UKRAINIAN MINISTRY OF PUBLIC HEALTH
Dnepropetrovsk State Medical Academy
«APPROVED»
At the methodological meeting of
the internal medicine propedeutics
department
Chief of the department
____________prof. Khomazuk T.A.
«
»
2013 y.
Guidelines
For Second-year Students of the Dentist Department
Subgect
Module №
Enclosure module №
Topic №6
Course
Faculty
Propedeutics of the internal medicine
Temperature, thermometry. Nursing the respiratory
patients. Assessment of patientcondition and his vital
sign.
2
Dnepropetrovsk- 2013
General purpose: to know the main types of fevers,. rules of temperature
registration in the temperature chart.
Specific purpose:
1. To know the types of fevers, nursing patients.
2. To study methodics of temperature registration in the temperature
chart
3. To know the first aid to patients with the critical decreasing
temperature.
4. Features of nursing patients with the critical decreasing temperature.
Topic content.
Temperature refers to the hotness or coldness of a substance. Some living
species are able to self-regulate the temperature of their body while others are warmed
and cooled by conditions in the enviromment. Humans are homeo-thermic that is, they
are warm-blooded and maintain body temperature independently of their environment.
It has been observed that environmental and physiological processes occur in
repeated cycles of time. Some events in humans, appear to recur at 24-hour intervals.
This cycling pattern is referred to as circadian (meaning nearly every 24 hours)
rhythm. Predictable fluctuations in measurements of body temperature and blood
pressure are examples of functions that exhibit a circadian rhythm.
The body temperature of a healthy person is maintained within a fairly constant
range by the hypothalamus in the central nervous system. This structure is located at
the base of the brain and plays an important role as the body's thermostat. It normally
allows the body temperature to vary only approximately 1 degree throughout the day.
This constancy is referred to as the point. The set point can be altered by the body's
response to infectious agents, allergens, and inflamed tissue.
The hypothalamus has two parts: the anterior hypothalamus which controls heat
dissipation, and the posterior hypothalamus that governs heat conservation. Thus, the set
point is maintained by a balance of mechanisms involving heat production and heat loss.
The following are examples of ways in which the body's thermal balance is maintained:
Heat is produced through the metabolism of food. More heat is produced when
the metabolism is increased, and less when the metabolism is decreased. Heat
production is increased by the body's secretions of epinephrine, nonepinephrine, and
thyroxin. Exercise produces heat through muscle contraction. The body's surface, but
not its internal structures, gains and loses heat physically from the sun, wind, and
humidity in the environment. Heat is transferred primarily through physical processes
of radiation, convection, evaporation, and conduction. Heat is lost in small amounts
through the urine, faeces, and the process of v/arming and exhaling inspired air.
Changes in vascularity of the skin modify body temperature. When blood is directed to
the skin through dilated vessels, heat loss is increased, when the skin vessels contract,
heat is conserved. The contraction of smooth muscles when gooseflesh occurs, and the
involuntary movement of skeletal muscles when shivering is present, produce heat and
promote the circulation of blood that has been warmed through this process.
In physiological conditions temperature of a body of healthy persons changes
within the limits of 36,4 — 37,0° C. Variations normally occur in each person, and a
range of 0,3 °C to 0,6°C (0,5 °F to 1,0 ° F) from the average normal temperature is
considered to be within normal limit. For instance, body temperature is usually about
0,6 ° C lower in the earl)’ morning than in the late afternoon and early evening. This
variation tends to be somewhat greater in infants and children. Current research
indicates that the period elevation of a person's temperature will occur in late afternoon,
between 4pm and 7 pm. However, wider variations from the average temperature have
been found to be normal for certain persons. Newborns and young children normally
have a higher body temperature than adults, their internal organs require a fairly
constant inner or core temperature for optimal functioning, whereas the surface and
periphery of the body can fluctuate widely while gaining or losing heat.
A patient's temperature should be taken to reveal possible fever. It should be
remembered, however, that an elevated temperature does not always correspond to the
gravity of the patient's condition.
In medicine, three types of thermometers can be used for the measuring body
temperature.
Type
Operating
principle
Advantages
Disadvantages
Mercury:
oral,rectal
Heat
expands
mercury
-easy to store -accuracy varies despite manufacturers efforts to
inexpensive -readily
standardize
available -eliminates risk -breakage and cross-contamination may occur if
of crosscontamination if the thermometer is used by multiple patients used by one patient
temperature is recorded more slowly than with
other types of thermometers -the mercury
column is difficult to read.
Electronic
digital:
institutional,individual
Heat alters
the amount
of current
running
through
a
register
- rapid recording and
easy-to-rcad temperature
-extremely
accurate(instituti onal
unit must be properly
charged and calibrated) eliminates risk of glass
breakage -easy to store
Chemical- Heat
dot
initiates a
chemical
reaction
-institutional unit is expensive,but the nursing
time saved may offset the cost
-institutional unit requires periodic recharging
and recalibration -cross- contain in at ion may
occur.
-eliminates risk of cross- -improper storage may cause an inaccurate
contamination and
reading
breakage -records
-an adapter is needed for rectal use
temperature faster than -the plastic strip in the patient's mouth may
mercury thermometer
cause discomfort.
Temperature can be measured by a several ways. Measuring body temperature in
the hospital will be carried out in an axilla (armpit) by the Glass medical maximum
thermometer. It gives as maximum because mercury column in a capillary of the
thermometer in measuring body temperature, having reached a maximum level, does not
fall to initial position independently. It is necessary to shake it until the mercury line
reaches at least 36° C. This phenomenon is reached because the capillary of the
thermometer has narrowing which reduces the back motion of the mercury in the tank
after termination of thermal influence.
Glass thermometers are generally calibrated in either degrees Centigrade (Celsius)
Fahrentheit, abbreviated C and F, respectively. The range is approximately 34 0 C (94 °
F) to approximately 42,2 ° C (108 0 F). The degrees on a thermometer using the Celsius
scale are subdivided into gradients of 0,1; the subdivisions on a thermometer using the
Fahrenheit scale are the equivalent to 0,2 degree. Before giving the thermometer to the
patient, it should be wiped dry, and the mercury column returned to the 34-35°C mark.
The thermometer should be kept in the armpit so that the mercury bulb is in close contact
with the skin on all its sides.
The patient's armpit should be dry because the wet thermometer reads a lower
temperature. The thermometer should be kept in the armpit for about 10 minutes. If a
patient is very weak and cannot hold the thermometer with the required force, he should
be assisted.
In some cases the temperature can be measured by the oral or rectal methods. The
thermometer should be held for about 5 minutes in the mouth (under the tongue) or
inserting it in the rectum. In the latter case the thermometer should be coated with
vaseline or another oil. The patient should lie on his side, the thermometer being inserted
into the rectum to half its length. The buttocks should be kept tight together. Rectal
temperature (and temperature taken in the mouth) are 0.5-1 degree higher than that taken
in the armpit.
The elevation of body temperature over 37°C in adults is called fever (pyrexia,
hyperthermia).
Pyrexia is a common symptom of illness, and there is sufficient to indicate that an
elevation in temperature helps the body fight disease. In children, this response is often
seen quickly. In the elderly person, pyrexia may be one of the later signs of illness, and
the temperature may be elevated only 1 or 2 degrees above normal, even when
pathologic processes are extensive.
Fever is usually caused by infection and products of tissue decomposition. Elevation
of the temperature unconnected with infection is sometimes observed in malignant
tumours or tissues necrosis (in myocardial infarction), tissue hemorrhages, rapid
decomposition of red blood cells in the blood. Fever occurs less frequently in diseases of
the central nervous system and also in diseases of reflex etiology. Non-infectious fever
does not strongly affect the patient's condition and is usually transient. Temperature may
elevates in physiological states.
Elevated temperature are characterized as follows: temperatures from 37° to 383C
are called subfebrile, from 38° to 39°C — moderately high, from 39° to 40°C —
high, and over 40°C — very high. Temperatures over 41°C and 42°C are called
hyperpyretie and are dangerous to the patient's life. Death is probably due to the
damaging effects to the respiratory center but may be due also to inactivation of body
enzymes and destruction of tissue proteins.
The temperature may be only transient, and a for few hours (febris ephemeral).
It occurs in mild infection, excess exposure to the sun, after blood transfusions,
sometimes after intravenous injections of medical preparations. Fever lasting up to 15
days is called acute, from 15 about 45 days — subacute, more than 45 day —
chronic.
Not only elevated temperature itself, but also its circadian variations are very
impoitamt for diagnosing the diseases. Variations of temperature during the day
determine the type of fever. The following main types of fever are differentiated.
Constant fever (febris continua) — within day the difference between
morning and evening temperature does not exceed 1°C, morning temperature smaller
than evening one. It is observed in patients with acute lobar pneumonia or II stage
typhoid fever.
Remittent fever: the daily of the temperature exceeds 1 C and the
morning's lowest temperature being over 37 °C, the morning temperature smaller than
evening one. It often occurs in tuberculosis, purulent diseases, III stage typhoid fever and
lobular pneumonia.
Intermittent fever (febris intermittens): the daily fluctuations of the
temperature exceed 1 °C, morning temperature smaller than evening one. The body
temperature alternates regularly between a period of fever and a period of normal
temperature. It occurs in malaria.
Irregular fever (febris irregularis) — the fever, when cicardian
variations are varied and irregular. It often occurs in rheumatism, endocarditis, sepsis,
tuberculosis.
Hectic fever (febris hectica): the temperature rises sharply (by 2 ° — 4
°C) and drops to normal and subnormal level, that is often accompanied by excessive
sweating, moming temperature smaller than evening one. It usually occurs in grave
pulmonary tuberculosis, suppuration, sepsis and lymphogranulomatosis.
Inverse fever (febris inversus) is type of fever, when morning
temperature is higher than evening. It sometimes occurs in sepsis, tuberculosis and
brucellosis.
Reccurent fever (febris reccurens) — is characterized by alternation of
fever and afebrile periods. It occurs in relapsing fever.
llndulant fever (febris undulans) — is characterized by periodic
elevation of the temperature followed by its drop. It often occurs, in brucellosis and
lymphogranulomatosis.
The course of the fever is characterized by a period of elevation of the
temperature (stadium incrementi), which is followed by the period of high
temperature (stadium fastigium) and ending with period of decreasing temperature
(stadium decrementi).
In first period heat oss is decreased or heat production is increased. The degree
of temperature rise is important for evaluating the patient's condition. Fever is attended
by accelerated heart and respiration rates and a fall in the arterial pressure. Patients
complain of chill, headache, dry mouth, thirst, the absence of appetite and excess
perspiration. Metabolism is intensified during the fever, while the amount of perspired
liquid may be more than 8 liters a day. As a result of decreased appetite and liquid loss
during a fever, the patient sometimes loses significant weight.
A quick and significant elevation of temperature is usually accompanied by a chill
that continuing from a few minutes to an hour; in rare cases it may be continue longer.
The blood vessels contract during chills, the skin turns pallid, and what is called
gooscflesh develops. The patient feels cold, he shivers, his teeth chatter. If the
temperature rises gradually, the patient may feel only a slight chill. Young children or
persons with very high fevers may experience periods of delirium or seizures.
In the period of high temperature the skin reddens, becomes warm, the
patient feels hot. The respiration and palpitation becomes frequent: in increasing the
temperature on 1 C the pulse stroke usually becomes frequent on 8-10 and respiration
becomes frequent on 4 respiratory movements one minute.
Decreasing temperature is characterized by decreasing of the heat production
and increasing of heat loss. The temperature may decrease gradually, during several
days. This termination of fever is called lysis. A sudden temperature drop to norm
within 24 hours is called crisis.
A sudden drop in temperature is accompanied by heavy perspiration. The
extremities become cold to the touch. Cyanosis of labiums occurs. The skin becomes
covered by a cold clammy sweat, the pulse becomes steady. The gradual decreasing of
the temperature is accompanicd by an improvement of a condition.
Care for patients with fever.
During increasing of the temperature it is necessary to give the patient rest,
to lay him in bed, and to apply a hot-water bottle to the legs, to avoid the draughts.
Depending on the condition of the patient it is recommended at this time to give some tea
or coffee to him. The nurse must keep at the physiological excretions of the patient.
During a fever the toxic products are adsorbed in an organism. It is necessary to give
the patient plenty of liquid such as fruit juices, mineral water without gases, for removing
of the toxic products from organism. High-calory and easy assimilated food is given as a
fluid or semifluid kind. The diet should include fruit and berry juices. In connection with
the fall in appetite the patients is fed 6 times per day with small portions, limiting the salt.
A bubble with ice, cold compress from a gauze napkin combined four times and
moistened in a solution of Acetum (50 ml on 0,5 1 of the water) is put on forehead for a
sharp headache. The wiping and irrigation of an oral cavity with 2% sol. of a
hydrocarbonate, and also moistening of labium cracks with a liquid sol. of Glyccrinum
or children's cream is necessary in the dryness of the oral cavity and fracturing on the
lips.
If the patient develops delirium or hallucinations his bed should be provided with
a protective structures to prevent him from falling out of bed. A special post for the nurse
should be arranged at his bedside.
In loss of consciousness, the constant control of the pulse and respiration rates
would be necessary. In a long term bed patients it is necessary to carry out prophylaxis
for skin ulcers. The cleansing enemas are used for constipation. The patient is on a strict
bed regimen.
In resolution of the pyrexia as crisis, the patient puts hot water bottles all
round himself. If the patient perspires excessively, his bedclothes and underwear should
be changed several times a day. Since sweat evaporates from the skin and leaves
metabolites on its surface (salts, urea), the skin should be cleansed with water mixed with
alcohol or vinegar, or toilet water (1:1).
Special attention should be given to the patient during a critical fall of temperature
which is often attended by a fall in arterial pressure (collapse).
Vascular and respiratory analeptics — Cordiaminum, Sulfocamphocainum,
Carnphora, coffeine, phenylephine hydrochloride are given to thti patient, if the arterial
pressure drops.
Tests self-knowledge and skills that students acquire while exploring themes.
Situational tasks:
1. What actions should you make if patient with high fever has intensive
sweating?
A. Aspirin
B. *Change of the underwear and bed-clothes
C. Oxygen therapy
D. Using hot compress
E. Using leeches
2. What is mild pyrexia?
A. 37,0 – 38,0 0С
B. *38,5 – 39,0 0С
C. 39,0 – 40,0 0С
D. 40,0 – 41,0 0С
E. More than 41,0 0С
3. The hectic fever can be at the patient with
A. *Malaria
B. Relapsing fever
C. Purulent diseases
D. Chronic bronchitis
E. Cholera
4. If body temperature increases on 1,0 0С pulse rate increases on
A. 5 beats in a min
B. 20 beats in a min
C. *8-10 beats in a min
D. 15 beats in a min
E. More than 20 beats in a min
5. What is a dyspnea?
A. Disorders of the respiratory rate
B. Disorders of the respiratory depth
C. Disorders of the respiratory rhythm
D. *Disorders of the respiratory rate, depth, rhythm
E. Northing from above
6. Remittent fever is characterized by:
A.
B.
morning temperature is higher, than evening temperature
the difference between morning and evening temperature does
not exceed 1oC
C. daily fluctuations is more than 1oC, and it's minimum is
normal
D. sharp increasing of temperature in the evening and
fluctuation within day is more than 2oC
E. daily temperature fluctuates more than 1oC, and morning
temperature is more than normal
7. What temperature is dangerous for the patient's life?
A.
B.
C.
D.
40
*41
42
more than 42
E. 44
8. What measures on a care should be applied in the first stage of fever?
A. *to give a hot tea
B. to cover the patient with hot water bottle
C. to change bed-linen
D. to put a cold compress on forehead
E. to change body-linen
9. Intermittent fever is characterized:
A.
daily temperature fluctuates more than 1°C, and morning
temperature is more than normal
B. *the difference between morning and evening temperature
does not exceed 1°C
C. daily fluctuations more than 1C, and its minimum is normal
D. sharp increasing of temperature in the evening and fluctuation
within day is more than 2°C
E. morning temperature is higher, than evening temperature
10. Hectica fever is observed in:
A. *malaria
B. lobar pneumonia
C. sepsis, serious pulmonary tuberculosis
D. endocarditis
E. bronchitis
11. What measures on a care should be applied in a second
stage of the fever?
A. to warm the patient
B. *to control a pulse rate, respiration, arterial pressure
C. to control a condition of the central nervous system
D. to carry out a care of an oral cavity
E. to give a hot tea
12. The patient’s daily temperature within 1,5 weeks fluctuates
between 38 — 38,8°C. What type of a fever is it?
A. continued fever
B. *remittent fever
C. hectic fever
D. recurrent fever
E. intermittent fever.
13. Name the normal temperature:
A.
B.
C.
D.
36,6°C
*36,4 — 36,9°C
37 — 38°C
39°C
E. 36,9°C
14. What measures on a care should be applied in the critical drop of
the temperature?
A.
B.
C.
D.
E.
*carefully to control condition of cardiovascular system
to change body and bed linens as needed
to put a cold compress on a forehead
to warm the patient and to give some hot tea to him
to carry out prophylaxis of skin ulcer
15. The patient’s the daily temperature fluctuates between 37-39°C. What
type of a fever is it?
A. continued fever
B. remittent fever
C. *hectic fever
D. recurrent fever
E. intermittent fever
16. Subfebril temperature is:
A. from 36 to 37°C
B. *from 37 to 38°C
C. from 38 to 39°C
D. from 39 to 40°C
E. over 40°C
17. How are the processes of the thermoregulation changed in the first
stage of the fever?
A. blood vessels of a skin are narrowed
B. *blood vessels of a skin are dilated
C. the diaphoresis intensifies
D. decreasing of a heat production and increasing of a heat loss
E. increasing of a heat production and decreasing of a heat loss
18. The patient has daily temperature variations within the limits of
36 - 40,2°C. Intense chill is preceded by increasing of the temperature. The
drop is accompanied by the exhausting diaphoresis. What type of a fever is
it?
A. continued fever
B. remittent fever
C. hectic fever
D. *recurrent fever
E. intermittent fever
19. Moderately high temperature is:
A.
B.
C.
D.
from 36 to 37°C
*from 37 to 38°C
from 38 to 39°C
from 39 to 40°C
E. over 40°C
20. How are the processes of the thermoregulation changed in the third
stage of fever?
A. *blood vessels of a skin are narrowed
B. blood vessels of a skin are dilated
C. the diaphoresis intensifies
D. decreasing of a heat production and increasing of a heat loss
E. increasing of a heat production and decreasing of a heat loss
21. Alternating the periods of fever with the afebril periods is presented in
the patient. What type of a fever is it?
A.
B.
C.
D.
continued fever
*remittent fever
hectic fever
recurrent fever
Recommended Reading:
1. Diseases and disorders : a nursing therapeutics manual / Marilyn Sawyer
Sommers, Susan A. Johnson, Theresa A. Beery.—3rd ed.
2. Учебное пособие для иностранных студентов медицинских вузов,
обучающихся на английском языке / Мостовой Ю.М, Демчук А.В.,
Константинович Т.В.-1-е издание. - Винница:, 2009.
3. Clinical Nursing Skills and Techniques: basic, intermediate and advanced.
The C.V. Mosby Company, 1986.-1296 p.
4. Clinical Skills and Assessment Techniques in Nursing Practice. Scott,
Foresman and Company, 1989.-1280 p.
5. Emergency Nursing: priciples and practice. The C.V. Mosby Company,
1985.-715p.
6. Instructor's Manual for Fundamentals of Nursing, J.B. Lippincott Company
Philadelphia, 1989.-120 p.
7. Nursing interventions and clinical Skills. Mosby — year Book, Inc., 1996.813p.
8. Nursing Procedures: Student Version. Springhouse Corporation,1992.-788
p.