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ASSESSING BODY TEMPERATURE MOST COMMON SITES: oral, rectal, axillary, tympanic membrane, and skin/temporal artery SITE

Oral ADVANTAGES Accessible and convenient DISADVANTAGES Thermometer can break if bitten Inaccurate if client has just ingested hot or cold food or fluid or smoked. Could injure the mouth following oral surgery. Inconvenient and more unpleasant for clients; difficult for client who cannot turn to the side. Could injure the rectum following rectal surgery. Presence of stool may interfere with thermometer placement. If the stool is soft, the thermometer may be embedded in stool rather than against the wall of the rectum. The thermometer must be left in place for a long time to obtain an accurate measurement. Could be uncomfortable and involves risk of injuring the membrane if the probe is inserted too far. Repeated measurements may vary. Right and left measurements can differ. Presence of cerumen can affect the reading. Requires electronic equipment that may be expensive or unavailable; variation in technique needed if the client has perspiration on the forehead.

Rectal

Reliable measurement

Axillary Tympanic membrane

Safe and noninvasive Readily accessible; reflects the core temperature. Very fast

Temporal artery

Safe and noninvasive

Alterations in Body Temperature Pyrexia and hypothermia

Pyrexia- a body temperature above the usual range - Hyperthermia, or in lay terms fever - Very high fever such as 41 (105.8F)=hyperpyrexia - Client with fever-febrile, no fever-afebrile 4 Types: 1. Remittent - wide range of fluctuations (more than 2C) occurs over 24-hour period, all of which are above normal. (cold or influenza) 2. Relapsing short febrile periods of a few days are interspersed with periods of 1 or 2 days of normal temperature. 3. Intermittent the body temperature alternates at regular intervals between periods of fever and periods or normal or subnormal temperature. (e.g. malaria) 4. Constant the body temperature fluctuates minimally but always remains normal. This can occur with typhoid fever. In some conditions, an elevated temperature is not a true fever. 2 examples: 1. Heat Exhaustion is a result of excessive heat and dehydration. Signs: paleness, dizziness, nausea, vomiting, fainting, and a moderately increased temperature (101F-102F) 2. Heat Stroke persons generally have been exercising in hot weather, have warm, flushed skin, and often do not sweat. They usually have a temperature of 106F or higher, and may be delirious, unconscious or having seizures.

Hypothermia is a core body temperature below the lower limit of normal Types: 1. Induced the deliberate lowering of the body temperature to decease the need for oxygen by the body tissues such as during surgeries. 2. Accidental can occur as a result of: a. Exposure to a old environment b. Immersion in cold water c. Lack of adequate clothing, shelter or heat Frostbite skin and underlying tissues are damaged by freezing cold - Most commonly occurs in hands, feet, nose and ears Interventions: Provide a warm environment. Provide dry clothing. Apply warm blankets. Keep limbs close to body. Cover the clients scalp with cap or turban. Apply warming pads.

Oral/Rectal/Axilla thermometer:

Tympanic

Skin/Temporal Artery Thermometer