Alteration in body temperature

Presented By
SAMJHANA NEUPANE
Msc. Nursing 1st year
SNSR
Definition of body temperature

• Body temperature is the degree of hotness or coldness of a

body or environment.

• It reflects the balance between the heat produced and the heat
lost from the body, and is measured in the units called
degrees ,temperature can be expressed as ℃ and ℉.Normal is
37℃ and 98.6℉ measured under tongue , axilla and rectum
 Types of body temperature
Core temperature
Temperature of internal
body tissues below the skin
& subcutaneous tissues.
Sites :
Tympanic and rectal
Esophagus and pulmonary
Surface body temperature
The body temperature of
external body tissues at the
surface that is of the skin &
subcutaneous tissues.
Sites:
Oral, axillary & temporal
Physiology of body temperature ( change)
A. Neural and vascular control
B. Heat producing mechanism
1. Basal metabolism
2. voluntary movements
3. Shivering
4. Non- shivering thermogenesis
C. Heat loss
1. Radiation
2. Conduction
3. Convection
4. Evaporation
5. Skin
D. Behavioral control
 pyrexia

Definition:

• A body temperature above the usual range is called pyrexia.

• A very high fever, such as 41℃ is called hyperpyrexia.

 Causes

Exogenous
Endogenous
 Causes

Exogenous pyrogens include bacteria, viruses, fungi, allergens,

incompatible blood products and foreign substances.

Endogenous pyrogens Endogenous pyrogens are produced by

monocytes, macrophages, neutrophils and eosinophils.

It also may result from inflammatory reactions, such as those that occur
in tissue damage, cell necrosis, rejection of transplanted tissues,
malignancy and antigen antibody reactions
 Pathophysiology
Exogenous pyrogens ( viruses, bacteria, fungi, pyrogenic steroids) enter the body

Activating leucocytes to produce interleukin 1 which is released into blood stream.

Causing the thermoregulatory center in the brain to reset to higher set point

Activating physiologic effectors to cold ( shivering)

 Conti……

Generating heat and causing fever

• Phases of fever

• Intitiation phase:

• During this phase, pyrogens act on the hypothalamus to reset the temperature set
point to higher than body temperature.

• Activation of effector mechanisms, such as shivering and decreased blood flow to

the skin, increases body temperature to attempt to reach the set point.

• In addition, the feverish client exhibits behaviors to decrease heat loss, such as
putting skin surfaces in fetal position and increasing insulation by adding blankets
or clothing.

• The client will feel cold and may have chills.

• Plateau phase:

• The body temperature has risen and is maintained at the new elevated
set point.

• The client will feel warm because of this elevation in the core body
temperature.
• Defervescent phase

• The body’s effector mechanisms are activated to promote heat loss

because the lowering of temperature set point.

• The client will feel warm and may sweat and appear flushed. Behaviors
include shedding of clothing and blankets and request for ice and fluids.

• Fever may resolve by a rapid return to normal over a period of a few

hours ( resolution by crisis) or resolve slowly( resolution by lysis).
• Clinical manifestations

• Respiratory system: shallow and rapid breathing

• Circulatory system: increased pulse rate and palpitation

• Alimentary system: dry mouth, coated tongue, loss appetite,

indigestion, nausea, vomiting, constipation or diarrhea

• Urinary system: diminished urinary output, burning micturition, high

colored urine
• Nervous system: headache, restlessness, irritability, insomnia ,
convulsions, delirium

• Musculoskeletal system: malaise, fatigue. Body pain, joints pain

• Integumentary system: heavy sweating, hot flushes, gooseflesh,

shivering or rigors
Classification Or Patterns Of Fever:

• 1. Intermittent fever: Temperature returns to acceptable value at least

once in 24 hours. The temperature curve returns to normal during the
day and reaches its peak in the evening. E.g.- in septicemia.

• 2. Remittent fever: fever spikes & falls without a return to the normal
temperature levels. The temperature fluctuates but does not return to
normal. E.g.- TB, viral diseases, bacterial infections
• 3.Sustained fever: the temperature remains continuously elevated
above 38 degree Celsius & demonstrates little

• 4. Relapsing fever: periods of febrile periods interspersed with

acceptable temperature values i.e. periods of fever are interspersed with
periods of normal temperature.

• 5. rigor : it is a sudden severe attack of shivering in which the body

temperature rises rapidly to the state of hyperpyrexia as seen in malaria.
• 6. crisis: is a sudden return to normal temperature from a very high
temperature within a few hours or days.

• 7. True crisis: the temperature falls suddenly within a few hours and
touches normal, accompanied by marked improvement in the patients
conditions.

• 8. lysis : the temperature falls in a zig zag manner for two or three days
or week before reaching, during which time the other symptoms also
gradually disappear.
 2)Fever Of Unknown Origin

• Fever of Unknown Origin(FUO) was defined by Peterson & Benson in

1961 as having following features-

• temperature of > 38.3 degree Celsius (>101 degree Fahrenheit) in

several occasions.

• A duration of fever of > 3 weeks.

• Failure to reach a diagnosis despite one week of inpatient investigation

• Causes of FUO

• Infections

• 1.Pyogenic infections: pyrogenic abscess, cholangitis, pelvic abscess,

thrombophlebitis.

• Vascular infections: infective endocarditis, infective vascular access

devices

• Chronic granulomatous infections: tuberculosis, fungal infections

• Other prolonged bacterial and rickettsial illness: brucellosis

• 2.Immunoinflammatory diseases: systemic lupus erythematosus

• 3.Neoplasms

• 4.Metabolic and familial conditions

• 5.Drug induced fever

• 6.Undiagnosed fever
• Diagnosis of fever

• History taking

• Physical examination

• Laboratory tests
• Management of FUO

• Objective are to reduce the elevated hypothalamic set point and second to
facilitate heat loss.

• Antipyrectic agents

• Oral aspirin and acteminophen is equally effective in reducing fever. Aspirin

blocks prostaglandin synthesis in the hypothahamus and elsewhere in the
body. Acetaminophen acts on the heat regulating center in the hypothalamus.

• Nonsteroidal anti inflammatory drugs ( NSAID) such as indomethacin and

ibuprofen are also excellent antipyretics.
• Physical cooling with sponging, fan, cooling blankets and even ice
baths can be used in conjunction with administration of appropriate
pharmacologic agents.

• If insufficient cooling is achieved by external means, internal cooling

can be achieved by gastric or perioneal lavage with iced saline.

• In extreme cases, hemodialysis or even cardiopulmonary bypass with

cooling of blood may be performed
Nursing Interventions For Client With Fever

1.Monitor vital signs

2.Assess skin color and temperature

3.Monitor white blood cell count, hematocrit value, and other pertinent
laboratory reports for indications of infection or dehydration.

4.Remove excess blankets when the patient feels warm, but provide extra
warmth when the client feels chilled.

5.Provide adequate nutrition and fluids (e.g. 2500-3000 ml per day) to meet
the increased metabolic demands and prevent dehydration.
6.Measure intake and output

7.Reduce physical activity to limit heat production, especially during the

flush stage.

8.Administer antipyretics ( drugs that reduce the level of fever) as

ordered.

9.Provide oral hygiene to keep the mucuous membranes moist

10.Provide a tepid sponge bath to increase heat loss through conduction.

11.Provide dry clothing and bed linens.

 3) Hyperthermia

• The term hyperthermia means elevated temperature, it is generally used

to refer to elevation in body temperature related to imbalance between
heat gain and heat loss.

• It is elevated body temperature due to failed thermoregulation that

occurs when a body produces or absorbs more heat than it dissipates.
Temperature ranges - >37.5-38.3degree Celsius (99.5- 100.9 degree
Fahrenheit).
• Causes Of Hyperthermia

• classic heat stroke

• Prolonged exposure to sun or high environmental temperatures. These condition

causes heat stroke . A dangerous heat emergency with a high mortality rate.

• Endogenous pyrogens include hormone like chemical messengers called

cytokines. Endogenous pyrogens are produced by monocytes, macrophages,
neutrophils and eosinophils. It also may result from inflammatory reactions,
such as those that occur in tissue damage, cell necrosis, rejection of transplanted
tissues, malignancy and antigen antibody reactions
• Exogenous pyrogens ( viruses, bacteria, fungi, pyrogenic steroids0
enter the body

• Activating leuckocytes to produce interleukin1 which is released into

the bloodstream

• Causing the thermoregulatory center in the brain to reset to higher set

point

• Activating physiologic effectors to cold ( shivering)

• Diagnosis

• Patient’s history reveals exposure to elevated ambient temperature or excessive

exercise.

• Physical examination: Found following things

• Profound central nervous system dysfunction ( Manifested by confusion, delirium,

coma)

• elevated body temperature ( 40.6 degree C / 105 degree F) or more or tachypnea or

thot dry skin usually anhidrosis ( absence of sweating).

• Victim of heatstroke do not sweat because of severe heat loss and hypothalamic
malfunction
Management of hyperthermia:

• Treatment for hyperthermia depends on its cause, as the underlying cause must
be corrected.

• Mild hyperthemia caused by exertion on a hot day might be adequately treated

through self-care measures, such as drinking water and resting in a cool place.

• Hyperthermia that results from drug exposures is frequently treated by

cessation of that drug, and occasionally by other drugs to counteract them.

• Fever-reducing drugs such as paracetamol and aspirin have no value in treating

hyperthermia.
 Treatment:

• Mechanical methods of cooling are used to remove heat from the body and to restore
the bodys ability to regulate its own temperatures.

• Passive cooling techniques, such as resting in a cool, shady area and removing
clothing can be applied immediately.

• Active cooling methods, such as sponging the head, neck, and trunk with cool water,
remove heat from the body and thereby speed the bodys return to normal temperatures.

• Drinking water and turning a fan or dehumidifying air conditioning unit on the affected
person may improve the effectiveness of the body’s evaporative cooling mechanisms
(sweating).
• Sitting in a bathtub of tepid or cool water (immersion method) can
remove a significant amount of heat in a relatively short period of time.
It is much productive, as it causes vasoconstriction in the skin and
thereby prevents heat from escaping the body core.

• When the body temperature reaches about 40°C, or if the affected

person is unconscious or showing signs of confusion, hyperthermia is
considered a medical emergency that requires treatment in a proper
medical facility. In a hospital, more aggressive cooling measures are
available, including intravenous hydration, gastric lavage with iced
saline, and even hemodialysis to cool the blood.
 4) Hypothermia

• Hypothermia is defined as when the body’s core temperature falls to 95

℉ or less

• For example, hypothermia occurs when a person is exposed to cold

environmental temperature for a prolonged period of time.
Causes

• Individual at the extreme of age, the elderly and neonates, particularly

vulnerable to hypothermia.

• As elderly have diminished thermal perception and more vulnerable to

immobility, malnutrition and systemic diseases that interfere with heat
generation or conservation.
• Several types of endocrine dysfunction can lead to hypothermia.
Hypothyroidism, particularly when extreme, as in myxedema coma,
reduces the metabolic rate and impairs thermogenesis and behavioural
response.

• Adrenal insufficiency and hypopituitarism can also increase

susceptibility to hypothermia.

• Hypoglycemia, most commonly caused by insulin or oral hypoglycemic

drugs, is associated with hypothermia.
• Neurologic injury from trauma , cerebrovascular accident, subarchnoid
hemorrhage or hypothalamic lesions increases susceptibility to
hypothermia.

• Sepsis : with extensive burns , psoriasis, and other skin diseases,

increased peripheral blood flow leads to excessive heat loss
Mechanism of heat loss in newborn

• Newborn loses heat by

• Evaporation particularly soon after birth due to evaporation of amniotic

fluid from skin surface. Conduction by coming in contact with cold
objects- cloth, tray etc

• Convection by air current in which cold air replaces warm air around
the baby, open the windows, switch on the fans.

• Radiation to cooler objects in the vicinity such as walls.

Causes

• The cold environment at the place of delivery.

• Inadequate drying and wrapping before and during transport of the

baby.

• Excessive heat loss by evaporation, conduction, convection and

radiation from wet baby to the cold linen, cold room and cold air and
also due to certain characteristics of the neonates.
• 3 physiologic mechanisms of hypothermia are:

• Excessive heat loss

• Inadequate heat production to counteract heat loss

• Impaired hypothalamic thermoregulation

Sign and symptoms
• Peripheral vasoconstriction
• Acrocyanosis
• Cool extremities
• Decreased peripheral perfusion
• Increased pulmonary artery pressure
• Respiratoy distress
• Tachypnea
• Increased metabolism
• Hypoglycemia
• Hypoxia
• Metabolic acidosis
• CNS depression
• Lethargy
• Bradycardia
• Apnea
• Poor feeding
• Chronic sign
• weight loss
Types of hypothermia

• Hypothermia may be induced or accidental

• Induced hypothermia is the deliberate lowering of the body temperature

to decrease the need for oxygen by the tissues such as during certain
surgeries.

• Accidental hypothermia can occur as a result of:

• Exposure to cold environment Immersion in cold environment.

• Lack of adequate clothing, shelter or heat

• Mgmt. includes of continual monitoring, rewarming and supportive
care.
• Mild hypothermia
• Passive rewarming methods such as- blankets and increased ambient
temperature. Covering and insulating the patient in warm environment.
With the head also covered. This technique is ideal for previously
healthy patients.
• Active warming methods may be incorporated in more severe cases. It
is necessary under these circumstances: core temperature less than
32℃, cardiovascular instability, endocrine insufficiency, or any
suspicious of secondary hypothermia.
Prevention of hypothermia in neonates

• Warm chain

• Baby must be kept warm at the place of birth ( home or hospital), during
transporation for special care from home to hospital or within the hospital.
The warm chain is a set of ten interlinked procedures carried out at birth and
later which will minimize the likelihood of hypothermia in all the newborns

• i.Warm delivery room (≥25℃)

• ii.Warm resuscitation

• iii.Immediate drying
• iv.Skin to skin contact between baby and the moher

• v.Breastfeeding

• vi.Bathing postponed

• vii.Appropriate clothing and bedding

• viii.Mother and baby nursed together

• ix.Warm transportation

• x.Training and awareness – raising of healthcare providers

• In the delivery room

• Conduct delivery in a warm room

• Immediately dry newborn with a clean, soft, preferably warm, towel

• Use another warm towel to wrap the baby in two layers

• Place the baby skin to skin on mother’s abdomen

• Later, clothe the baby ensuring that the head is well covered. Nurse the
baby by the side of mother in close proximity in the same bed.
• Kangaroo mother care

• KMC is a powerful, easy to use method to promote the health and wellbeing of low
birth weight babies. Its key features are:

• Early, continuous and prolonged skin to skin contact between the mother and the
baby.

• Exclusive breastfeeding .

• Initiated in a facility and continued at home.

• Healthful effects

• KMC helps in maintaining temperature of an infant, facilitates breastfeeding ,

improves growth, reduces infections and improves mother infant bonding.
• Instituting KMC

•All babies less than 2000gm are candidates for KMC

•Place the baby naked, with or without nappy, upright inside mothers
clothing against skin.

•Let the baby suckle at breast as often as he wants but least 2 hourly.

•Sleep prop up so that the baby stays upright.

•Make sure that the baby stays warm at all times. If the environment is
cool, dress the baby with extra clothing and covers its head.
• When the mother wants to bath or rest, ask the father or another family
member to kangaroo the baby or wrap it in several layers of warm clothing,
covered with blankets.

• Take the baby for regular check-up for vaccination and weight record.
• Bathing should be avoided for at least 6 hours after birth. Ensure before
giving bath that the temperature is normal.

• Preferably give bath to normal baby on second day in summer. In

winter bathing may be avoided for several days.

• Likewise, bathing is avoided in low birth weight neonates till they

reach 2500g. Sponging is good enough to clean the baby.
• The nurse or attendant should follow the instructions as given below

• i. Use warm room and warm water

• ii. Bath quickly and gently

• iii. Dry quickly and thoroughly from head to toe

• iv. Wrap in warm, dry towel

• v. Dress and wrap infants, use cap on the head.

• vi. Place the infant close to its mother.

• Temperature maintenance

• Temperature maintenance during transport

• Let the baby’s temperature stabilize before transport

• Record temperature before transport and take remedial measures. If the

temperature cannot be documented, use hand touch to judge the temperature.
Baby’s hand and feet should be as warm as the abdomen.
• Carry the baby close to the chest of the mother.

• Thermocol box with prewarmed linen or plastic bubble sheet or silver

swaddler may be used during transport.

• Warm filled mattress with thermostat to control temperature

• Management of hypothermia ( in Neonates)
• A hypothermic baby has to be rewarmed as quickly as possible. The
method selected will depend on severity of hypothermia and
availability of staff and equipment. The choices include:
• •Skin to skin contact
• •A warm room or bed
• •A 200 watt bulb
• •A radiant heater or an incubator.
• Moderate hypothermia (. 32 to , 36℃)
• Skin to skin contact should be in warm room and warm bed.
• A warmer/incubator may be used. If available.
• Continue rewarming till the temperature reaches the normal range.
• Monitor the temperature every 15-30 minutes.
• Radiant warmers
• The use of radiant warmers facilities the care of the neonate,
particularly the care of a critically ill neonate, who requires
cardiorespiratory support and monitoring. Radiant warmers promote
insensible water loss and a small increase in metabolic rate. Severe
hypothermia

• Use air heated incubator ( air temperature 35-36℃) or manually

operated radiant warmer or thermostatically controlled heated mattress
set at 37-38℃. Once the baby’s temperature reaches 34℃ , the
rewarming process should be slowed down. Monitor BP, heart rate,
temperature and glucose ( if facilities are available).
• In addition, take measures to reduce heat losses, start IV 10%
dextrose, give injectable vitamin k ( 1mg for term baby: 0.5 mg for
preterm baby) and provide oxygen. All efforts must be made to
maintain the warm chain, early detection of hypothermia and prompt
remedial measure to correct it. This will significantly reduce mortality
and morbidity in the new born period.
 FROSTBITE
• Definition
• Frostbite is trauma from exposure to freezing temperature and actual
freezing of the tissue fluids in the cell and intracellular spaces ,
resulting in vascular damage.
• Frostbite is the medical condition whereby damage is caused to skin
and other tissues due to extreme cold, at or below 0°C (32° F), blood
vessels close to the skin start to narrow.
• Sites:

• It can occur on any skin surface but is generally limited to the nose,
ears, face, hands, and feet

• Frostbite has been reported in the penis and scrotum of joggers and in
burn patients after prolonged treatment with ice

• Freezing keratitis of the cornea has been reported in snow- mobilers

and skiers who did not wear protective goggles
• Degree of cold injury

• Frostnip: Frostnip is a mild form of frostbite. ...

• Superficial frostbite: Superficial frostbite appears as reddened skin

that turns white or pale. ...

• Deep (severe) frostbite:

• As frostbite progresses, it affects all layers of the skin, including the

tissues that lie below.
• Management

• i. The goal of management is to restore normal body temperature:

• ii.Do not allow the patient to walk if the lower extremities are
involved.

• iii.Remove all constricting clothing that can impair circulation, rings

and watches are removed.
• decrease the amount of tissue loss.

• Administer an analgesic for pain as prescribed: the rewarming process

may be painful.

• Handle the part gently to avoid further mechanical injury. Do not

massage.
• Protect the rewarmed part: do not rupture blebs, which develop 1 hour
to a few after rewarming.

• Place sterile gauze or cotton between the affected fingers and toes to
prevent maceration. Elevate the part to help control swelling.

• Use foot cradle to prevent contact with bedclothes if the feet are
involved
• Conduct physical assessment to observe for concomitant injury ( soft tissue
injury, dehydration, alcohol coma, fat embolism)

• vi. Restore electrolyte balance: dehydration and hypovolemia occur

frequently in frostbite victims.

• vii. Use strict aspectic technique during dressing changes.

• viii. Give tetanus prophylaxis as prescribed if there is an associated trauma.

• ix. The following may be carried out when appropriate

• • Whirlphool bath for the affected extremity to aid circulation, debride dead
tissue and help infection.
• Escharotomy ( incision through eschar) to prevent further tissue
damage, to allow for normal circulation, and to permit joint motion.

• Fasciotomy ( incison in fascia to release pressure on the muscle, nerve,

blood vessels ) to treat compartment syndrome.

• xi. Encourage hourly active motion of the affected digits to promote

maximum restoration of function and to prevent contractures.

• xii. Advice the patient not to use tobacco because of

vasoconstrictive effects of nicotine, which further reduce the already
deficient blood supply to the injured tissues.
• References
• Brar,nc and rawat.hc 2015. Textebook of advanced nursing practice. Jaypee
brothers medical publisher ltd
• https://www.slideshare.net/lisachadha/altered-body-temperature-68807683
• https://www.slideshare.net/JaysGeorge/alteration-in-body-temperature-
80786276
• https://www.slideshare.net/JaysGeorge/alteration-in-body-temperature-
80786276
• https://accessmedicine.mhmedical.com/content.aspx?
bookid=1130&sectionid=63549358
• https://www.ncbi.nlm.nih.gov/pubmed/15127194
• https://www.mayoclinic.org/diseases-conditions/frostbite/symptoms-
causes/syc-20372656
• https://www.healthline.com/health/frostbite-stages
• https://en.wikipedia.org/wiki/Frostbite