Class Notes Nursing Fundamentals

NCA 1 – FUNDAMENTALS IN NURSING
2. CONVECTION
THERMOREGULATION - Dispersion of heat through air currents;
- Ex. Electric Fan
Body Temperature – reflects the balance between the
heat produced and the heat lost from the body. 3. RADIATION
- Indirect heat transfer.
Heat Production - Transfer of heat from the surface of
 Basal metabolism another object without contact between
 Muscular activity (shivering) the two objects, mostly in the form of
 Thyroxine and epinephrine (stimulating effects on infrared rays.
metabolic rate) - Ex. Sunlight cause far
 Temperature effect on cells
4. VAPORIZATION
Heat Loss - Continuous evaporation of moisture from
respiratory tract and skin
 Radiation
- Ex. Tepid Sponge Bath
 Conduction/Convection
 Evaporation

Factors affecting body temperature
1. AGE
 Infants greatly influenced by T of the
environment
 Children’s T are variable
 Older people are usually prone to
hypothermia.
 Inadequate diet
 Loss of SC fat
 Lack of activity
 Reduced thermoregulatory efficiency

2. DIURNAL VARIATIONS (circadian rhythms)
 T change throughout the day
 Highest at 8:00pm and MN
 Lowest at 4:00am and 6:00am

3. EXERCISE & METABOLISM
 Exercise increase BT
 Muscle activities including shivering,
Alterations in body temperature
increase metabolic rate
1. PYREXIA, HYPERTHERMIA (fever)
 Basal metabolic rate is the rate of energy - Temperature above normal
utilization in the body - Febrile; afebrile
2. HYPEREXIA
4. HORMONES
- A very high fever usually 41°C
 Women usually experience more hormone
3. INTERMITTENT FEVER
fluctuations than men
- Alternates at regular intervals between
 In women, progesterone secretion at
periods of fever and periods of normal or
ovulation raises body temperature by about
subnormal temperatures.
0.3°C-0.6°C above basal temperature
4. REMITTENT FEVER
5. STRESS - Wide range of temperature fluctuations
(more than 2°C) occurs over 24-hour
 Stimulation of sympathetic nervous system
period all of which are above normal
can increase the production of epinephrine
and norepinephrine thereby, increasing 5. RELAPSING FEVER
metabolic activity and heat production. - Short febrile periods of few days are
interspersed with periods of 1 or 2 days of
6. ENVIRONMENT normal temperature.
 Extremes in environmental temperatures 6. CONSTANT FEVER
can affect a person’s temperature regulatory - The body temperature fluctuates minimally
system. but always remains above normal

BODY TEMPERATURE HEAT TRANSFER: Variations in Normal Body Temperature by Age
AGE AXILLARY
1. CONDUCTION Newborn 36.8°C

, BODY TEMPERATURE CONVERSION HYPOTHERMIA
- Excessive heat loss
From Fahrenheit to Celsius - Inadequate heat production
°C = (°F – 32) x 5/9 - Impaired hypothalamic thermoregulation
Ex: °C = (100°F – 32) x 5/9
= 68 x 5/9 Clinical Manifestations of Hypothermia
= 37.8°C - Decreased body temperature, pulse and
respirations
From Celsius to Fahrenheit - Severe shivering
°F = (Celsius x 9/5) + 32 - Feelings of cold and chills
Ex: Celsius reading is 40 - Pale, cool, waxy skin
°F = (40 x 9/5) + 32 - Hypotension
= 72 + 32 - Decreased urinary output
= 104°F - Lack of muscle coordination
- Disorientation
- Drowsiness progressing to coma


Clinical Manifestations of fever ONSET
COLD OR CHILL PHASE
- Increased heart rate
- Increased respiratory rate and depth
- Shivering
- Pallid, cold skin
- Complaints of feeling cold
- Cyanotic nail beds
- “goose flesh” appearance of the skin
- Cessation of sweating

COURSE (PLATEAU PHASE)
- Absence of chills
- Skin that feels warm
- Photosensitivity
- Glassy-eyed appearance
- Increased pulse and respiratory rate
- Increased thirst
- Mild to severe dehydration
- Drowsiness, restlessness, delirium or convulsions
- Herpetic lesions of the mouth Nursing Interventions for clients with FEVER
- Loss of appetite (if the fever is prolonged) - Monitor V/S
- Malaise, weakness and aching muscles - Assess skin color and temperature
- Monitor WBC counts, hematocrit value, and other
pertinent laboratory reports for indications of
DEFERVESCENCE (fever abatement/flush phase)
infection or dehydration
- Skin that appears flushed and feels warm
- Remove excess blankets when the client feels
- Sweating
warm but provide extra warmth when the client
- Decreased shivering feels chilled.
- Possible dehydration Provide adequate nutrition and fluids (e.g. 2,500 –
-
3000 ml./day) to meet the increased metabolic
demands and prevent dehydration.
Measure intake and output
-
Provide clothing and bed linens.
-
Reduce physical activity to limit heat production,
-
especially during the flush stage
Administer antipyretics (drugs that reduce the level
-
of fever) as ordered.
Provide oral hygiene to keep the mucous
-
membranes moist
Provide TSB to increase heat loss through
- conduction


Nursing Interventions for clients with HYPOTHERMIA
- Provide warm environment
- Provide dry clothing
- Apply warm blankets