Thermoregulation

4 methods of heat loss

-Radiation - heat transfer that does not rely upon any contact between the heat source and the heated object -Conduction - direct transfer of heat from one object to another -Convection - flow of heat from body to cooler surroundings/air -Evaporation - heat loss when liquid is converted to vapor

F to C conversion equation

C=(F-32)*5/9

Management of heatstroke

-Reduce body temp ASAP - constant monitoring of temp with thermometer placed in the rectum, bladder, or esophagus to evaluate core body temp -Maintain oxygenation -Establish IV access - administer normal saline or lactated Ringer's solution -Remove clothing -Circulating fan -One or more of the following methods: cool sheets and towels or continuous sponging with cool water, ice packs applied to neck, groin, chest, and axillae, cooling blankets, immersion of the patient in a cold water bath

Malignant hyperthermia

-Severe, life-threatening reaction to inhaled anesthesia that results in a rapid rise in body temp -Treated with dantrolene sodium

Which information should the nurse include in the discharge plan for a client with multiple sclerosis who has an impaired peripheral sensation? Select all that apply. A. Carefully test the temperature of bath water. B. Avoid kitchen activities because of the risk of injury. C. Avoid hot water bottles and heating pads. D. Inspect the skin daily for injury or pressure points. E. Wear warm clothing when outside in cold temperatures.

A, C, D, E

The nurse has just measured an adult patient's oral temperature and obtained a result of 102.4ºF (39.1ºC). The patient states, "I just finished my coffee right before you came in. Can I have another cup?" Which response by the nurse is most appropriate? A. "I will bring you another cup when I return in 30 minutes to reassess your temperature. Please do not drink any other beverages until I return." B. "You will need to remain NPO until I notify your primary healthcare provider about your increased temperature." C. "Before you drink another hot beverage, drink some cool water so I can obtain an accurate oral temperature." D. "I'll be right back with your coffee and a different thermometer. I'm not sure this one measured your temperature correctly."

A. "I will bring you another cup when I return in 30 minutes to reassess your temperature. Please do not drink any other beverages until I return."

A school-age child with a severe head injury is unconscious and has coarse breath sounds, a temperature of 39° C (102.2° F), a heart rate of 70 bpm, a blood pressure of 130/60 mm Hg, and an intracranial pressure (ICP) of 36 mm Hg. Which action should the nurse perform first? A. Administer prescribed IV mannitol. B. Suction the child. C. Encourage the parent to talk to the child. D. Administer prescribed rectal acetaminophen.

A. Administer prescribed IV mannitol

You are preparing to assess a patient's oral temperature. You should plan to place the thermometer probe in which of the following areas of the patient's mouth? A. Deep in the posterior sublingual pocket B. Superior to the tongue with the tip touching the hard palate C. In the inferior buccal space on either side of the tongue D. Along either upper gum line adjacent to an incisor

A. Deep in the posterior sublingual pocket

Nursing assessment findings reveal a temperature of 96.2°F, pulse oximetry 90%, shivering, and client complains of chilling. The nurse recognizes the client is experiencing: A. Hypothermia B. Atelectasis C. Sepsis D. Pain

A. Hypothermia

A student is reading the medical record of an assigned patient and notes the patient has been afebrile for the past 12 hours. What does the term "afebrile" indicate? a. normal body temperature b. decreased body temperature c. increased body temperature d. fluctuating body temperature

A. Normal body temp

A client admitted with a wound infection has a temperature of 102.1°. The nurse administers ordered acetaminophen. How does the nurse plan to reassess the effectiveness of the medication? A. Reassess the client's temperature in one hour. B. Reassess the client's white blood cell count in one hour. C. Reassess the client's respiratory rate in one hour. D. Reassess the wound exudate in one hour.

A. Reassess the client's temperature in one hour

An adolescent client is admitted with a diagnosis of rheumatic fever and is on bed rest. He has a sore throat. His joints are painful and swollen. He has a red rash on his trunk and is experiencing aimless movements of his extremities. What should the nurse do first? A. Report the heart rate to the health care provider (HCP). B. Apply lotion to the rash. C. Splint the joints to relieve the pain. D. Request a prescription fto treat the elevated temperature.

A. Report the HR to the HCP

Heatstroke

Acute medical emergency caused by failure of the heat-regulating mechanisms of the body

The nurse should give which discharge instructions about thermal injury to a client with peripheral vascular disease? Select all that apply. A. "Warm the fingers or toes by using an electric heating pad." B. "Avoid sunburn during the summer." C. "Wear extra socks in the winter." D. "Choose loose, soft, cotton socks." E. "Use an electric blanket when you are sleeping."

B, C, D

A client preparing for discharge with her first baby states that she does not know how to bathe her infant. The nurse demonstrates how to bathe the newborn. What is the best method to reinforce the teaching? A. Recommend newborn care classes to the client. B. Have the client return demonstrate how to bathe the infant. C. Assess if the client has questions. D. Refer the client to the hospital's newborn care booklet.

B. Have the client return demonstrate how to bathe the infant.

Nursing assessment findings reveal a temperature of 96.2°F, pulse oximetry 90%, shivering, and client complains of chilling. The findings are indicative of which nursing diagnosis? A. Acute incisional pain B. Ineffective thermoregulation C. Decreased cardiac output D. Ineffective airway clearance

B. Ineffective thermoregulation

What is the primary source of heat in the body? a. hormones b. metabolism c. blood circulation d. muscles

B. Metabolism

When teaching a group of parents about the potential for febrile seizures in children, which information should the nurse include? A. The exact cause is known. B. The seizures occur as the fever rises. C. Children older than age 3 years are most at risk. D. These seizures commonly occur after immunization administration.

B. The seizures occur as the fever rises

Normothermia

Body temp is within normal range (35-37 C = 95-98.6 F)

A client postoperative from an appendectomy reports feeling cold and has a temperature of 96.2 degrees Fahrenheit. Which action should the nurse do first? A. Check the client's blood pressure. B. Apply an oxygen saturation monitor. C. Apply warm blankets to the client. D. Notify the health care provider.

C. Apply warm blankets to the client

A child is admitted to the hospital with a febrile seizure. What action should the nurse take? A. Keep the child supine. B. Place the child in isolation. C. Keep the room temperature low and bedclothes to a minimum. D. Place a padded tongue blade at the bedside.

C. Keep the room temp low and bedclothes to a minumum

Which of the following sites results in measuring a client's core body temperature? A. Tympanic B. Oral C. Rectal D. Axillary

C. Rectal

During the surgical procedure, the client's temperature falls to 96.6°F. Which of the following nursing actions is inappropriate? A. Warm IV and irrigating fluids. B. Increase the temperature of the OR environment. C. Remove wet gowns and drapes. D. Place a cooling blanket under the client.

D. Place a cooling blanket under the client

Environmental effects on thermoregulation

Extreme temperatures (ie hot environment without ventilation and high humidity)

C to F conversion equation

F = (C*1.8)+32

Risk factors of hyperthermia across the lifespan

Febrile seizures in infants ages 3 months to 5 years

What is the principle of homeostasis as it relates to thermoregulation?

Hypothalamus controls body temp and signals for mechanisms to increase heat production or facilitate heat loss by activating responses to lower or raise body temp based on info received from thermoreceptors

An adolescent is on the football team and practices in the morning and afternoon before school starts for the year. The temperature on the field has been high. The school nurse has been called to the practice field because the adolescent is now reporting that he has muscle cramps, nausea, and dizziness. Which action should the school nurse do first? A. Administer cold water with ice cubes. B. Take the adolescent's temperature. C. Have the adolescent go to the swimming pool. D. Move the adolescent to a cool environment.

Move the adolescent to a cool environment

When assessing an infant's axillary temperature, it will be A. One degree lower than an oral temperature B. One degree higher than a rectal temperature C. One degree higher than an oral temperature D. The same as the tympanic temperature

One degree lower than an oral temp

What site for taking body temperature with a glass thermometer is contraindicated in patients who are unconscious? a. rectal b. tympanic c. oral d. axillary

c. oral

What is the regulatory process related to thermoregulation?

homeostasis

Superficial frostbite symptoms

−Numbness, itching, prickling sensation −Cyanotic, reddened, white

Frostbite - thawing of tissues

−Skin white or yellow −Loses elasticity −Burning pain −Edema, blisters −Necrosis, gangrene -Rapid thawing may significantly decrease tissue necrosis

Deeper frostbite symptoms

Parethesias and stiffness

Compare and contrast hypothermia and hyperthermia

-Hypothermia is when body temp drops below 35º C; mild, moderate, severe; heat produced by body < heat lost -Hyperthermia is when body temp rises above 104º C; fevers, heat exhaustion, heat stroke; heat produced by body > heat lost

Risk factors for heatstroke

-Individuals not acclimated to heat -Elderly -Very young -Individuals unable to care for self -Chronic and debilitating disease -Certain meds (tranquilizers, anticholinergics, diuretics, beta-blockers)

Risk factors for hypothermia

-Infants, young children -Adolescents -Older adult -Decreased ability to shiver -Decreased basal metabolic rate -Evaporation from skin in cool environments -Exposure to cool environments -Acute or chronic illness -Malnutrition -Medications -Trauma -Hypothyroidism -Damage to hypothalamus -Immaturity of newborn

Frostbite

-Injury of skin resulting from freezing −If limited exposure, skin and subcutaneous tissue involvement (superficial frostbite) −Increased exposure = deeper structures freeze (deeper frostbite) −Skin freezes when temp drops to 21-24°C −Occurs most commonly on exposed and peripheral areas -As tissue freezes, ice crystals form and small vessels vasoconstrict then vasodilate -Continued exposure -> vasoconstriction

Common examples of hypothermia

-Mild (34-36 C) -Moderate (30-34 C) -Severe (<30 C)

What are the physiologic responses to hypothermia?

-Mild - shivering, tachycardia, tachypnea, fatigue, slurred speech, goose bumps, cyanotic skin, confusion -Moderate - no shivering, hypotension, hallucinations, depressed mental state, depressed respirations, slow pulse or irregular HR, pale or cyanotic skin -Severe - stiffness, passing out, absence of respirations or pulse, coma, ventricular fibrillation, and dilated and unresponsive pupils

How does dehydration affect thermoregulation?

One is sweating too much and doesn't have enough electrolytes (losing sodium from sweating too much)

What factors affect client temperature?

-Age -Diurnal variations -Exercise -Hormones -Stress -Environment - extremes affect thermoregulation

What is a fever?

-An upward shift in a patient's body temp -Body is fighting off an infection -Classified as low, moderate, or high -May also be classified as remittent, intermittent, sustained, relapsing, or undulant

Appropriate nursing interventions for hypothermia

-Blankets, heating pads, warm baths, or heaters that blow warm air -Warm fluids through IV -Warm O2 to breathe, or a breathing tube if needed -Warming the inside of the body with water - warm saltwater can be used to bring heat to the organs (water goes into the body through a small tube, then back out) -Meds - sometimes needed to treat related issues like low BP or heart problems -Blood rewarming

Possible complications of hyperthermia

-Coma -Febrile seizures -Tachycardia

Appropriate interventions with a patient with a fever?

-Drink plenty of fluids -Rest -Stay cool

Common examples of hyperthermia

-Fever -Heat exhaustion (body temp may be normal to 104 F) -Heat stroke (elevated body temp of 105 F)

Appropriate nursing interventions for hyperthermia

-Fever managed with antipyretics, adequate hydration as shown with skin turgor and edema tests -Keeping the environment cool; moving the resident to a cool environment -Removing excess clothing from the resident -Applying cool water to the resident -Fanning the resident -Applying ice packs to the neck, groin, and axillae. -Perform rapid cooling procedures for heatstroke -Using evaporative cooling measures (ie undressing resident, spraying with cool water, and using large fans) -Using ice water or slush immersion as an alternative method -Using cooling blankets -Performing peritoneal, thoracic, rectal, or gastric ice water lavage. -Provide adequate fluid intake -Oral fluids for a resident with mild exertional heat illness, IV fluids for a resident with more severe exertional heat illness, or IV crystalloid solutions for a resident with heatstroke -IV access for fluid administration

What are the physiologic responses to hyperthermia?

-Flushing -Skin warm and hot to touch -Increased metabolic rate -Fatigue, malaise, weakness -Decreased responsiveness -Difficulty concentrating -Poor appetite -Skin rash -Body aches -Vomiting and/or diarrhea

Sites to measure body temperature

-Oral (wait 30 mins if patient just ate/drank) -Axillae -Rectal (HR, BP can decrease, can puncture rectum when inserting) -Temporal -Tympanic

Clinical manifestations of heatstroke

-Profound CNS dysfunction manifested by confusion, delirium, bizarre behavior, coma -Elevated body temp of 40.6°C (105°F) -Hot, dry skin -Anhydrosis (absence of sweating) -Tachypnea -Hypotension -Tachycardia

Most common cause of heatstroke

Prolonged exposure to an environmental temp >39.2°C (102.5°F)

What place does shivering have in thermoregulation?

Shivering is in response to cold. When the core body temp drops, shivering is triggered to maintain homeostasis. Skeletal muscles begin to contract, creating warmth by expending energy.