重醫(yī)大護(hù)理學(xué)基礎(chǔ)課件14體溫

Chapter14

BodytemperatureVitalsigns

WhatareVital

signs(生命體征)?Vitalsignsincludeperson’stemperature,

pulse,respiration,andbloodpressure.Achangeinvitalsignscanindicateachangeinphysiologicalfunctionandpathologicalcondition.Vitalsigns

Thesesignsindicatetheeffectivenessofrespiratory,circulatory,neural,andendocrinebodyfunction.

Vitalsignsareaquickandefficientwayofmonitoringclients’conditionoridentifyingproblemsandevaluatingtheclients’responsetointervention.Vitalsigns

Whatdoesnursedoforclient’svitalsigns?Measurethevitalsignscorrectlyandpromptly.

Understandandinterpretthevalues.Vitalsigns

Guidelinesforvitalsignsmeasurement:1.Thenursecaringfortheclientisresponsibleforvitalsignsmeasurement.2.Equipmentshouldbefunctionalandappropriate.3.Thenurseshouldknowtheclient’snormalrangeofvitalsigns.

4.Thenurseknowstheclient’smedicalhistory,therapies,andmedications.Vitalsigns

5.Thenursecontrolsorminimizesenvironmentalfactorsthatmayaffectvitalsigns.6.Thenurseusesasystematicmethodwhentakingvitalsigns.7.Thenursecollaborateswiththephysiciantodecidethefrequencyofvitalsignassessment.

Vitalsigns

8.Thenurseusesvitalsignsmeasurementstodetermineindicationformedicationadministration.9.Thenurseanalysestheresultsofvitalsignsmeasurement.10.WhentotakevitalsignsLearningObjectives1.Definethefollowingterms:fever,hyperthemia,hypothermia,continuousfever,remittentfever,intermittentfever,irregularfever.2.Discussthenormalvalueofbodytemperatureandfactorsaffectbodytemperature.3.Identifytheclassificationoffeverandnursinginterventionsforclientwithfever.4.Demonstratethestepsoftemperaturetaking.

ContentsPhysiology1FactorsAffectingBodyTemperature2AlterationsinBodyTemperature3NursingProcessandThermoregulation4Bodytemperatureistheheatofthebody,measuredinheatunitscalleddegrees.Bodytemperaturereflectsthebalancebetweentheheatproducedandtheheatlostfromthebody.

section1

PhysiologyTwokindsofbodytemperature:Coretemperature（體核溫度）

isthetemperatureofthedeeptissuesofthebody.Itremainsrelativelyconstant.Surface(shell)temperature（體表溫度）isthetemperatureoftheskin,thesubcutaneousandthefattissue.It,bycontrast,risesandfallsinresponsetotheenvironment.Physiology1RegulationofTemperatureThebalancebetweenheatproducedandheatlostispreciselyregulatedbyphysiologicalandbehavioralmechanism.Thesystemthatregulatesbodytemperaturehasthreemainparts:sensorsintheshellandthecore（軀體和內(nèi)臟感受器）anintegratorinthehypothalamus（下丘腦體溫調(diào)節(jié)中樞）aneffectualsystem（效應(yīng)系統(tǒng)）

Physiology1HeatProductionHeatisproducedinthebodythroughmetabolism,whichisthechemicalreactioninallbodycells.Heatproductionisthrough:Voluntarymovements(自主運(yùn)動(dòng))Involuntaryshivering(不自主寒顫)Nonshivering

thermogenesis(無寒顫生熱)Physiology1HeatLossHeatlossbySkin（70%）、respiratory（29%）、evacuate（1%）NormalheatlossisthroughRadiationconductionconvectionevaporationPhysiology1RadiationItisthetransferofheatfromthesurfaceofoneobjecttothesurfaceofanotherwithoutdirectcontactbetweenthetwo.Radiationincreasesasthetemperaturedifferencebetweentheobjectsincreases.Theclient’spositionincreasesradiationheatloss.Physiology1ConductionItisthetransferofheatfromoneobjecttoanotherwithdirectcontact.

Heatconductsthroughcontactwithsolids,liquids,andgases.Thenurseenhancesconductiveheatlosswhenapplyinganicepackorbathingaclientwithcoolwater.Thebodygainsheatbyconductionwhencontactismadewithmaterialswarmerthanskintemperature,suchasapplyingawarmpackorbathingaclientwithwarmwater.Physiology1ConvectionItisthetransferofheatawaybyairmovement.Heatisfirstconductedtoairmoleculesdirectlyincontactwiththeskin.Anelectricfanpromotesheatlossthroughconvection.Convectiveheatlossincreaseswhenmoistenedskincomesintocontactwithslightlymovingair.Physiology1Evaporation

Itistransferofheatenergywhenaliquidischangedintogas.Twoways:Insensiblewaterloss（不感蒸發(fā)）sweating（發(fā)汗）Evaporationisamainheatlosswhenenvironmenttemperatureishigherthanbodytemperature.Physiology1BahavioralControlHumansvoluntarilyacttomaintaincomfortablebodytemperaturewhenexposedtotemperatureextremes.Theabilityofapersontocontrolbodytemperaturedependson:thedegreeoftemperatureextreme;theperson’sabilitytosensefeelingcomfortableoruncomfortable;emotionsandthoughtprocesses;theperson’smobilitytoremoveoraddclothes.Physiology1TemperatureRange:36℃To37.5℃Averageoral:37℃AverageTympanic:37.5℃AverageRectal:37.5℃AverageAxilla:36.5℃

section2

FactorsAffectingBodyTemperaturetoCircadianrhythmsBodytemperaturenormallychanges0.5℃to1℃duringa24hourperiod.However,temperatureisoneofthemoststablerhythmsinhumans.Thetemperatureisusuallylowestbetween1:00and4:00(2-6)AMandhighestbetween2:00and8:00PM.FactorsAffectingBodyTemperature2AgeInfanttemperaturemayresponddrasticallytochangesintheenvironmental.Temperatureregulationisunstableuntilchildrenreachpuberty.Thenormaltemperaturerangegraduallydropsasindividualsapproacholderadulthood.Olderadultsareparticularlysensitivetotemperatureextremesbecauseofdeteriorationincontrolmechanisms.FactorsAffectingBodyTemperature2ExerciseMuscleactivityrequiresanincreasedbloodsupplyandanincreasedcarbohydrateandfatbreakdown.Thisincreasedmetabolismcausesanincreaseinheatproduction.Anyformofexercisecanincreaseheatproductionandthusbodytemperature.

FactorsAffectingBodyTemperature2StressPhysicalandemotionalstressincreasesbodytemperaturethroughhormonalandneuralstimulation.Stimulationofthesympatheticnervoussystemcanincreasetheproductionofepinephrineandnorepinephrine,therebyincreasingmetabolicactivityandheatproduction.FactorsAffectingBodyTemperature2HormonelevelWomentendtohavemorefluctuationsinbodytemperaturethanmen.Hormonalvariationsduringthemenstrualcyclecausebodytemperaturefluctuations.Bodytemperaturechangesalsooccurinwomenduringmenopause.FactorsAffectingBodyTemperature2EnvironmentalTemperature

Extremesinenvironmentaltemperaturecanaffectaperson’temperatureregulatorysystems.Iftemperatureisassessedinaverywarmroom,thebodytemperaturewillbeelevated.Ifthepersonhasbeenoutsideinextremelycoldweatherwithoutsuitableclothing,thebodytemperaturemaybelower.FactorsAffectingBodyTemperature2feverorhyperthermiahypothermia

section3

AlterationsinBodyTemperatureElevatedBodyTemperatureAbodytemperatureabovetheusualrangeiscalledfeverorhyperthermia.Fever：機(jī)體在致熱源作用下，體溫調(diào)節(jié)中樞的調(diào)定點(diǎn)上移而引起調(diào)節(jié)性體溫升高，當(dāng)體溫上升超過正常值班０.5℃或一晝夜體溫波動(dòng)在１℃以上時(shí)，稱為發(fā)熱．Hyperthermia：體溫調(diào)節(jié)系統(tǒng)失去調(diào)控或發(fā)生調(diào)節(jié)障礙所引起的被動(dòng)性體溫升高，稱為過熱．AlterationsinBodyTemperature3Fevercanbecausedbymanyreasonselevatinghypothalamicsetpoint,andresultinginexcessheatproduction,ordecreasedheatloss.Pyrogenssuchasbacteriaandvirusescauseariseinbodytemperature.Prolongedexposuretothesunorhighenvironmentaltemperaturescanoverwhelmthebodyheat-lossmechanism.AlterationsinBodyTemperature3發(fā)熱過程及癥狀體溫上升期：特點(diǎn)：a產(chǎn)熱>散熱；

b病人表現(xiàn)為畏寒、有時(shí)伴寒戰(zhàn)，皮膚蒼白、干燥無汗，繼而體溫逐漸上升；

c體溫上升的方式有：

漸升

常見于傷寒；

驟升

常見于肺炎球菌肺炎。

發(fā)熱持續(xù)期特點(diǎn)：a產(chǎn)熱和散熱在較高水平上趨于平衡，體溫維持在較高狀態(tài)。

b病人表現(xiàn)顏面潮紅、口干舌燥、皮膚灼熱，R、HR增快，尿量減少。

c此期持續(xù)的時(shí)間可因疾病和治療效果而異。退熱期特點(diǎn)：

a散熱增加、產(chǎn)熱趨于正常；

b病人表現(xiàn)為大量出汗和皮溫降低；

c退熱的方式有兩種：

驟退

應(yīng)注意由于大量出汗、喪失體液病人易出現(xiàn)BP下降、P細(xì)速等虛脫或休克現(xiàn)象；

漸退體溫逐漸下降。ClassificationofFever

Oraltemperatureasanexample:Mild:37.5℃to37.9℃Moderate:38℃to38.9℃Sever:39℃to40℃Profound:41℃andaboveAlterationsinBodyTemperature3Duringafever,cellularmetabolismincreaseandoxygenconsumptionrises.Thebodymetabolismincreases13%foreverycelsiusdegreeoftemperatureelevation.Heartandrespiratoryratesincreasetomeetthemetabolicneedsofthebodyfornutrients.Afeverisusuallynotharmfulifitstaysbelow39℃.AlterationsinBodyTemperature3PatternsofFeverConstantFever（Continuousfever）

Thebodytemperaturesustainsabove38℃thatdemonstrateslittlefluctuationoflessthan1℃within24h.Itcanbeseeninpneumoniaandtyphoid.AlterationsinBodyTemperature3RemittentFever

Thebodytemperaturehasgreatfluctuationabovethenormalwithmorethan1℃in24handfevercannotreturntonormaltemperaturelevels.Itcanbeseeninsepticemiaandrheumaticfever.AlterationsinBodyTemperature3IntermittentFever

Thebodytemperaturefluctuatesin24h,whichmaysuddenlyriseabovethenormalthensuddenlyfalltothenormalorbelowthenormal.Thebodytemperaturealternatesregularlybetweenaperiodoffeverandaperiodofnormaltemperaturelevels.Itcanbeseeninmalariaandtuberculosis.AlterationsinBodyTemperature3IrregularFever

Thebodytemperatureirregularityalternatesbetweenaperiodoffeverandaperiodofnormaltemperaturevalues.Itcanbeseenininfluenzaandcancer.AlterationsinBodyTemperature3hypothermia.Abodytemperaturebelowthelowerlimitofnormal35℃iscalledhypothermia.Classificationofhypothermia:Mild:33.1℃to35℃Moderate:30.1℃to33℃Sever:27℃to30℃Profound:<27℃AlterationsinBodyTemperature3hypothermia.Reasons:ExtremeheatlossDecreaseheatproductionDeteriorationinthecenteroftemperatureregulationAlterationsinBodyTemperature3Scientificknowledgeofbodytemperatureregulationhelpsthenursetoassesstheclient’sresponsetotemperaturealterationsandtointervenesafely.Nursingmeasurescanbeimplementedtoincreaseorminimizeheatloss,topromoteheateffecting,andtoincreasecomfort.

section4

NursingProcessandThermoregulationAssessmentSitesThefourmostcommonsitesformeasuringbodytemperatureareoral,rectal,axilla,andthetympanicmembrane.NursingProcessandThermoregulation4Thermometers

Bodytemperatureisassessedbyusingthedevices.Theseareglassthermometers,electronicthermometers,disposablethermometers,andtympanicmembranethermometers.EachdevicemeasurestemperatureusingtheCelsiusorFahrenheitscale.NursingProcessandThermoregulation4

先將體溫計(jì)的汞柱甩至35OC

以下，同時(shí)放入40OC

的溫水中，3min后取出檢視。如體溫計(jì)讀數(shù)相差

0.2OC

以上或汞柱有

裂隙，則不能再使用。

水銀體溫計(jì)的檢查法水銀體溫計(jì)的消毒：

7０%乙醇

、1%過氧乙酸、０.５%碘伏等；

先將體溫計(jì)全部浸沒于消毒液中，５min

后取出，甩表至35OC以下再放入另一容器中

浸泡30min后取出，用冷開水沖洗，再用消毒

紗布擦干備用。

浸泡體溫計(jì)的容器每周消毒一次；

傳染病人應(yīng)設(shè)專用體溫計(jì),并單獨(dú)進(jìn)行消毒。測(cè)量體溫的方法Attention（1）根據(jù)病情選擇合適的測(cè)量方法：嬰幼兒、昏迷、精神異常、口鼻手術(shù)、張口呼吸不宜采用口腔測(cè)溫；直腸和肛門疾患、手術(shù)、腹瀉、心肌梗死病人不宜直腸測(cè)溫；腋下有創(chuàng)傷、手術(shù)或炎癥，腋下出汗較多，肩關(guān)節(jié)受傷或消瘦夾不緊體溫計(jì)不宜測(cè)腋溫。（2）進(jìn)食、飲水或面頰部熱敷或冷敷、吸煙、坐浴或灌腸、腋窩局部冷熱敷待情況時(shí)，應(yīng)間隔30min后測(cè)量相應(yīng)部位的體溫。（３）如病人不慎咬破體溫計(jì)：應(yīng)立即清除玻璃碎屑以免傷唇、舌、口腔及消化道黏膜；再口服牛奶或蛋清液以延緩汞的吸收；病情允許可口服膳食纖維豐富的食物，加速汞的排泄。Attention（４）為嬰幼兒、重病人、躁動(dòng)者測(cè)溫時(shí)，應(yīng)有專人守護(hù)，以防發(fā)生意外。（５）發(fā)現(xiàn)體溫與病情不相符合時(shí)，應(yīng)在病床旁監(jiān)測(cè)，必要是將肛溫與口溫對(duì)照復(fù)查。（６）甩體溫計(jì)時(shí)應(yīng)用腕部的力量，不可觸及他物，以防撞碎；切忌將體溫計(jì)放在熱水中清洗或沸水中煮，以防爆裂。用離心機(jī)甩體溫計(jì)時(shí)，應(yīng)先消毒后再放于離心機(jī)內(nèi)。AttentionNursingDiagnosisNuringdiagnosisDiagnosticfoundationHyperthermia

IncreasebodytemperatureaboutusualrangeFlushedskin,skinwarmtotouchIncreasedpulseandrespiratoryrateHerpeticlesionsofthemouthNursingProcessandThermoregulation4NursingDiagnosisNuringdiagnosisDiagnosticfoundationHypothermiaDecreasedbodytemperaturePale,coolskinDecreasedpulseandrespiratoryrateFeelingsofcoldandchillIneffectivethermoregulation

Olderadultorinfants,weakInabilitytoadapttoenvironmenttemperatureNursingProcessandThermoregulation4PlanningThenurseagainsynthesizesinformationfrommultipleresourcesanddevelopsanindividualizedplanofcareforeachnursingdiagnosis.Thenurseandclientsetrealisticexpectationsforcare.Goalsaretobeindividualizedandrealisticwithmeasurableoutcomes.NursingProcessandThermoregulation4Sampleofnursingplanareasfollows.AssessmentMr.Liisa50-year-oldschoolteacherwhoarrivesatthecommunityclinicwiththecomplainofmalaise,coughandfever.Hisskiniswarmanddrytotouch.Hisfaceisflushed,andheappearstohavelaboredbreathing.Vitalsignsobtainedare:bloodpressure120/70mmHg,pulserate100/min,respiratoryrate24/min,oraltemperature39.2℃.NursingProcessandThermoregulation4NursingDiagnosisHyperthermiarelatedtoinfectionsprocessPlanningInterventionEvaluationNursingProcessandThermoregulation4ImplementationHealthPromotion:ThenurseinstructsclientstoavoidstrenuousexerciseinhotPreventionisthekeyforclientsatriskforhypothermia.NursingmeasuresNursingProcessandThermoregulation4NursingmeasuresforclientwithafeverandhypothermiaAssessement

ObtaintemperatureAssessforaffectingfactorsIdentifyphysiologicalresponsetotemperatureObtai