Temperature – Vital Signs (Nursing)

by Samantha Rhea, MSN, RN

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    00:00 So, in our vital signs series, let's talk about how we collect our patient's temperature.

    00:09 So first, it's important to know your normal vital sign range. Our temperature range is going to be anywhere from about 36-38 degrees Celsius to 97.8 to about 99.1 degrees Fahrenheit. Just know, this is going to vary a little bit depending on what site you take this temperature at. We'll talk about this a little bit later in the presentation. So why in the first place is it even important to collect temperature on our patient? Well, this is going to help monitor our patient's condition especially if maybe they have an infection that could be occurring in the body. And again, just as we just talked about, identifying a potential problem and then evaluating that response to a nursing intervention. So let's take a look at different ways to determine body temperature. So if you take a look at the body image on the screen, all these potential sites can be used for taking a temperature on the patient.

    01:06 So if you take a look at the top here that's in portal is very common and we're going to use that in our acute care facilities. Also, oral temperature is really common especially for home use. But you've got to remember when we're talking about oral temperature, things can affect that. Right? If we ate or drink something right before we took that temperature.

    01:26 Tympanic is talking about ear. And axillary is something we don't really use this very often.

    01:32 It's also slightly lower than oral. So again, depending where you take these temperature sites at, your temperature reading can be just varied a little bit. Also you see here bladder which is our core temperature which is really uncommon that we're going to take a body temperature here as well as rectal. So sometimes we may use this in the pediatric client, but again it's not often used and it's slightly higher than our oral temperature. So why is our normal body temperature important? Well, normal body temperature is what our body needs for important enzymes in our body to function. So if we have extreme high or extreme low temperatures, this can cause complete imbalances and can even become a life threatening emergency in our patient. Now, there are many factors that affect body temperature so let's talk about those. One of those being age and of course exercise can raise our body temperature. Now, hormonal levels can affect that as well as our Circadian rhythm with that sleep-wake cycle. Also, the environment that we're in will definitely affect our body temperature. Summer, winter for example, extreme heat, extreme cold, and of course illness or infection. So let's look at those individual factors that affect body temperature, age being that first one that we discussed. Newborns can actually loose up the 30% of heat through their heads. So let's look at the other end of the spectrum when we're talking about age. It's not unusual for an older adult to reach temperatures know higher than about 36 degrees Celsius or about 96.8 degrees Fahrenheit. Now again, there are some variations for these. And of course, don't forget about exercise. The more that we increase our metabolic demand, the higher our heat production will be and our body temperature will increase. Now, hormone levels can also affect our body temperatures.

    03:30 Women usually experience greater fluctuations because there are hormonal variations that can occur during the menstrual cycle. Also, women may experience hot flashes caused by hormonal changes in a menopause period. Now, let's talk about our Circadian rhythm.

    03:48 So, as a person looking at our body temperature over 24-hour period, if you took our temperature at about 01:00 in the morning to 0400 hours all early early in the morning, our lowest body temperature is about this time. Now our body temperature reaches maximum temperature at about 1800 hours or 6 pm in the evening. So as you can see throughout your day, your body temperature varies a little bit depending on your Circadian rhythm.

    04:19 Now, let's talk about environment. Of course, this is going to affect our temperature and sometimes pretty easily. So if we just enter a warm room for example, our body heat can rise. Now for outside without any warm clothing on at all, our person's body temperature maybe low owing to that radiant and conductive heat loss. And I don't know about you but of course if you think about in the summer or because of outside temperatures, our body temperature rises, we may sweat, same thing if we're in extreme cold. We could have a really low body temperature that can lead to hypothermia or dangerous events. Now, infection illness is something that we commonly will see in the patient's hospital and taking care of our patients. So if we see the presence of a fever, it's usually related to that stimulation of the body's immune system. That's because if we see a fever in our patient, that body is trying to kill a virus or a bacteria that's causing illness on our patient. So that's why checking body temperature with our patients are so very important when they're in the hospital. It's also harder for bacteria and viruses to survive at higher temperatures. So as a nurse, let's ask ourselves. When is a fever a serious sign? When we're talking about our adult population, a fever may be uncomfortable, it's usually not a cause for concern though unless it reaches about 39.4 degrees Celsius or about 103 degrees Fahrenheit or even higher. Now, let's look at the younger population. So for infants and toddlers though, a slightly elevated temperature may even indicate a serious infection. So let's look at some causes of abnormal body temperatures and classifications. So the first one we have here is pyrexia otherwise known as fever. Now if you remember, this is actually an important defense mechanism. Sometimes the higher the body heat, this can help kill viruses or bacteria for example. Now we'll call this febrile. You may hear this often. Now, however if a patient is febrile, this can turn into hypothermia and even malignant hyperthermia which can be dangerous for our nervous system and our body's functions. Now, hypothermia, when we're talking about malignant hypothermia, this can result from a body's inability to promote heat loss or reduce heat production. So that temperature just keeps going up and up and up. Also a heat stroke means we're having prolonged exposure to the sun or high environmental temperatures. This can also be dangerous for us as well. This can also, another form of this is heat exhaustion where you have profuse diaphoresis otherwise known as profuse sweating that results in a lot of water and electrolyte loss. And if you lose a lot of water or electrolyte from your body, this can also be become dangerous for your patient. Now on the flipside of this, we have hypothermia or frostbite. This is exposure to extreme cold and that body is unable to compensate. Now when we're talking about extreme hypothermia or frostbite, this can affect our body's tissues, for example. Now let's take a look at some different thermometers on how we collect that temperature. One of those is an electronic ear thermometer. This is really great when you're talking about the pediatric patient, for example, very non-invasive and this goes in our patient's ear otherwise known as a tympanic temperature. Or you may be able to use a digital oral thermometer. This many times the probe will go underneath the patient's tongue and again we've got to screen our patient to see that they just have something really cold to drink like ice water or really hot to drink like a cup of coffee, this is going to affect our patient's oral temperature. And a very favorite of many of the acute care places is a forehead thermometer. So we use this called a temporal thermometer because this is non-invasive for our patients as well and accurate. So, just know when you're talking about thermometers there are different devices that your facility may use and also for home use.

    About the Lecture

    The lecture Temperature – Vital Signs (Nursing) by Samantha Rhea, MSN, RN is from the course Vital Signs (Nursing).

    Included Quiz Questions

    1. 36–38°C (97.8–99.1°F)
    2. 35–37°C (95–98.6°F)
    3. 37.5–39°C (99.5–102.2°F)
    4. 34.5–36.5°C (94.1–97.7°F)
    1. Up to 30%
    2. Up to 10%
    3. Up to 20%
    4. Up to 40%
    1. Temporal
    2. Oral
    3. Tympanic
    4. Bladder
    5. Rectal
    1. When temperature is 39.4°C (103°F) or higher
    2. When temperature is 39°C (102.2°F) or higher
    3. When temperature is 40°C (104°F) or higher
    4. When temperature is 38.5°C (101.3°F) or higher

    Author of lecture Temperature – Vital Signs (Nursing)

     Samantha Rhea, MSN, RN

    Samantha Rhea, MSN, RN

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