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Sites for assessing temperature
4. tympanic route
Types of thermometers
1. Mercury - in - glass thermometers
2. Electronic thermometer
3. Disposable thermometer
Purpose of taking Temperature
To aid in diagnosis or the patient' s condition
To find out the progress of the patient
Taking temperature by mouth
Oral temperature should not be taken immediately after the patient has had a hot or a cold drink or food.
Oral temperature should not be taken for the following patients
Children below the age of five years
a. patients receiving oxygen
b. Patients with nasal obstruction, dyspnoea or sore mouth
c. Patient who are delirious, unconscious and not cooperating, hysterical, restless or mentally ill
d. Patients with oral surgeries
Procedure ( Recording temperature - oral)
1. 3 or 4 test tubes or bottles with antiseptic lotions savlon 2%) and a little cotton underneath
2. A glass tumbler with clean water and little cotton underneath
3. A bowl containing a bit soapy white wipers
4. A small piece of clean cloth
5. A kidney tray
6. A paper bag
7. watch with second hand
8. red lead pen
1. Explain the procedure and take the patients cooperation
2. Let the patient be sitting or lying down
3. Remove thermometer from the lotion, wash with clean water and dry with clean piece of cloth from the bulb upwards to prevent bacteria from setting down on the lower part which goes into the mouth of the patient.
Shake down the mercury by a quick sudden movement of the wrist and bring down the mercury level at 95º F.
5. Place the bulb of the thermometer under the tongue and tell the patient not to bite the thermometer but to hold it with his lips.
6. Leave the thermometer in the mouth for 2 minutes (during this time take his pulse and respiration).
7. Remove the thermometer , note the temperature clean with the soapy wiper from above downwards towards the bulb (to prevent bacteria from spreading all over the thermometer.
8. Collect the dirty soapy water in the kidney tray and place the dirty wiper in the paper bag
9. Replace thermometer in the test tube or bottle with the lotion
Record the temperature in the chart
After care of the equipment
Clean all the articles used.
Wash the thermometer with soap and cold water
Keep the thermometer in the antiseptic lotion for 2 to 5 minutes
Reset the tray and keep it ready for the next use.
Nursing care of individual with altered body temperature Hyperthermia - Assessment
obtain all vital signs
observe skin color
observe for shivering are diaphoresis
Non - pharmacological therapy are methods that increase heat loss by evaporation, convection conduction or reduction.
Tepid sponge bathes
Bathing with alcohol - water solution
Allow rest period
Limit physical activity
Reduce external covering on patient' s body to promote heat
loss through reduction and conduction.
Provide fluids (atleast 3 litres per day) to replace fluids loss.
Encourage oral hygiene because oral mucous membranes dry easily from dehydration.
Provide measures to stimulate appetite and offer well balanced meals.
Provide supplemental oxygen therapy as ordered to improve oxygen delivery to body cells.
Control environmental temperature without inducing
shivering. Eg. Cooling fans
The best treatment for heat stroke is prevention. The nurse teaches the patient:
To avoid strenuous work in hot weather.
To drink fluids such as clear fruit juices before, during and after exercise.
To wear loose cotton clothing.
To avoid exercising in areas with poor ventilation.
To wear protective hats over the head when going
First aid for heat stroke
Move the patient to cooler environment.
Reduce clothing covering the body
Place wet towel over the skin
Use cooling fans to increase heat loss
Summon emergency medical treatment (intravenous fluids)
Prevention is the key for patient' s at risk for hypothermia and frostbite.
Educate patient who are at risk for hypothermia (Eg. the very young, the very old, persons debilitated by trauma, stroke, diabetes, drug or alcohol intoxication, sepsis, mentally ill, alcohol intoxication, malnutrition).
Prevent a further decrease in body temperature.
Remove wet clothes, provide dry ones and wrap the client in blanket.
If the patient is conscious offer warm liquids such as milk or soups
Place the patient in a warm room
When the patient reaches emergency treatment, patients are closely monitored for cardiac irregularities and electrolyte imbalances.
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