FAR EASTERN UNIVERSITY

Institute of Nursing
FUNDAMENTALS OF NURSING

Module: ASSESSING BODY TEMPERATURE

Introduction:
The measurement of a person’s physiological observations or vital sign is a core nursing function and
key to the recognition of patient deterioration. Vital signs provide important information about the
condition of a person’s vital organ. Vital signs that are within normal limits reflect a person’s
physiological well-being whereas abnormal vital signs maybe an early warning of clinical deterioration.

Learning Outcomes

At the end of this module, the student will be able to;

1. Discuss the rationale, knowledge and skills require for assessing body temperature.
2. Describe factors affecting that may affect the accurate measurement of temperature.
3. Identify the variation that may occur in normal temperature across the lifespan.
4. Verbalize the steps used in assessing body temperature.
5. Describe the appropriate nursing care for alteration in temperature.
6. Demonstrate appropriate documentation and reporting of temperature.
Topic Outline:
1. Vital Sings
2. Purposes of Vital signs
3. Temperature
4. Factors influencing temperature
5. Site for temperature measurements
6. Common types of fever
7. Nursing Interventions to fever

VITAL SIGN is the term that includes:

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 ➢ Body temperature
➢ Pulse rate
➢ Respiratory
➢ Blood Pressure
➢ Oxygen concentration (O2 sat.)
➢ Pain

PURPOSES of taking vital signs;

1. To obtain baseline data
2. To identify whether the core body temperature is within normal
3. To detect or monitor change in the client’s health status
4. To monitor client’s at risk for alteration in health

When do we take Vital Signs?

1. Upon admission
2. Changes in the status of the patient
3. Nursing or medical orders
4. Before, during and after an invasive procedure
5. Before and after administration of drugs
6. Before and after any nursing intervention.

Body TEMPERATURE
➢ Reflects the balance between the heat produced and the heat lost from the body and is measured
in degrees Celsius (⁰C).

Two kinds of Body Temperature

1. Core Temperature- relatively constant temperature of deep tissues of the body (e.g. abdominal
cavity and pelvic cavity).
2. Surface Temperature- temperature of the skin, subcutaneous tissue and fat. Surface temperature
fluctuates in response to environment.

Four processes of heat loss

1. Radiation- the transfer of body heat to a cooler solid object not in contact with the body.
2. Conduction- the transfer of heat from to a cooler solid object in contact with the body.
3. Convection- the dispersion of heat by air currents.
4. Vaporization- a continuous evaporation of moisture from the respiratory tract, the mucosa of the
mouth and the skin. This continuous and unnoticed fluid loss is called insensible fluid loss and
the accompanying heat loss is called insensible heat loss.

Thermoregulation Center- HYPOTHALAMUS

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 • Your hypothalamus is a section of your brain that controls thermoregulation. When it
senses your internal temperature becoming too low or high, it sends signals to your
muscles, organs, glands, and nervous system. They respond in a variety of ways to help
return your temperature to normal.
• When your internal temperature changes, sensors in your central nervous system (CNS)
send messages to your hypothalamus. In response, it sends signals to various organs and
systems in your body. They respond with a variety of mechanisms.
• The anterior hypothalamus controls heat loss by initiating the mechanisms of sweating
and vasodilation of blood vessels. Blood is redistributed to surface vessels (flushing of
the skin) to promote heat loss, not heat retention. The posterior hypothalamus controls
heat production by initiating the mechanisms of shivering, vasoconstriction of blood
vessels, and reduction of blood flow to the skin and extremities.

Factors that Influence Body Temperature

1. AGE
• Infant is greatly influenced by the temperature of the environment
• Child’s temperature continues to be variable until puberty
• Older people, those over 75 years of age, are at risk of hypothermia
2. DIURNAL VARIATIONS (circadian rhythms)
• Person body temperature normally changes throughout the day, varying in 1.0⁰C between
early morning (4 a.m.-6 a.m.) and late afternoon (4p.m. – 9 p.m.)
3. EXERCISE
• hard work or strenuous exercise can increase a person’s body temperature to levels as
high as 40⁰C
4. HORMONES
• Women usually experience more hormone fluctuations than men. In women,
progesterone secretion at the time of ovulation raises body temperature by about 0.3⁰C to
0.6⁰C above basal temperature.
5. STRESS
• Stimulation of the sympathetic nervous system can increase the production of adrenaline
and noradrenaline, thereby increasing metabolic activity and heat production.
6. ENVIRONMENT
• Extremes in environmental temperature scan affect a person’s temperature regulatory
system.

Normal Body Temperature range: 96.4 ⁰F – 99.1 ⁰F average of 98.6 ⁰F

35.8 ⁰C average of 37 ⁰C

*Generally considered an axillary temperature is one

degree lower and rectal temperature is one degree higher.

Average body Temperature based on age:

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 • Babies and children- 97.9°F (36.6°C) to 99°F (37.2°C)
• Adults- (36.1°C) to 99°F (37.2°C)
• Adults over age 65- 98.6°F (36.2°C)
❑ Keep in mind that normal body temperature varies from person to person. Your body
temperature might be up to 1°F (0.6°C) higher or lower than the guidelines above.
Identifying your own normal range can make it easier to know when you have a fever.

TYPES OF THERMOMETERS
1. Glass thermometers (mercurial thermometer) – no longer the instrument of choice.
oral- (2-3 mins.)
axilla- (9 mins adults/ 5 mins child)
rectal- (2 mins.)
2. Electronic thermometers/ digital thermometer – can provide reading in 2 to 60 seconds. The
equipment consists of a battery- operated portable electronic unit, a probe cover and LCD
measures reading. (1 min.)
3. Tympanic thermometer – detect infrared energy which is converted into an electronic
temperature reading displayed on an LCD screen. Used for infection control purposes, an
appropriate disposable probe cover is used for each person and usually has an automatic probe
cover eject button to minimize cross- contamination. (2 secs.)
4. Temperature sensitive tape - used to obtain a general indication of body surface temperature. It
does not indicate the core temperature. (15 secs.)

Temperature Conversion Scale: Fahrenheit to Celsius: ⁰C=(°F-32) ×5/9

Celsius to Fahrenheit: ⁰F=(°C×9/5) +32

SITE FOR TEMPERATURE MEASUREMENT

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 Terminologies
• Febrile- temperature that is above normal or patient has fever
• Afebrile- temperature is normal or patient without fever

ALTERATIONS IN BODY TEMPERATURE

➢ Pyrexia aka Hyperthermia or fever- is defined as a core temperature greater than 40.6 ⁰C.
Hyperthermia is a medical emergency which is often fatal despite intervention. A child or older person
with a physical or development disability has a greater risk of hyperthermia and dehydration than other
people.
➢ Hyperpyrexia- an extremely high fever 41 ⁰C or 105.8 ⁰F
➢ Hypothermia- is a core body temperature below the lower limit of normal. A temperature below
34 ⁰C

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 Clinical Manifestations of Hypothermia
- Decreased body temperature and decreased pulse and respiration rates
- Severe shivering (initially)
- Feelings of cold and chills
- Pale, cool, waxy skin
- Hypotension
- Decreased urinary output (oliguria)
- Lack of muscle coordination
- Dis-orientation
- Drowsiness progressing to coma

FOUR COMMON TYPES OF FEVER

1. Intermittent fever- occurs when the body temperature alternates at regular intervals between
periods of fever of normal or subnormal temperature. (e.g. malaria)
2. Remittent fever- a wide range of temperature fluctuations, occurs over the 24- hour period all of
which are above normal. (e.g. cold or influenza)
3. Relapsing fever- occurs when there are short febrile periods of a few days interspersed with
periods of 1 or 2 days of normal temperature.
4. Constant fever- occurs when the body temperature fluctuates minimally but always remains
above normal. (e.g. typhoid fever)
*When a person’s temperature rises to fever level rapidly following is normal temperature and then
returns to normal within a few hours, the condition is called a fever spike

THREE PHASES OF FEVER

1. Chill (or cold) phase- characterized by heat production responses that cause elevation of a
person’s body temperature such as chills, feelings of coldness, cold skin due to vasoconstriction
and shivering. This occurs in the interval (typically several hours) during which core body
temperature (e.g. the blood temperature) reaches the new set point.

Chill (or cold) phase (onset of fever)

- Increased heart rate (tachycardia)
- Increased respiratory rate (tachypnea) and depth
- Shivering
- Pale, cold skin
- Complaints of feeling cold
- Cyanotic nail beds
- Goosebumps on the skin
- Cessation of sweating

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 2. Plateau phase- begins when a person’s core temperature reaches the new set point; the person
feels neither cold nor hot and no longer experiences chills.

Plateau phase (course of fever)

- Absence of chills
- Skin that feels warm
- Photosensitivity
- Glassy- eyed appearance
- Tachycardia and tachypnea
- Increased thirst (polydipsia)
- Mild to severe dehydration
- Drowsiness, restlessness, delirium or convulsions
- Herpetic lesions of the mouth (e.g. an ulceration of the skin)
- Anorexia (persistent loss of appetite) if the fever is prolonged
- Malaise, lethargy, weakness and aching muscles

3. Defervescence (or flush) phase- begins when person’s body resolves the cause of the high
temperature. The hypothalamic set point is adjusted to a lower value, perhaps even back to the
original normal level.

Defervescence (or Flush) phase (fever abasement)

- Skin that appears flushed and feels warm
- Sweating (diaphoresis)
- Decreased shivering
- Possible dehydration

NURSING CARE FOR PATIENT WITH FEVER

• Monitor vital signs
• Assess skin color and temperature
• Monitor laboratory results for signs of dehydration or infection
• Remove excess blankets when the client feels warm
• Provide adequate nutrition and fluid
• Measure intake and output
• Reduce physical activity
• Administer antipyretic as ordered
• Provide a tepid sponge bath
• Provide dry clothing and bed linens

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 NURSING CARE FOR HYPORTHERMIA
• Provide warm environment
• Provide dry clothing
• Apply warm blankets
• Keep limbs close to body
• Cover the client’s scalp
• Supply warm oral or intravenous fluids
• Apply warming pads

TEMPERATURE: Lifespan Consideration

▪ Infants -Unstable
-Newborn must be kept warm to prevent hypothermia
▪ Children -Tympanic or temporal artery sites is preferred
▪ Elders -Tends to be lower than that of middle- aged adult

NURSING DIAGNOSIS
1. Potential altered body temperature related to:
a. illness or trauma affecting temperature regulation.
b. medication or vigorous activity.
2. Altered body temperature (hyperthermia) related to exposure to excessively hot environment,
increase metabolic rate, or dehydration.
3. Altered body temperature (hypothermia) related exposure to excessively cool environment,
debilitating or trauma, or lack of adequate clothing and shelter.
4. Ineffective thermoregulation related to decreased basal metabolism secondary to aging, or
trauma, or illness.
5. Risk for imbalanced body temperature, at risk for failure to maintain body temperature within
normal range.

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