Essential Nursing Considerations of Temperature Physiology

Taking the vital signs of your client is one of the most basic things that you should do upon assessment and temperature is the first vital sign that should be taken.

Though the process of taking the temperature of a client seems effortless, there are still nurses who get it wrong, especially when taking into consideration the different protocols for inserting the thermometer. Which is why we’ll be going into the essential information that you should keep in mind when taking your client’s temperature.

Thermometer Routes

Basic knowledge: there are three routes where a thermometer can be inserted, namely:

  • Axilla or the armpit
  • Oral or Sublingual (under the tongue)
  • Rectal

Currently, there are more advanced ways to take the temperature which can be through scanning the forehead or going under the ear.

Among the three routes, the rectal route is the most accurate.

Routes for Ages

When it comes to age, there are a couple of considerations that one must follow:

  1. Adults – orally
  2. Adolescents – axillary
  3. Pediatrics – rectally

In nursing school, you are taught to identify the different types of thermometers with their respective color-coding scheme; therefore, you should never insert a red thermometer in a client’s mouth because those are meant to be inserted in the rectum.

Normal Temperature

The average normal temperature is around 98.7 Fahrenheit. Recently, there have been new standards saying that the normal range is from 97.5 up to 99.1 Fahrenheit. At this point, it depends on the metabolic rate of your client’s body type because there are people who burn calories at a much faster rate while there are those who take time to do so.

What Affects Temperature

There are a couple of things that affect temperature; however, the primary cause is an infection. Infection, no matter where it’s located – toe, lungs, skin, and so on – will have a significant effect on a person’s temperature. Areas infected are usually warm or hot to touch, and for this reason, the client will experience fever.

Sepsis is another factor that affects temperature. If a client becomes septic due to an infection of the blood, it is immediately manifested by increased temperature. Sepsis can be due to numerous factors including:

  • Urinary tract infection (UTI)
  • Pneumonia
  • Cellulitis
  • Diabetes

Sepsis in diabetic clients is common. For this reason, it is necessary that nurses need to watch out for signs and symptoms of sepsis, especially in older clients. If an elderly or geriatric client has sepsis, their immune system is expected to be low. Once that infection hits the bloodstream, it will travel through the entire body, affecting vital organs like the heart, brain, kidneys, etc.

Temperature with Sepsis

Clients who have sepsis are expected to have a temperature ranging from 103 up to 104 Fahrenheit; it can even go up to 105 Fahrenheit. At this point, the body will have its hypothalamus, the thermal regulator device inside the brain, to shut down due to increased heat inside the body. The moment thermal regulation ceases, there will be a drop in body temperature, which is what happens with sepsis.

Sepsis Intervention

The primary goal when you have a client when sepsis, is to bring down their temperature to avoid organ failure immediately. Taking the rectal temperature is advisable to get accurate data on the status of your septic client. In hospitals, there are standard core measures when handling septic workups. It is best to get acquainted as to what these core measures are.

Points to Remember

Here are a couple of things that you have to take into great consideration when getting your client’s temperature:

  1. You should not take the temperature of chemotherapy clients rectally. Chemotherapy shrinks down the tumor and all the while, the process also kills new cells. Therefore, those who are getting chemotherapy have thin epithelial lining especially around the rectal area, and inserting a rectal thermometer may cause complications.
  2. A client undergoing chemotherapy who also has sepsis should not be given a rectal thermometer to avoid bowel perforation.
  3. Axillary thermometers are given to clients who are unable to open their mouths like those who have neurological diseases like MS, ALS, myasthenia gravis, or those with altered level of consciousness.
  4. Among the three thermometer sites, the axillary temperature provides the least accurate data.

So, those are some important nursing considerations when taking the temperature. For other vital signs discussions, you can visit our SimpleNursing website.

Septic Shock: Diagnoses and Nursing and Medical Management

Sepsis is one of the main reasons why geriatric clients are admitted into the ICU. To know more about what sepsis is and how septic shock happens, we will go into a bit of its pathophysiology, its diagnoses, and its nursing and medical management.

Let’s begin.

Sepsis

The main complication of sepsis is septic shock which is very dangerous for the client. However, how does one know if the sepsis is getting better or is getting worse?

When a client comes in with conditions like urinary tract infection, pneumonia, or even a cat bite, it develops into an infection. If that infection becomes severe that it reaches the bloodstream, the condition will be referred to as sepsis. If that infection in the blood circulates and starts to infect the other organs, it will mess around with organ function.

Blood’s primary function is to maintain perfusion while transporting drugs and nutrients to every part of the body. However, without oxygen, the body is compromised and eventually dies. This is what happens in sepsis.

Stages of Septic Shock

  1. Early Sepsis – Low MAP

Initially, a client who is going into septic shock will first experience a decrease in mean arterial pressure (MAP).

Mean arterial pressure is referred to as the state in which a person has decreased blood perfusion around the body.

How does one get the mean arterial pressure?

First, add up two diastolic pressures; and then add the systolic pressure. Remember that the systolic pressure is the first number or the top number of your client’s blood pressure. Okay, so after adding two diastolic pressures and one systolic pressure, divide the sum by three. If the result is greater than 60, then you can breathe easy because your client will be fine. However, if the MAP is less than 60, it means that your client’s body is being suffocated from oxygen.

A drop in mean arterial pressure means that the infection has gone worse that it’s turning off some of the barrel receptors inside the body. Barrel receptors are the receptors in the blood vessels that help regulate the constriction of blood vessels.

On the other hand, massively widened vessels cause a decrease in resistance which will result in a decreased pressure; thus, creating low oxygen perfusion around the body.

  1. Compensatory Stage

When your body is trying to compensate for any type of shock, not just septic shock, it will increase the heart rate and respiratory rate to get more oxygen since there is not enough blood perfusion.

  1. Progressive Phase

The third phase of septic shock is the moment when the infection has become so severe that the body is compensating by igniting an inflammatory process. This inflammatory process is the body’s defense mechanism to fight off the infection. However, in septic shock, the inflammatory process has gone haywire, and it has become widespread and systemic.

The progressive stage is where the majority of clinical manifestations occur, mainly:

  • Hypothermia – a temperature less than 97.
  • Pneumonia – the alveoli are damaged and disrupt oxygen exchange.
  • Decreased urinary output – glomeruli in the kidneys become inflamed. The dilated vessels cause reduced resistance and perfusion that the body compensates by holding on to volume; thus, decreasing urine output.
  • High specific gravity – dark brown, thick, odorous, and very concentrated urine output.
  • Bleeding – since the kidneys make erythropoietin, the inflammatory process will cause broken vessels
  1. Refractory Stage

What happens when a client bleeds and how can it be stopped? Since this is a septic shock, the body will stop the bleeding by putting platelets on the affected areas to patch it up. However, there are occasions wherein a client develops disseminated intravascular coagulation (DIC) with septic shock.

The platelets will patch up the inflamed, bleeding organs in the body. The problem is, production of platelets inside the body is limited, and once they are used up, it will take a while for the body to regenerate the fibrin and fibrinogen – the receptors that help in blood clotting. 

Without platelets, the body will experience systemic bleeding that can cascade into DIC. Disseminated intravascular coagulation is severe bleeding that is hard to stop. This systemic bleeding leads to multiple organ dysfunction syndrome (MODS) that is basically multi-organ system failure, meaning all the body organs are shutting down.

On our next lecture, we will further discuss the other clinical manifestations and the nursing and clinical management of septic shock. Check it out at SimpleNursing.com.