidly with exertion.

A young child excited at her birthday party Suggested response: Excitement would cause release of epinephrine and increased rate and depth of respirations.

An adult who has consumed alcoholic beverages Suggested response: Alcohol is a depressant and would depress both the respiratory rate and depth.

Mrs. Dowell has smoked two packs of cigarettes per day for 45 years. She has recently been diagnosed with pneumonia—an infection of the lungs. What VS assess- ments would be important for Mrs. Dowell, and why? Suggested response:

Respirations, because (1) smoking increases respi- ratory rate and alters the concentrations of oxygen and carbon dioxide in the body; and (2) pneumo- nia can affect rate, depth, and effort of breathing
Temperature, because pneumonia is an infection, which can cause temperature increases
Pulse, to assess cardiac status; increases in temper- ature and respirations can affect the pulse
Clinical signs associated with hypoxia secondary to pneumonia and compromised respiratory status, such as pallor, cyanosis, restlessness, apprehension, confusion, fatigue, and level of consciousness
Breath sounds and cough, which may be caused by the pneumonia

Recall the clients you encountered at the community health fair scenario [Meet Your Patients, in your textbook]. Mr. Jackson is short of breath and strug- gling to breathe. His respiratory rate is 28 breaths/min. What else do you need to know about the client situation? What is important and what is not important in this scenario? What is probably least important? Suggested responses:

The depth and rhythm of his respirations; whether there are associated clinical signs, such as cyanosis or cough
Whether Mr. Jackson has a history of respiratory or cardiac problems
Whether he is experiencing any other discomfort (e., chest pain, abdominal pain)
What he was doing before seeing you (e., climbing stairs or just strolling around) All aspects are important. His respiratory rate is probably least important because it is not far outside the normal limits for an adult.

Evaluate the following adult blood pressures. Are they high, low, or normal? Suggested response: 116/90 mm Hg Systolic is within normal range; diastolic is high (stage 1 hypertension). 80/50 mm Hg Both systolic and diastolic are lower than normal. 184/102 mm Hg Both systolic and diastolic are higher than normal. 140/90 mm Hg Both systolic and diastolic are high. 140/90 is the number that identifies hypertension. 40/0 mm Hg Both systolic and diastolic are very low, even for an infant.

What theoretical knowledge did you use to evaluate the blood pressures? Suggested response: Knowledge of the normal ranges of systolic and diastolic blood pressures and of the reading that identifies prehypertension and stage 1 hypertension

Recall the clients you encountered at the community health fair [Meet Your Patients, in your textbook]. Lucas is 35 years old. He has been under a lot of stress. His blood pressure is 150/98 mm Hg.

To evaluate his BP, what else do you need to know about Lucas’s situation (the context)? Suggested response: (1) Are any other factors contributing to his increased blood pressure (e., did he just jog in from the parking lot)? (2) Has he previously had an increased blood pressure? (3) Does he have any other risk factors for hypertension (e., smoking, obesity, family history)?

What possible actions should you consider while meeting with Lucas? Suggested response: (1) Wait a few minutes and recheck the blood pressure in his other arm. (2) If this is his first high

blood pressure reading, advise him to have it rechecked in a week or so. (3) Advise him of any lifestyle factors that may increase his risk of hypertension.

What is the theoretical knowledge (rationale) to support your decisions Suggested response: (1) Be sure that the reading was accurate. (2) You cannot diagnose hypertension on one reading alone because blood pressure fluctuates. Assessment and diagnosis must be based on a pattern. (3) Even if he does not have hypertension, certain lifestyle changes may help him to prevent it in the future.

■ ■ ■ Applying the Full-

Spectrum nursing, model—suggested, patient situation.

A patient in the critical care unit had a stable pulse and BP for the first few days. He has become more ill and now his pulse and BP are weak and difficult to palpate. His last BP reading was abnormally low, so it must be monitored frequently. He is receiving intravenous fluids in both arms.

Critical Thinking (Reflecting and Deciding What to Do): Which of the patient’s vital signs (temperature, pulse, respiration, and BP) might you be able to delegate to a NAP? Suggested response: Temperature and respirations might be delegated. The nurse definitely needs to personally assess the pulse and blood pressure because they are weak and difficult to palpate. They indicate some change in condition that the nurse will need to assess.

Doing 2. Practical Knowledge: How would you take the patient’s blood pressure? Be specific. a. What site would you use? b. What equipment would you use?

Multiple Choice

Course : Fundamentals Of Nursing (NUR1110)

University : pearl river community college.

critical thinking activities measurement of body temperature

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Vital Signs: Assessing Body Temperature

Body Temperature - Nursing Notes Study Guides

Body temperature is a fundamental aspect of nursing assessment , reflecting the body’s ability to maintain homeostasis and adapt to physiological changes. It serves as a critical indicator of health, often revealing the presence of infection, inflammation, or other systemic conditions. Monitoring body temperature allows nurses to detect potential health issues and guides appropriate interventions to promote patient safety and recovery.

What is body temperature, factors affecting body’s heat production, regulation of body temperature, factors affecting body temperature, types of fever, hypothermia, purposes of taking body temperature, methods of body temperature measurement, indications for taking body temperature, contraindications for taking body temperature, nursing assessment in taking body temperature, oral temperature measurement, rectal temperature measurement, axillary temperature measurement, tympanic (ear) temperature measurement, temporal (forehead) temperature measurement, nursing interventions in taking body temperature.

Body temperature is a vital sign reflecting the body’s ability to maintain a stable internal environment through heat production and heat loss. It is a vital parameter used to assess a patient’s physiological status. Body temperature can be categorized into two types: core temperature and surface temperature.

Core Temperature. This is the temperature of the body’s internal organs, such as the brain , heart, and abdominal cavity, typically maintained within a narrow range (around 36.5°C to 37.5°C or 97.7°F to 99.5°F). Core temperature is crucial for enzymatic and cellular functions and is regulated by the hypothalamus .
Surface Temperature. This refers to the temperature of the skin and subcutaneous tissues. It fluctuates more than core temperature as it is influenced by external environmental conditions, such as air temperature, humidity, and clothing.

Heat balance is the physiological equilibrium between heat production and heat loss, essential for maintaining a stable body temperature and optimal functioning of bodily processes. The human body produces heat through metabolic activities, muscle contractions, and other physiological processes, while heat is lost primarily through the skin and respiratory system . Heat balance ensures that the core temperature remains within a normal range, typically around 36.5°C to 37.5°C (97.7°F to 99.5°F).

Heat Production. This occurs mainly from cellular metabolism, including basal metabolic activities, physical activity , and shivering. Hormonal influences, such as the release of thyroxine or epinephrine , can also increase heat production.
Heat Loss. Heat is dissipated through mechanisms like radiation , conduction, convection, and evaporation. Sweating and increased blood flow to the skin during vasodilation are key methods the body uses to lose heat in warmer conditions.
Regulation. The hypothalamus acts as the body’s thermostat, detecting temperature changes via thermoreceptors and initiating corrective actions. For instance, in cold environments, shivering generates heat, while in hot conditions, sweating promotes cooling.

Several key factors influence the body’s ability to produce heat. Among the most significant are these five considerations:

Basal Metabolic Rate (BMR). The energy expended by the body at rest to maintain vital functions, contributing to heat generation.
Muscle Activity. Physical movement and exercise increase heat production through metabolic activity in muscles.
Thyroxine Output. Hormones like thyroxine from the thyroid gland enhance metabolic rate and heat production.
Epinephrine, Norepinephrine , and Sympathetic Stimulation. Stress responses activate these hormones, boosting metabolic activity and body heat.
Fever. An immune response that raises the body’s set-point temperature to fight infection, leading to increased heat production.

Heat is lost from the body through radiation, conduction, convection, and evaporation (insensible water loss & insensible heat loss).

Radiation. The transfer of heat from the body to surrounding objects without direct contact. Heat is emitted in the form of infrared rays, with warmer objects losing heat to cooler surroundings. For example, a person loses body heat in a cold room.
Conduction. The direct transfer of heat through physical contact between the body and another surface. For instance, lying on a cold metal table causes the body to lose heat to the surface.
Convection. The loss of heat through the movement of air or water across the skin. Warm air near the body is replaced by cooler air, as happens when sitting in front of a fan or being in a breeze.
Insensible water loss. Continuous and unnoticed water loss through the skin and respiratory tract.
Insensible heat loss. The heat energy used to vaporize water during insensible water loss, contributing to temperature regulation.

The body temperature regulation system consists of three key components: peripheral and core sensors that detect temperature changes, the hypothalamus acting as an integrator that processes the sensory input, and an effector system that manages heat production and loss.

Sensors (Peripheral and Core Sensors). Sensors are specialized receptors located in the skin (peripheral sensors) and internal organs (core sensors) that detect changes in temperature. These sensors transmit temperature information to the brain. Peripheral sensors are more sensitive to cold, while core sensors monitor internal conditions For example, when you step outside in winter without a jacket, the cold sensors in your skin detect the temperature drop and send signals to your brain, initiating shivering to generate heat.
Integrator (Hypothalamus). The hypothalamus is the brain’s control center for temperature regulation. It integrates information from temperature sensors and activates appropriate responses to maintain a stable core temperature. For instance, if your core body temperature rises during exercise, the hypothalamus detects this and signals sweat glands to release sweat, promoting heat loss through evaporation.
Effector System. The effector system includes mechanisms that regulate heat production and loss, such as muscle activity (shivering), blood vessel constriction/dilation, and sweat gland activity. It adjusts bodily processes based on signals from the hypothalamus to maintain homeostasis. In cold weather, the effector system constricts blood vessels near the skin (vasoconstriction) to reduce heat loss and preserve warmth in the core. Conversely, in hot weather, it dilates blood vessels (vasodilation) to release heat through the skin.

Nurses should understand the factors that influence body temperature to identify normal variations and assess abnormal readings. Key factors that can affect temperature include:

Age. Age influences body temperature regulation, as infants and elderly individuals have less efficient thermoregulation . Newborns have a higher risk of hypothermia because their body surface area is greater than their body mass, making them lose heat quickly. Older adults may have a lower body temperature due to decreased metabolism and circulation.
Diurnal Variations (Circadian Rhythms). Body temperature follows a daily rhythm, usually lowest in the early morning and highest in the late afternoon or evening. A person’s temperature might be 36.5°C in the early morning and rise to 37.5°C by evening. This fluctuation is part of the body’s internal clock.
Exercise. Physical activity increases body temperature due to increased muscle activity and metabolism. After strenuous exercise, the body temperature can rise by 1-2°C, which is why, for example, an athlete’s core temperature may be higher post-workout.
Hormones. Hormonal changes, especially those related to the menstrual cycle or thyroid function, can significantly influence body temperature. Women often experience a slight rise in body temperature during ovulation due to increased progesterone . Thyroid disorders can also cause abnormal temperature regulation, with hypothyroidism leading to cold intolerance and hyperthyroidism causing heat intolerance.
Stress. Stress triggers the release of hormones such as epinephrine and norepinephrine, which can elevate body temperature by increasing metabolism and causing vasoconstriction. A person experiencing acute stress (e.g., before a big presentation) may have a slight increase in body temperature due to the body’s fight-or-flight response.
Environment. External environmental factors such as ambient temperature, humidity, and clothing can affect heat loss or gain from the body. A person in a hot environment may experience heat exhaustion or hyperthermia if they are not adequately hydrated or dressed in breathable clothing. Conversely, in cold conditions, the body may lose heat rapidly, causing a drop in body temperature.
Food Intake. The process of digestion can increase body temperature temporarily as the body uses energy to break down food. After a large meal, people often experience a slight increase in body temperature due to the thermic effect of food.
Medications. Certain medications can alter body temperature regulation, either by increasing heat production or impairing the body’s ability to cool down. Medications like aspirin can reduce fever (antipyretic effect), while drugs like anesthetics or anticholinergics may impair sweating , leading to an elevated body temperature.
Hydration Status. Dehydration impairs the body’s ability to dissipate heat effectively.

Alterations in Body Temperature

The typical body temperature range for adults is between 36°C and 37.5°C (96.8°F to 99.5°F). Deviations from this range can result in two main conditions: hyperthermia or pyrexia (fever) and hypothermia (abnormally low body temperature). These alterations indicate disruptions in the body’s normal thermoregulation and can be associated with various health conditions or environmental factors.

Hyperthermia, Pyrexia, or Fever

Pyrexia ( Fever ) refers to an elevation in body temperature above the normal range, typically above 38°C (100.4°F), often as a response to infection or inflammation. It is part of the body’s natural defense mechanism, helping to fight pathogens by creating an environment less favorable for bacterial or viral growth. Hyperthermia, while often used interchangeably with fever, refers to an abnormally high body temperature caused by the body’s inability to regulate heat properly, as seen in heat stroke .

Febrile refers to the condition of having a fever.
Afebrile means the absence of fever, indicating a normal body temperature within the standard range.

Common types of fevers are intermittent, remittent, relapsing, constant, and fever spike:

Intermittent Fever. This type of fever is characterized by periods of fever alternating with normal body temperature. The fever comes and goes, often on a regular cycle, with temperature returning to normal or near-normal levels before spiking again. Seen in conditions like malaria .
Remittent Fever. This fever fluctuates throughout the day but does not return to normal temperature levels. The body temperature remains elevated but varies within a range. Common in bacterial infections like typhoid fever .
Relapsing Fever. In this type, there are recurrent episodes of fever that last several days followed by periods of normal temperature. These cycles repeat over weeks or months. Seen in diseases like Lyme disease or certain bacterial infections like Borrelia.
Constant Fever. This fever remains consistently elevated, with only slight variations in temperature. It does not fluctuate significantly or return to normal. Seen in conditions like tuberculosis or viral infections.
Fever Spike. This refers to a rapid and sharp rise in body temperature over a short period of time, often in response to an infection or other triggering factors. Seen in bacterial infections or after certain medical treatments.

An elevated temperature is not always an indication of a true fever, especially in heat-related illnesses like heat exhaustion and heat stroke . These conditions occur when the body is unable to regulate temperature properly due to prolonged exposure to high temperatures or excessive physical exertion in hot environments.

Heat Exhaustion. Heat exhaustion occurs when the body’s cooling mechanisms, such as sweating , become overwhelmed, leading to symptoms like weakness , dizziness, nausea , and a body temperature that may rise to 100.4°F (38°C) or higher.
Heat Stroke . Heat stroke is a life-threatening emergency in which the body’s temperature regulation fails completely, causing the body temperature to soar above 104°F (40°C). This condition often involves dry, hot skin and can result in severe complications such as organ failure or neurological damage if not treated immediately.

Hypothermia occurs when the core body temperature falls below the normal lower limit. The condition arises through three main physiological mechanisms: excessive heat loss, insufficient heat production to compensate for the heat lost, and impaired thermoregulation by the hypothalamus. These factors disrupt the body’s ability to maintain a stable internal temperature, leading to potential complications as the body becomes unable to regulate heat effectively. Hypothermia can be classified as either induced or accidental.

Accidental hypothermia typically occurs due to environmental exposure, such as prolonged exposure to cold weather, water, or inadequate clothing. People at risk include those in extreme climates, the elderly , or individuals who are homeless or intoxicated.
Induced hypothermia is deliberately induced in a medical setting to treat certain conditions like brain injury , cardiac arrest, or to reduce metabolic demands during surgery .

The following are the purposes of taking temperature in nursing:

Fever Detection. An elevated temperature (fever) often indicates infection, inflammation, or other underlying health issues.
Hypothermia. A low body temperature can be a sign of shock, severe blood loss , or prolonged exposure to cold, and may require urgent intervention.
Monitoring Treatment Response. Nurses use temperature measurements to evaluate the effectiveness of treatments, especially in patients with infections, post- surgery , or other conditions requiring temperature regulation.
Assessing Recovery. In post-operative or critically ill patients, temperature measurement helps in identifying complications, such as infections or fever related to surgical trauma .

There are several methods to measure body temperature, each suited to different patient conditions and clinical settings. Understanding these methods helps nurses choose the most appropriate approach to ensure reliable and accurate readings.

Oral Temperature. Measured by placing a thermometer under the patient’s tongue, usually for adults who are conscious and able to breathe through their nose. It provides a fairly accurate reading of body temperature.
Rectal Temperature. Considered the most accurate method for assessing core body temperature, commonly used for infants, unconscious patients, or those who cannot use other methods.
Axillary Temperature. Measured under the armpit. This method is less accurate but may be used for screening, especially in children or patients who cannot tolerate other methods.
Tympanic (Ear) Temperature. Measured using an infrared thermometer in the ear canal. It provides a quick reading but may be less accurate if the ear canal is not positioned correctly.
Temporal Artery (Forehead) Temperature. A non-invasive, quick method using an infrared scanner across the forehead. This method is becoming more popular for its ease and accuracy in certain patient populations.

Temperature measurement is indicated in the following situations:

Infections. A rise in body temperature may suggest an infection.
Post-surgical monitoring. To monitor for potential post-operative complications, such as infection.
Chronic illnesses. Conditions such as rheumatoid arthritis or cancer may cause fluctuating body temperatures.
Changes in mental status. Altered consciousness can be a sign of fever or hypothermia.
Emergency situations. During trauma or shock, temperature can provide insight into the body’s stress response.

Certain conditions may make specific temperature-taking methods inappropriate:

Oral temperature measurement is contraindicated in patients who are unconscious, in shock, or under the influence of medications that affect their ability to swallow or control their airway.
Rectal temperature should not be used in patients with rectal conditions, post-surgical patients with anal or rectal wounds, or infants with a history of rectal irritation.
Axillary temperature is less accurate than other methods and may not be reliable in critically ill patients.

Before taking a patient’s temperature, it is important to conduct a comprehensive nursing assessment to ensure accuracy, safety, and comfort during the procedure. Below are the key nursing assessments to consider and perform when taking a patient’s body temperature:

1. Assess the patient’s general condition. Observe for signs of infection or systemic issues, such as sweating, chills, flushed or pale skin, and shivering. These signs may indicate fever, infection, or other health changes that affect body temperature, guiding the urgency and method of measurement.

2. Evaluate recent activities and intake. Ask if the patient has recently consumed hot or cold food or beverages, smoked, or engaged in physical activity. These activities can temporarily raise or lower body temperature, potentially leading to inaccurate readings if not accounted for.

3. Determine the appropriate method. Choose the method (oral, rectal, axillary, tympanic, or temporal) based on the patient’s age, mental status, level of consciousness, physical condition, and comfort level. Each method has advantages and is suited to different situations and patient needs. For example, rectal temperature may be more accurate for infants, while tympanic or temporal methods may be less intrusive for patients who are confused or uncooperative.

4. Obtain baseline temperature readings. Review the patient’s medical record for previous temperature readings to understand their usual temperature range. Baseline readings provide a reference for evaluating new measurements, especially since normal body temperature can vary from person to person.

5. Identify contraindications. Assess for conditions that may contraindicate certain methods. Contraindications help avoid discomfort, inaccurate readings, or potential harm. For instance, oral thermometers may be unsafe for those with respiratory issues, while rectal thermometers could trigger a vagal response in cardiac patients.

Oral. Contraindicated in patients who have mouth injuries, respiratory issues, altered mental status , recent oral surgery , or are unable to keep the thermometer in place.
Rectal. Contraindicated for patients with rectal injuries, hemorrhoids , diarrhea , recent rectal surgery , or cardiac conditions (due to vagal response risks).
Tympanic. Avoid if the patient has ear infections, excessive earwax , or recent ear surgery.

6. Assess the patient’s comfort and privacy needs. Ask about any concerns or preferences regarding the procedure. Respecting patient dignity and ensuring comfort increases cooperation and reduces anxiety , particularly for potentially invasive methods like rectal temperature measurement.

7. Check equipment and supplies. Ensure the thermometer is clean, calibrated, and functioning correctly. Accurate, hygienic, and properly functioning equipment is crucial for obtaining a reliable reading and preventing cross-contamination.

Step-by-Step Procedure for Measuring Body Temperature

There are several ways to measure body temperature: orally, rectally, axillary, tympanically (ear), and temporally (forehead). Below are the procedures for each method:

Oral temperature measurement is a method of assessing a patient’s body temperature by placing a thermometer in the mouth, specifically under the tongue. This technique uses the sublingual pocket—the area beneath the tongue at the back of the mouth—which closely reflects the body’s core temperature due to its high blood flow.

1. Wash hands thoroughly and gather a digital or mercury-free oral thermometer. Hand hygiene reduces the risk of infection transmission, and using a digital or mercury-free thermometer ensures safety and accuracy without the risks associated with mercury exposure.

2. Position the patient comfortably, ideally seated or lying back, and instruct them to place the thermometer under their tongue towards the back of the mouth. Ensuring the thermometer is placed in the posterior sublingual pocket provides a more accurate reading, as this area closely reflects core body temperature due to its rich blood supply.

3. Instruct the patient to keep their mouth closed and breathe through their nose without biting down on the thermometer. Keeping the mouth closed minimizes air exposure, which could cool the thermometer and give a lower and inaccurate reading. Breathing through the nose prevents the patient from disturbing the thermometer’s position, while avoiding biting protects both the thermometer and the patient’s teeth.

4. Wait for the thermometer to beep (digital) or for the recommended time if using a glass thermometer (usually 3-5 minutes). Waiting for the thermometer’s signal ensures the device has fully captured an accurate reading. Following manufacturer guidelines prevents premature removal, which could result in an inaccurate measurement.

5. Carefully remove the thermometer and immediately record the reading. Recording the reading immediately ensures accurate documentation and helps monitor trends over time. Accurate records support continuity of care, enabling other healthcare providers to track the patient’s temperature changes effectively.

Rectal temperature measurement is a method of assessing a patient’s core body temperature by inserting a thermometer into the rectum. This technique is considered one of the most accurate methods for measuring body temperature because the rectum’s temperature closely reflects the body’s core temperature, given its stable environment and rich blood supply.

1. Perform hand hygiene and put on gloves. Hand hygiene is essential to prevent the spread of microorganisms, and gloves provide an added barrier against exposure to bodily fluids, ensuring both patient and nurse safety during the procedure.

2. Prepare a thermometer, preferably a digital one, designated for rectal use. A dedicated rectal thermometer prevents cross-contamination between different sites (e.g., oral and rectal). Digital thermometers are preferred because they provide faster readings and reduce the risk of breakage compared to glass thermometers, which contain mercury and pose a safety hazard.

3. Position the patient in a side-lying (left lateral ) position with knees slightly flexed. The left lateral position with slightly flexed knees relaxes the rectal muscles, making insertion easier and minimizing discomfort. This position also reduces the risk of injury to the rectal lining by providing a stable, comfortable posture.

4. Lubricate the thermometer tip with a water-based lubricant. Lubrication reduces friction and eases the insertion of the thermometer into the rectum, minimizing discomfort and protecting the delicate rectal tissue from potential injury. A water-based lubricant is preferred because it is less irritating than oil-based lubricants and won’t damage medical equipment.

5. Gently insert the thermometer 1 to 1.5 inches into the rectum for adults (or 0.5 to 1 inch for infants and small children). Inserting the thermometer to the recommended depth ensures accurate placement within the rectum for an accurate reading of core body temperature. Inserting it too deeply or not deep enough could result in an inaccurate reading or discomfort. Using caution is critical to avoid injury, especially in pediatric and elderly patients with fragile rectal tissues.

6. Wait for the thermometer to beep (digital thermometer) or for the specified time if using a non-digital thermometer, then remove it gently. Waiting for the thermometer’s signal ensures an accurate reading. Digital thermometers beep when they reach a stable temperature, while non-digital thermometers must be left in place for a specific duration. Gentle removal reduces discomfort and minimizes the risk of accidental trauma .

6. Clean the thermometer according to protocol, remove gloves, and perform hand hygiene . Cleaning the thermometer according to infection control guidelines prevents cross-contamination. Removing gloves safely and performing hand hygiene afterward protects both the healthcare provider and other patients from potential exposure to bodily fluids.

Axillary temperature measurement is a method of assessing body temperature by placing a thermometer in the armpit (axilla). This approach measures the skin temperature rather than core temperature, making it slightly less accurate than oral or rectal methods, as it is affected by external factors like ambient temperature and skin exposure.

1. Wash hands and prepare a thermometer (preferably a digital one). Hand hygiene is essential for infection prevention . Using a digital thermometer ensures quicker and safer measurements, reducing the risk of breakage associated with traditional glass thermometers.

2. Position the patient with the arm extended and the axilla (armpit) exposed. Positioning the arm correctly exposes the axillary cavity, allowing for an accurate placement of the thermometer. Extending the arm ensures full access to the area and helps the patient prepare to hold the arm against their side comfortably during the procedure.

3. Place the thermometer in the center of the axillary cavity and close the arm to hold it in place. Positioning the thermometer in the center of the axilla ensures it is surrounded by skin, which enhances temperature reading accuracy. Keeping the arm close to the body prevents ambient air from affecting the reading and provides consistent skin contact for better accuracy.

4. Wait for the thermometer to signal that it has finished taking the temperature. Waiting for the thermometer to beep (if digital) ensures that it has captured an accurate reading. Premature removal may yield a lower reading, compromising the assessment of the patient’s true temperature.

5. Remove the thermometer and record the reading immediately. Prompt recording of the temperature reading ensures data accuracy for ongoing patient monitoring. Temperature changes over time are essential for assessing a patient’s condition, so accurately documented readings contribute to this evaluation .

Tympanic (Ear) Temperature Measurement is a method of assessing body temperature by using an infrared thermometer to measure the heat emitted from the tympanic membrane ( eardrum ). The tympanic membrane shares its blood supply with the hypothalamus, the part of the brain responsible for regulating body temperature. Because of this, tympanic temperature measurement is often considered a good indicator of core body temperature and can provide quick and fairly accurate readings.

1. Perform hand hygiene and prepare the ear thermometer. Hand hygiene prevents the transmission of microorganisms between the healthcare provider and the patient. Preparing the thermometer, such as ensuring a new probe cover is in place, prevents cross-contamination and allows for accurate measurement.

2. Position the patient’s head so the ear canal is easily accessible. Proper positioning minimizes discomfort and helps the nurse align the thermometer correctly within the ear canal, which is essential for an accurate reading. Keeping the head stable also reduces the risk of accidental movement , which could affect placement and accuracy.

3. Gently pull the ear upward and backward for adults, or downward and back for children under three, to straighten the ear canal. Straightening the ear canal by gently pulling the ear makes it easier for the thermometer to access the tympanic membrane directly, improving the accuracy of the reading. Pulling in the correct direction based on age accommodates anatomical differences, enhancing access to the membrane in each group.

4. Insert the thermometer gently into the ear canal and press the button to take the temperature. Gentle insertion prevents discomfort and reduces the risk of injury to the sensitive structures of the ear canal. Pressing the button activates the infrared sensor to capture the temperature quickly without causing patient discomfort.

5. Wait for the thermometer to beep and then remove it gently. Waiting for the beep signal ensures the thermometer has captured a stable and accurate reading. Gentle removal protects the ear canal from injury, especially in patients with sensitive ears or ear conditions.

Temporal (Forehead) Temperature Measurement is a method of assessing body temperature using an infrared thermometer that scans the temporal artery on the forehead. The temporal artery is a major blood vessel located close to the skin’s surface, allowing the thermometer to measure the infrared heat emitted from the skin over the artery, which is a reliable reflection of core body temperature.

1. Perform hand hygiene and gather the temporal artery thermometer. Performing hand hygiene is crucial to prevent cross-contamination between healthcare providers and patients. Ensuring that the temporal thermometer is properly cleaned and functioning, with a new probe cover if required, helps maintain accuracy and hygiene.

2. Position the thermometer probe on the patient’s forehead, just above the eyebrow. Placing the thermometer at the center of the forehead, near the temporal artery, ensures the sensor is close to the blood vessel, which is ideal for capturing the temperature most accurately. This placement helps prevent errors that can occur if the thermometer is too far from the artery.

3. Gently swipe the thermometer across the forehead, moving laterally toward the temple. Swiping across the forehead allows the thermometer to continuously measure the temperature as it crosses the temporal artery, capturing the highest, most accurate reading. Moving to the temple ensures that the sensor has passed over the entire length of the artery, enhancing reliability. Avoiding excessive pressure or speed ensures comfort and prevents inaccurate readings.

4. Wait for the thermometer to indicate the reading is complete, then remove it from the forehead. Allowing the thermometer to finish processing before removing it ensures that the reading reflects the peak temperature captured. Removing the thermometer too soon may result in an incomplete or incorrect measurement. Waiting for a signal or beep provides confirmation that the reading is accurate and ready to record.

Nursing interventions in taking temperature focus on ensuring accurate measurements, promoting patient comfort, and addressing potential complications related to abnormal temperature readings. The following are the essential nursing interventions to consider and implement when measuring a patient’s body temperature:

1. Before initiating the procedure, introduce yourself to establish rapport and create a trusting environment. Introducing yourself and verifying identity align with professional standards of care, ensuring patient safety and building rapport.

2. Verify the patient’s identity using the agency’s established protocols, such as checking wristbands or asking for name and date of birth, to ensure safety and prevent errors. Verifying the patient’s identity is vital to ensure the correct care is provided to the intended patient, minimizing the risk of errors such as misdiagnosis, incorrect procedures, or medication administration to the wrong individual.

3. Explain the procedure, its purpose, and the patient’s role to reduce anxiety and foster cooperation. Additionally, discuss how the results will contribute to treatment planning or ongoing care, emphasizing their importance in managing the patient’s condition. Explaining the procedure and its significance helps alleviate the patient’s fears and encourages active participation, which can lead to more accurate and efficient outcomes. Highlighting the relevance of the results in care planning reassures the patient of the procedure’s value in their treatment journey.

4. Perform hand hygiene thoroughly and adhere to infection prevention protocols to maintain a sterile environment and reduce the risk of cross-contamination. Hand hygiene is a cornerstone of infection control and is essential in preventing the spread of pathogens between patients and healthcare workers. Following infection prevention procedures ensures that the environment remains clean and safe for both the patient and the nurse.

5. If taking a rectal temperature, ensure gloves are worn to minimize the risk of exposure to bodily fluids and maintain proper hygiene standards. Wearing gloves during a rectal temperature measurement protects against exposure to potentially infectious materials, such as feces , and prevents the transmission of microorganisms, safeguarding the health of both the patient and the caregiver . This practice also adheres to standard precautions established by infection control guidelines.

6. Ensure the patient’s privacy is protected throughout the procedure by drawing curtains, closing doors, or using screens as necessary. Maintaining patient privacy fosters a sense of dignity, respect, and trust, which is essential in promoting a positive healthcare experience. It helps reduce patient anxiety and ensures compliance with ethical and legal standards, such as those outlined by patient confidentiality laws like HIPAA.

7. Regularly assess temperature and observe for signs of infection such as fever, chills, sweating, or localized redness and swelling . Temperature monitoring is crucial for early detection of infection or inflammatory conditions. A fever may indicate an immune response to an infection, and recognizing it promptly allows for timely interventions.

8. Position the patient comfortably and explain the procedure to alleviate anxiety. Use appropriate techniques for the chosen method (e.g., oral, rectal, tympanic). Patient comfort promotes cooperation and accurate readings. An uncomfortable or anxious patient may move, resulting in erroneous measurements.

9. Position the thermometer appropriately and proceed with the required steps based on the method of measurement: oral, rectal, axillary, tympanic (ear), or temporal (forehead). Following the correct placement and procedural guidelines ensures accurate temperature readings, which are necessary for assessing the patient’s condition and determining appropriate care. Using the proper technique for each method minimizes the risk of error, discomfort, or injury to the patient while maintaining procedural efficiency.

10. Follow evidence-based practices for the chosen temperature measurement method, including proper placement of the thermometer and adherence to manufacturer guidelines. Proper technique ensures accurate readings, reducing the likelihood of diagnostic or treatment errors.

11. Allow the thermometer to process for the recommended duration. Electronic and tympanic thermometers will signal when the reading is complete through a light or sound. For chemical dot or tape thermometers, refer to the product’s instructions to determine the required waiting time before reading the result. Waiting for the appropriate amount of time ensures that the thermometer has had sufficient time to accurately measure the temperature, preventing errors. The use of audible or visual cues in electronic and tympanic thermometers helps confirm the procedure’s completion, while following product-specific instructions for other thermometers reduces the risk of incorrect readings. This careful timing is essential for obtaining reliable results, which are crucial for patient care and decision-making .

12. If a high fever is present, administer antipyretic medications such as acetaminophen or ibuprofen as prescribed. Reassess the temperature after administration. Antipyretics help reduce fever, improving patient comfort and preventing complications such as febrile seizures or dehydration . Monitoring effectiveness ensures the intervention achieves its intended outcome.

13. Encourage the patient to drink fluids or administer intravenous fluids if oral intake is inadequate. Monitor urine output for signs of dehydration . Fever increases fluid loss through sweating and evaporation. Maintaining hydration supports thermoregulation and prevents complications like hypovolemia .

14. Observe for other symptoms such as confusion , dizziness, or skin changes that might accompany abnormal temperatures. Symptoms like altered mental status or cold, clammy skin can indicate serious conditions like hyperthermia, hypothermia, or sepsis . Prompt identification of these symptoms allows for rapid response.

15. Provide information about the importance of temperature monitoring, signs of fever, and when to report changes. Educating patients and families empowers them to actively participate in managing their condition, ensuring better outcomes and early detection of complications.

16. Record the temperature, time of measurement, method used, and any accompanying symptoms in the patient’s chart. Accurate documentation provides a clear record for the healthcare team, enabling effective communication and continuity of care.

The effectiveness of temperature assessment and subsequent interventions can be evaluated through:

Patient response. Evaluate the patient’s comfort and any reported symptoms such as chills or sweating.
Temperature trends. Monitor for fluctuations in temperature that may indicate improvement or worsening of the underlying condition.
Patient satisfaction . Ensure that the patient feels informed and comfortable with the procedure.
Assessment of underlying conditions. Reassess the patient’s overall condition and effectiveness of treatments based on temperature changes, and take appropriate action if necessary.
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“7.8 Skills Checklist: Oral, Tympanic, Axillary, Rectal, and Temporal Temperatures.” Nursing Assistant (Open Educational Resources).