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33 Cards in this Set
- Front
- Back
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What is Body T? |
heat produced + heat entering + heat exiting |
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How is heat lost (assuming that the environment is colder than your body T)? Name 4 ways |
conduction convection radiation vaporization |
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What are the 2 types of body heat? |
core T surface T |
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how is heat produced by the body? |
Basal metabolic rate Muscle activity Thyroxine output sympathetic stimulation fevers |
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What regulates the T of your body? |
The hypothalmus |
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What happens when skin becomes cold? |
Shivering Sweating is inhibited Vasoconstriction |
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What happens when skin becomes hot? |
Sweating enabled Vasodilation |
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What is the average T for an adult? (oral) |
36,7 to 36 BUT normal is from 36 to 38 |
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What factors affect body temperature? |
Age circadian rhythm exercise hormones Stress and anxiety |
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What age groups are at risk of temperature regulation issues? |
Newborns Children (under 12) Elderly (over 75) |
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Word for when body temperature is above the normal range. When the heat loss mechanism cannot keep pace with heat production |
pyrexia or hyperthermia or fever |
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word for very high fever (41C) |
hyperpyrexia |
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Word for when a client has a normal T |
afebrile |
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Word for when a client has a fever |
febrile |
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What is another word to describe the infections that cause fever? |
pyrogens |
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Type of fever where body T alternates at regular intervals between periods of fever and periods of normal or subnormal temperatures |
intermittent fever (malaria) |
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Type of fever that has a wide range of temperature fluctuations (greater than 2C over a 24 hour period) |
remittent (cold/influenza) |
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Type of fever that has short, febrile/afebrile periods of a few days are interspersed with each other (1-2 day cycles) |
relapsing |
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Type of fever that has body T fluctuations being minimal, but always staying above normal |
Constant |
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True or false: The "set-point" for the body T is only changed by the presence of pyrogenic substances. |
False. The effects of dehydration on the hypothalmus and tissue destruction also increase the set point. |
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What are the stages of fever? |
Onset (pyrogens released in body causing hypothalmus to increase set-point) Course (or plateau) - core temperature is above the set point and so the hypothalmus initiates the regulating mechanisms to decrease core temperature (Increase TPR, vasodilation, skin warmer and dry, dehydration with increased thirst, malaise, drowsiness, loss of appetite) Flush (defeverescence, fever abatement) - Hypothalmus attemps to lower T to 37C. This usually leads to sweating, flushed skin, warm, possible dehydration and decreased urine output. Temperature returns to normal or "breaks" |
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When the patient is hyperpyrexic, what should you be aware of? |
It can damage cells, particularly the brain's neurons (irreversible), but can also damage, kidneys and liver... |
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Where are the different sites to measure T? |
-Oral -Rectal -Axillary -Tympanic membrane -Skin and temporal artery -Arterial |
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Whan assessing a patient with fever, what are you looking for? |
Temperature, pulse, respirations Skin color Skin condition Pattern of fever If pt states that they are hot or cold If pt states that they feel weak, tired/lethargic |
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Can you give me an example of a nursing Dx related to temperature regulation? |
UMN for comfort due to elevated body temperature related to infection, inflammation, pyrogenic, etc. |
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When planning to deal with pt's fever what are the 2 things that must be done? |
1-Pt's T has to be within normal limits within 48h 2-Pt will suffer no long term effects from the fever while hospitalized (ex: brain damage, injury from seizure) |
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During the chill stage of a fever, what do you do? |
Promote heat production by -decreasing physical activity -monitor v/s -monitor I&O -encourage fluid intake Prevent heat loss by -Decrease radiation (provide blankets, increase room temperature) -Decrease conduction (change wet clothing and blanket) -Decrease conduction (close windows and doors to protect from drafts) -Decrease evaporation (keep pt dry) |
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During the course stage or flush stage, what do you do? |
1.Promote heat loss by: -radiation (remove covers, covers over siderails) -convection (fan, open window, door) -conduction (tepid sponge bath, cool cloth to forehead, underarms, and groins, cooling blanket) -evaporation (leave skin damp following tepid bath) 2. Reduce set point: -with medication (Tylenol) 3. promote pt comfort: -fatigue = assist with ADL -increased perspiration = good hygiene (sponge bath/tepid water, mouth care, replace fluids) 4. Treat cause of fever -if bacterial = antibacterial -if dehydration = water -if viral = tylenol, vaccine |
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What is the term used to describe core temperature that remains persistently below normal range (usually <35C)? |
Hypothermia |
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What are the causes of hypothermia? |
1- Excessive heat loss -Inadequate heat production -Exposure to the cold -Impaired hypothalmic thermo-regulator 2- Decreased heat production (elderly, depression, sedatives) |
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Who are the different people at risk of hypothermia? |
-very young -very old -those who are unknowledgeable to cold environment -participants of cold weather activities -neurologic problems (dimished ability to feel cold) -alcoholics |
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What are the manifestation of hypothermia? |
-decreased TPR -Severe shivering -feeling cold, schills -pale, cool, waxy skin -hypotension -decreased urinary output -lack muscle coordination -disorientation -drowsiness progressing to coma |
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Nursing interventions for hypothermia? |
-remove pt from cold -rewarm patient -remove wet clothing (decrease conduction) -provide extra sweaters, blankets etc and warm room air -provide warm beverages -keep limbs close to body (HELP position) |
