Prof.

ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF

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NURSING, TJOHN COLLEGE OF NURSING
Vital signs
• Body temperature
• Pulse
• Respiration and
• Blood pressure
• Indicate the functioning of the body; especially functioning of the
vital organs- brain, heart, lungs and kidney

Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF

NURSING, TJOHN COLLEGE OF NURSING 2
When to assess vital signs?
• Frequency varies from person to person, hospital to hospital.
• More frequently assessed for clients in following conditions-
• Clients with elevated body temperature
• Breathing difficulty
• Low or high BP
• Changes in pulse rate or rhythm
• On medications that affect CVS or respiratory functioning
eg:Morphine, Digoxin
• Critically ill clients

Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF

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NURSING, TJOHN COLLEGE OF NURSING
Can the nurse delegate this
responsibility?

• Yes, but she should ensure accuracy of data

and
• Report abnormal findings
• She should know the normal values for various
age groups so that she can recognize the
variations.

Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF

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NURSING, TJOHN COLLEGE OF NURSING
 Guidelines
• When to Check vital signs?
• When client reports a change in health condition eg: feeling
giddy, feeling chills
• Before and after surgery or invasive procedures eg: blood
transfusion
• Before and after medicine administration
• Before and after nursing intervention that may affect vital
signs eg: before ambulating a patient on bedrest for many
days.

Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF

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NURSING, TJOHN COLLEGE OF NURSING
 Guidelines contd……..
• Choose appropriate device and site for checking vital signs.

• Eg: if critically ill client- continuous monitoring is done.

• For an infant- oral route is not used.

• Record and report the vital signs timely.

• Whenever the nurse can take independent interventions based

on vital signs, she should do it. Eg: giving a cold compress if
temperature is >101F
Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF
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 Body temperature

• Is the heat of the body measured in degrees.

• It indicates the difference between heat produced in the body

and heat lost.

• 2 kinds of body temperature:

• 1. core body temperature

• 2. surface temperature
Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF
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NURSING, TJOHN COLLEGE OF NURSING
Core vs Surface
temperature

Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF

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NURSING, TJOHN COLLEGE OF NURSING
Core temperature

• Is the temperature of the deep tissues of the body, such

as the abdominal cavity and pelvic cavity.
• It remains highly constant, within a range of 97F
(36Celsius ) to 99.5F(37.5C)
• Sites- rectum, tympanic membrane, oesophagus,
pulmonary artery, urinary bladder,

Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF

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NURSING, TJOHN COLLEGE OF NURSING
Core temperature- sites PULMONARY ARTERY

Oesophagus

URINARY BLADDER
Tympanic membrane
Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF
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NURSING, TJOHN COLLEGE OF NURSING
Surface temperature

• Is the temperature of skin, subcutaneous tissue and fat.

• It rises and falls in response to the environment.

• Sites- mouth, axilla, forehead, skin

Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF

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NURSING, TJOHN COLLEGE OF NURSING
Heat production in the body

• Body metabolism

• Muscle activity

• Hormones like thyroxine

• Chemicals like epinephrine, norepinephrine

• Oxidation of food

Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF

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NURSING, TJOHN COLLEGE OF NURSING
Factors that affect body’s heat
production
• Basal metabolic rate (BMR)- Is the rate of energy
utilization in the body required to maintain essential
activities such as breathing.
• Muscle activity- exercise, shivering etc increase
metabolic rate and then body temperature is
increased.

Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF

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NURSING, TJOHN COLLEGE OF NURSING
• Increased thyroxine output
increases cellular metabolism and
thus increase body temperature.

• Epinephrine, norepinephrine
directly affect the liver and muscle
cells, thereby increase cellular
metabolism.

Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF

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NURSING, TJOHN COLLEGE OF NURSING
 Heat loss
• Radiation is the transfer of heat from one
surface to another surface without contact
between the 2 surfaces.
• Conduction is the transfer of heat from one
molecule to another of lower temperature
through contact between them

• Convection is the dispersion of heat by air

currents.
• Vaporization is the loss of heat through
the continuous evaporation of moisture.
Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF
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NURSING, TJOHN COLLEGE OF NURSING
• When we put a wet cloth on forehead of a client with fever, heat is
lost through ………………
• When it is very hot, we switch on fan to reduce heat. Heat is reduced
by ………………………….
• A cup of hot coffee kept open on the table is found to be cold after 1
hr. this is due to heat loss through ……………………………
• In hot climate, we sweat and then we feel temperature is reduced.
This is due to ………………………………..

Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF

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NURSING, TJOHN COLLEGE OF NURSING
Regulation of body temperature
(physiology )

• body temperature of a healthy person is maintained constant by

the thermoregulatory centre in the hypothalamus.

• has 3 main parts:

• Sensors in the shell and in the core.

• Integrator in the core.

• Effector system that adjusts heat production and loss.

Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF
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NURSING, TJOHN COLLEGE OF NURSING
• Sensory receptors are in the skin, more
cold receptors than heat receptors.

• Hypothalamic integrator is located in the

preoptic area of the hypothalamus.

• Anterior hypothalamus- controls

heat loss
• Posterior hypothalamus- controls
heat production
Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF
NURSING, TJOHN COLLEGE OF NURSING
18
• When cold sensors are stimulated, the hypothalamic
integrator initiate effectors such as vasoconstriction ,
shivering and increases cell metabolism (thus increasing
body heat.

• when the heat sensors are stimulated, the hypothalamic

integrator initiates measures to decrease body heat which
include sweating, peripheral vasodilation as well as
behavioural mechanisms like switching a fan
Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF
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NURSING, TJOHN COLLEGE OF NURSING
Normal body temperature

• In adults- 36-38C/ 36.1-37.2C (97-99F)

• 98.6F
• A temperature over 100.4F/ (38°C) (Rectal/
ear/ temporal artery means fever. oral >100F,
Axilla >99F

Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF

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NURSING, TJOHN COLLEGE OF NURSING
Factors affecting body temperature

• Age – infant’s body temperature is greatly influenced by

environment. temperature fluctuates widely because of
immature temperature control mechanisms.

• Newborn’s temperature is normally within 95.9 to 99.5 F

• Older adult has a narrow range of body temperature than young

adult and are sensitive to extremes of temperature.
Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF
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NURSING, TJOHN COLLEGE OF NURSING
 Factors contd………..
• Exercise – Muscle activity requires an increased blood supply
and increased carbohydrate and fat breakdown. Exercise
increases body temperature.
• Hormone level- women generally experience greater
fluctuations in body temperature than men.
• Hormonal variations during menstruation causes this.
• When progesterone levels are low, temperature also
decreases.
• During ovulation greater amount of progesterone increases
temperature.

Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF

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NURSING, TJOHN COLLEGE OF NURSING
???

• Why women have slightly increased body temperature during

ovulation?
• Which test is used to find out the time of ovulation in women?

Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF

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NURSING, TJOHN COLLEGE OF NURSING
 4. Circadian rhythm
• Body temperature normally changes 0.5C to 1C (0.9F TO
1.8F) during 24 hour time period.
• Temperature is usually lowest between 1AM and 4AM
and ,maximum temperature comes at about 6PM and
then declines.

Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF

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NURSING, TJOHN COLLEGE OF NURSING
Quick revision

• Normally which time of the day a person has:

• A. lowest body temperature?

• B. Highest temperature?

Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF

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NURSING, TJOHN COLLEGE OF NURSING
5. Stress
• Physical and emotional stress increases body
temperature.
• Through hormonal and neural stimulation.
• This increases metabolism and thus heat production.

Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF

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NURSING, TJOHN COLLEGE OF NURSING
 6. Environment
• Influences body temperature.
• A warm environment leads to increase in body
temperature.
• If the person is outside in the cold environment without
warm clothes, body temperature becomes low

Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF

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NURSING, TJOHN COLLEGE OF NURSING
7. Diseases- infections, malignancies may lead to increase in body
temperature.
•Head injury can lead to malignant hyperthermia.
•Also intake of medicines –anaesthetics.
8. Site- rectal is 1F greater than oral and axillary is 1F lesser than
oral.
9. Intake of food- fats produce more heat .

Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF

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Types of thermometers

• glass thermometer
• Digital/ electronic
• Tympanic membrane
• Chemical dot thermometers
• Temporal artery thermometers
• Continuous monitoring devices

Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF

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NURSING, TJOHN COLLEGE OF NURSING
Digital /electronic thermometer

Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF

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NURSING, TJOHN COLLEGE OF NURSING
Tympanic membrane thermometer

Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF

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NURSING, TJOHN COLLEGE OF NURSING
Tympanic membrane thermometer

Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF

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NURSING, TJOHN COLLEGE OF NURSING
Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF
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NURSING, TJOHN COLLEGE OF NURSING
Chemical dot thermometer

Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF

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NURSING, TJOHN COLLEGE OF NURSING
Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF
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NURSING, TJOHN COLLEGE OF NURSING
NON-INVASIVE SKIN TEMPERATURE
MONITORING

Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF

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NURSING, TJOHN COLLEGE OF NURSING
INFRA RED THERMOMETER

Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF

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NURSING, TJOHN COLLEGE OF NURSING
Parts of a glass thermometer
STEM

Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF

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NURSING, TJOHN COLLEGE OF NURSING
Glass thermometer
• 2 Types- mercury glass thermometer and mercury free glass
thermometer.
• Mercury-free glass thermometers have blue coloured alcohol instead
of mercury.
• It has a silver tip. A silver line runs along the numbers to show the
temperature.
• Green is for oral or axillary and red for rectal

Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF

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NURSING, TJOHN COLLEGE OF NURSING
Mercury Glass thermometer- oral

1small division= 0.1C = 0.2F

• Needs to disinfect after each use.

• Chance of biting/ breaking
• Holding under tongue for the
required duration is difficult

Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF

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NURSING, TJOHN COLLEGE OF NURSING
Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF
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NURSING, TJOHN COLLEGE OF NURSING
Glass Rectal thermometer

Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF

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NURSING, TJOHN COLLEGE OF NURSING
Oral thermometer Vs rectal
thermometer

Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF

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NURSING, TJOHN COLLEGE OF NURSING
Lotion thermometer

Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF

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NURSING, TJOHN COLLEGE OF NURSING
Oesophageal stethoscope

Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF

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NURSING, TJOHN COLLEGE OF NURSING
Units of temperature measurement

• Celsius
• Fahrenheit
• C=F-32X5/9
• F= 9C/5+32

Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF

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NURSING, TJOHN COLLEGE OF NURSING
• Convert 95F to Celsius.
• 35C
• Convert 38C to Fahrenheit
• 100.4F

Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF

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NURSING, TJOHN COLLEGE OF NURSING
1. Oral
• Under the tongue, in the sublingual pocket

• Duration- 2-3 minutes

Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF

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NURSING, TJOHN COLLEGE OF NURSING
• Advantages of oral route
• Easy access.
• Accurate temperature.
• Less time needed.
• Disadvantages
• Chance of cross infection
• Bad taste of disinfectant .
• Chance of biting thermometer
• Not safe for use in children below 5 yrs, mentally unstable clients
• Difficult to hold in position (especially weak clients
• Temperature affected by intake of hot or cold food

Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF

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NURSING, TJOHN COLLEGE OF NURSING
Contraindications of oral route

• Oral surgeries / injuries

• Mouth breather
• Continuous cough
• Unconscious clients
• Children<5years
• Mentally ill clients, disoriented clients
Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF
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NURSING, TJOHN COLLEGE OF NURSING
 2. Axilla

• The normal axillary temperature is usually a degree lower

than the oral (under the tongue) temperature.
• The axillary temperature may be as much as two degrees
lower than the rectal temperature.
• A normal axillary temperature is between 96.6° (35.9° C)
and 98 °F (36.7° C).
• Duration- 5-7 minutes

Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF

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NURSING, TJOHN COLLEGE OF NURSING
 Advantages
• No chance of cross infection
• No taste of disinfectant
• No biting of thermometer
• Can be used for clients who can’t use oral route.
Disadvantages
• Need for privacy
• Least accurate route
• More time needed.

Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF

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NURSING, TJOHN COLLEGE OF NURSING
Rectal route
• Left lateral position
• Duration-1-2minutes
• Lubricate -1 inch of thermometer

Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF

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NURSING, TJOHN COLLEGE OF NURSING
Advantages of rectal route
• Most accurate
• Less time duration
Disadvantages
• Chance of soling of nurse’s hands
• Inaccurate reading if rectum is loaded with stools
• Needs privacy
• embarrassing

Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF

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NURSING, TJOHN COLLEGE OF NURSING
Contraindications of rectal route
Haemorrhoids
• Rectal surgeries

• Haemorrhoids

• diarrhoea

Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF

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NURSING, TJOHN COLLEGE OF NURSING
Tympanic membrane

• The thermometer is inserted into the ear canal .

• Position- side-lying

• Pull pinna backward, up and out for an adult.

• For children less than 3 yrs, pull the pinna down and back.

Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF

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NURSING, TJOHN COLLEGE OF NURSING
Advantages

• Easily accessible
• Minimal client repositioning needed.
• Used for clients with tachypnea
• Accurate reading (core temperature).
• Very rapid measurement
• Unaffected by oral intake of hot or cold fluids.

Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF

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NURSING, TJOHN COLLEGE OF NURSING
Disadvantages

• Needs to remove hearing aid before measurement.

• Requires disposable sensor cover.

• cannot be used in case of ear surgeries.

• Ear wax impaction distorts reading.

• Need to position the probe very accurately.

Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF

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 Skin
• Advantages
• Inexpensive
• Provides continuous reading
• Safe and non-invasive
• Used for neonates.
• Disadvantages
• Measurement lags behind other sites.
• Adhesion (sticking) reduced by sweating.
• Reading is affected by environmental temperature.
• Cannot be used for clients with allergy to adhesive tape.

Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF

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Temporal artery- forehead

Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF

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NURSING, TJOHN COLLEGE OF NURSING
 Temporal artery
• Advantages
• Easy to access
• Very rapid measurement
• No risk of injury
• No need for privacy
• Comfortable for client
• Used in premature infants, newborn

Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF

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NURSING, TJOHN COLLEGE OF NURSING
Disadvantages

• Inaccurate with head covering

• Affected by skin moisture
• Cannot use if continuous monitoring is needed .

Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF

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Disinfection of clinical thermometer

SOLUTION STRENGTH DURATION

DETTOL 1:40 5 MIN

SAVLON 1:20 5 MIN

LYSOL 1:40 3 MIN

FAIRGENOL 1:40 5 MIN

Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF

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Alterations in temperature
• Hyperthermia
• Heat stroke
• Heat exhaustion
• Hypothermia
• Frost bite
• Fever

Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF

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NURSING, TJOHN COLLEGE OF NURSING
FEVER (PYREXIA)
• A body temperature above usual range is called pyrexia,
hyperthermia or fever.
• Normal temperature range is 96.8F -100.4F
• Fever is is characterised by a body temperature of above
37.2°C (98.9°F) (axillary),
• 37.5°C (99.5°F) (oral) or
• 38°C (100.4°F) (rectal and tympanic)
• Temperature >99F (37.2C)
• FEBRILE- client who has fever.
• Afebrile- client who doesn’t have fever.
Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF
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NURSING, TJOHN COLLEGE OF NURSING
 98.6F 103.2F
.6 .6

• The set point of hypothalamic thermostat changes

suddenly from normal to a higher value due to tissue
destruction, pyrogenic substances etc.
• So heat production measures like chills, feeling of
coldness, shivering etc starts

Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF

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NURSING, TJOHN COLLEGE OF NURSING
• Fever is not a disease, but a defense.
• The rise in temperature prevent the growth of
microorganisms.
• It hastens the destruction of bacteria by increasing
phagocytosis and by producing immune bodies.
• The range of temperature within which cells can function
normally is 34C to 41C.
• The CNS is very sensitive to temperature changes.
• Irreversible changes may occur in the nervous system
and damage parenchymal cells

Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF

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NURSING, TJOHN COLLEGE OF NURSING
Grades of fever

• Low pyrexia- 99-100F

• Moderate pyrexia- 100-103F

• High pyrexia- 103-105F

• Hyperpyrexia / Hyperthermia > 105F

Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF

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NURSING, TJOHN COLLEGE OF NURSING
Phases of fever

• Onset (invasion)- when the body temperature is rising.

• Fastigium or stadium- is the period when body temperature has

reached maximum and remains fairly constant at higher level.

• Defervescence or decline- elevated temperature is returning to

normal.(it may be sudden or gradual)

Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF

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NURSING, TJOHN COLLEGE OF NURSING
• Crisis- sudden return to normal temperature from a very high
temperature.
• True crisis- when temperature falls suddenly to normal with a
marked improvement in client’s condition.
• False crisis- a sudden fall in temperature not accompanied by
improvement in general condition.
• LYSIS- Temperature falls in a zig-zag manner in 2-3 degrees before
reaching normal.

Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF

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Causes of fever
• Infections
• Diseases of nervous system
• Malignant neoplasm
• Leukaemia
• Heat stroke
• Exposure to hot environment
• Dehydration
• Reactions to foreign proteins
• Head injury
Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF
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Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF
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Effects of fever on body system

• Respiratory system- rapid and shallow breathing

• CVS- increased pulse rate, palpitation.

• GIT- dry mouth, coated tongue, loss of appetite, indigestion,

nausea, vomiting, constipation, diarrhoea.

• Urinary system- decreased urinary output, burning micturition,

highly coloured urine.
Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF
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Effects of fever on body system ………

• Nervous system- headache, restlessness, irritability, insomnia,

convulsions, delirium

• Musculoskeletal system- malaise, fatigue, body pain, joint pain.

• Integumentary system- heavy sweating, hot flushes, goose

flush, shivering, rigor.

Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF

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NURSING, TJOHN COLLEGE OF NURSING
• Q1. a client’s temperature reading is as follows.
• 6am- 98.6F , 10AM -101F, 2PM - 102F, 6PM- 103F, 10PM-101F, 2AM-
99F
• Q2. A client’s temperature is recorded as follows.
• 6am-100F, 10AM- 101F, 2PM- 103F, 6PM- 104F, 10PM-101F, 2AM-100F
• Q3. day 1- 6am-101F, 10AM-102F,2PM-103F,
• DAY2-6am-101F, 10AM-102F,2PM-103F,
• DAY-3 6am- 98.6F , 10AM -98.4F, 2PM - 99F, 6PM- 98.6F, 10PM-98.8F,
• Q4 6am-101F, 10AM-102F,2PM-103F, 6PM102,10PM- 101F
• Q5 6am-105F, 10AM-104F,2PM-103F, 6PM101,10PM- 100F
• Q6 6am-101F, 10AM-102F,2PM-103F, 6PM -106F, 10AM- 105F

Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF

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Types of fever

• Intermittent fever- temperature rises from normal to high fever

and back at regular intervals. Interval may vary from few hours
to 3 days.

• Remittent fever- a fever characterized by variations of more

than 2 degrees between morning and evening but does not
reach normal.

Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF

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NURSING, TJOHN COLLEGE OF NURSING
• Relapsing fever- is one in which there are brief febrile periods
followed by one or more days of normal temperature.

• Constant fever- fever in which temperature doesn’t vary more than

2 degrees between morning and evening and does not touch
normal.

• Fever spike- a temperature that rises to fever level rapidly following

normal temperature and then returns to normal within few hours.

Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF

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NURSING, TJOHN COLLEGE OF NURSING
 • Hectic or swinging fever- when the difference
between high and low points is very great.

• Inverse fever- the highest range of temperature is

recorded in the morning and lowest in the evening.

• Rigor- is a sudden severe attack of shivering.

Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF

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NURSING DIAGNOSIS -Hyperthermia R/T
Infection
goal- client maintains normal body temperature

Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF

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ASSESSMEN NURSING GOAL & OUTCOME NURSING RATIONALE IMPLEME EVALUATI
T DIAGNOSIS INTERVENTIONS NTATION ON

Objective HYPERTHERMIA Client maintains

data- TEMP- R/T INFECTION normal body
101F temperature

Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF

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 Nursing management of client with fever
• 1. regulation of body temperature
• Maintain room temperature at comfortable level-
• Using electric fans, A/C. open doors and windows
• Cold sponging, tepid sponging, cold compress, ice cap
• Cold lavages,cold enema
• Use of hypothermia blankets
• Antipyretics- paracetamol

Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF

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 2. Meeting nutritional need
• Cellular metabolism is high and oxygen consumption
increases.
• Provide a high calorie diet
• Easily digestable
• Increase fluid intake-3litres/day
• Avoid fats and oils
• Maintain intake output chart
• Provide a soft diet with plenty of fruits and fluids
• Provide small frequent feed
• Serve food attractively
• Consider likes and dislikes
Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF
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3. Rest and sleep

• Bed rest
• Provide a calm and quiet environment
• Help client to change position regularly.
• Clothing should be light , smooth and non-
irritating ( preferably cotton garments).

Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF

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4. Maintenance of personal hygiene
• Mouth care (oral hygiene 4hrly)
• Apply emollient on lips .
• Care of skin and pressure points.
• Sponge bath twice daily.

Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF

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5. Safety of client
• Never leave a client with high fever alone.
• ( chance of delirium and convulsions)
• Surface cooling should be done gradually.
• Once temperature brought down to normal, cover with blanket
• Check skin for any discolouration if using moist cold application.

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6. Monitoring of client

• Check vital signs 4 hrly

• Measure urine output periodically.

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 Rigor
• A rigor is an episode of shaking or
exaggerated shivering which can occur with
a high fever.
• The affected person (who now has a fever)
will suddenly feel too hot. They will want to
cool down, will look flushed and may sweat
profusely.
• It occurs because cytokines and
prostaglandins are released as part of an
immune response.
• Causes- Bacterial infection including ear
infection, chest infection, blood transfusion.
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STAGES OF RIGOR
1. Cold stage- skin is cold, face pale, feeble & rapid pulse,
temperature rises rapidly.
Cover with blankets, apply warmth, give warm drinks, protect
from falling
2. Hot stage- skin feels hot and dry, thirsty, shivering stops,
restless, temperature may continue to rise.
Cover with thin blanket, cold compress
Check temperature 10-15 minutes, watch pulse and respiration.
Cold sponging if temp is high

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Contd…
3. Sweating stage-
sweats profusely, temperature falls, pulse improves,
•Change wet clothes,
•quick sponge, provide clean dry clothes,
•cover with light cotton linen,
•sleep,
•monitor vitals 15 minutes

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Hyperthermia

• is defined as a body temperature greater than 40 C.

• is an abnormally high body temperature caused by a failure of

the heat-regulating mechanisms of the body to deal with the
heat coming from the environment.

• Forms of hyperthermia- Heat fatigue, heat syncope, heat

cramps, heat exhaustion and heat stroke
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RISK FACTORS

• not drinking enough fluids,

• living in housing without air conditioning,

• lack of mobility and access to transportation,

• overdressing,

• visiting overcrowded places

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Who is at risk?

• Older people, particularly those with chronic medical

conditions- Heart, lung and kidney diseases, high BP, on
multiple medications.

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Heat stroke

• Is a dangerous heat emergency due to

depression of hypothalamic function due to
heat.
• Prolonged exposure to sun or high
environmental temperatures.

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Clients at risk for heat stroke
• Those who are very young or old

• Those who have cardiovascular diseases

• Hypothyroidism

• Diabetes or alcoholism

• Medications that decrease body’s ability to lose heat-

phenothiazines, anticholinergics
• Those who exercise strenuously

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 Signs and symptoms of heat stroke
• Giddiness, confusion, delirium, excess thirst, nausea,
muscle cramps, visual disturbances, incontinence
• T- 113 F
• Increased heart rate, increased respiration
• Hot, dry skin
• no sweating
• Unconsciousness,(HEAT SYNCOPE)
• fixed, non-reactive pupils

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 Heat exhaustion
• Occurs when profuse sweating resulting in excess
water and electrolyte loss.

• Caused by environmental heat exposure

• Signs and symptoms of fluid volume deficit

• First aid –transporting client to cooler environment,

restoring fluid and electrolyte balance.
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Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF
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Malignant hyperthermia
• is a severe reaction to certain drugs used for anesthesia.

• a dangerously high body temperature, rigid muscles or spasms, a

rapid heart rate,

• Risk factor-the gene that puts you at risk of malignant hyperthermia.

• Treatment- the medication dantrolene ,ice packs and other

measures to cool body temperature,

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Hypothermia
• Is a condition in which temperature falls below 95 F (35 C).

• subnormal temperature. A body temperature below the normal

range of 97.5° to 99.5°F (36° to 38°C
• Heat loss during prolonged exposure to cold reduces body’s ability to produce
heat, causing hypothermia eg; falling in a frozen lake.
• Intentional hypothermia for surgeries
• T- 35 C, uncontrolled shivering, loss of memory, depression and poor judgement.
• T- 34C, heart rate, resp rate and BP falls.

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Hypothermia
• Temperature falls below 95 F (35 C).
• Occurs when body loses more
heat then it produces.
• Risk factors- exposure to cold
environment, alcohol, fatigue,
open wounds.
• Mild- treated easily
• Untreated- fatal

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Prof.ROSAMMA JOSEPH, Dept of FUNDAMENTALS OF
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• Skin- cyanotic, if continues cardiac arrhythmias, loss of
consciousness and unresponsive to painful stimuli.

• Severe hypothermia- death signs

• Check core temperature using low reading thermometers

• measures to improve temperature.

• Define hypothermia. Discuss nursing measures for hypothermia

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Nursing measures for hypothermia
• Monitor temperature through the use of a low-range thermometer if available
• Assess and record the mental status of the patient
• Remove From wet/ cold Environment
• To prevent further decrease in core body temperature, patients should be removed
from the cold environment as soon as possible.
• Insulate the person's body from the cold ground. If client is
outside, lay the person on his or her back on a blanket or
other warm surface.
• Monitor breathing. If the person's breathing has stopped or
appears dangerously low or shallow, begin CPR immediately if
you're trained.
• Remove Wet Clothing .
• Passive Rewarming - used for patients with mild hypothermia. dressing the patient
in warm clothing, while allowing the patient to spontaneously rewarm.
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• Active Rewarming – used for clients with moderate to severe
hypothermia.
• Electric Heating Blanket/ Heated blankets are used during active
rewarming of hypothermic patients.
• patient’s trunk should be warmed first before the extremities.
Warming extremities first can cause shock.
• Warm IV Solutions Warmed IV-stand -IV solutions can be warmed up
to 98.6ºF (37ºC)
• Heated Oxygen - Warmed O2-tank. Supplemental oxygen can be
heated and humidified during active internal or core rewarming.
• Warm Gastric Lavage - Gastric lavage with warm fluids is another
intervention that can be used to treat moderate to severe
hypothermia.
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Frost bite
• When body is exposed to subnormal temperature

• Ice crystals form inside the cell, permanent circulatory and tissue
damage occurs

• Areas- earlobes, tip of nose, fingers and toes

• Injured area becomes waxy, white , firm to touch ; loses sensation in

affected area

• Gradual warming measures, analgesia and protection of injures tissues.

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