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Chapter: 11th 12th std standard Class Nursing Health Care Hospital Hygiene Higher secondary school College Notes

Taking temperature by mouth - Procedure, Equipment

Sites for assessing temperature 1. Oral 2. rectal 3. axillary 4. tympanic route

Sites for assessing temperature

1.     Oral

2.     rectal

3.     axillary

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

 

General instructions

            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)

 

Equipment

Tray containing

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

Procedure

 

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 95 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

 

Cooling fans

 

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

Heat stroke

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

 

outdoors.

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)

 

Hypothermia

 

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).

 

Treatment

 

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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11th 12th std standard Class Nursing Health Care Hospital Hygiene Higher secondary school College Notes : Taking temperature by mouth - Procedure, Equipment |


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