2/11/14

Strategies to raise and lower body temperature

Raising body temperature
Lowering body temperature
Add extra layers of thin clothing or bedding. Multiple layers of thin clothing are more effective than one or two thick layers, as they trap the warm air. Some man-made
fibres can encourage sweating and thus may decrease temperature. Cotton is therefore preferable
Remove layers of clothing/bedding. Do not remove all at once or you may cause the client to shiver, which will have the overall effect of increasing rather than
decreasing body temperature
Encourage the client to wear a hat or cover the head, as most heat is lost through the scalp
Encourage the client to wear natural cotton fibres as these absorb heat
If possible close any open windows and doors
Use a fan positioned on the client’s back as this forms a larger surface area
Give the client warm drinks if allowed
Give the client cold drinks if allowed or ice to suck
If possible increase the room temperature
If possible reduce the room temperature or place the client near an open window but not in a draught
Adults and older children can be helped or encouraged to wash their hands and face in warm water provided that they have full sensation. Otherwise there is a risk of burn
injury. For this reason hot-water bottles and high-temperature heat pads are not recommended and are indeed banned in most institutions
Adults and older children can be helped or encouraged to wash their hands and face in tepid water. Tepid sponging of the whole body where the client is allowed to dry by the process of evaporation is not generally recommended as this can reduce the temperature too rapidly (see below)
Monitor the client’s temperature when actively intervening and ensure that it does not rise more rapidly than 1oC per hour as this can lead to shock. If the client requires their temperature restoring more quickly, this should be undertaken in a critical-care area where the client can be closely monitored
Monitor the client’s temperature when actively intervening and ensure in the case of adults that it does not fall more
rapidly than 1oC per hour as this can lead to shock. In the case of infants high temperatures can cause febrile convulsions; it is therefore appropriate to reduce their
temperature more rapidly. This can be achieved by immersing them fully in a cool water bath
If the client is seriously hypothermic (i.e. a temperature of 32.5oC or below) and continuously monitored a foil blanket may be used with caution, but again care should be taken to ensure that the body temperature does not increase too rapidly. Warmed intravenous fluids may also sometimes be prescribed for this client group but again great care is needed
An antipyretic such as paracetamol may be prescribed if other methods of temperature reduction have failed, though this should not be the action of first resort as it can interfere with the body’s natural defence mechanisms



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Recording and documenting body temperature

Care should be taken to ensure that temperature measurement is recorded accurately to provide a clear picture of the client’s condition over time.

If done correctly it enables us to see at a glance any change in the client’s condition and helps us determine whether or not interventions are being effective, as can be seen in Figure 9.3. If you use an alternative route to the one commonly used in the environment of care it is important that this is recorded on the chart as this may account for any apparent variation, as can be seen on 12/11/02 at 10.00 hrs.

Figure 9.3 Client’s temperature chart


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Rectal measurement

Equipment:
Gloves
Disposable bag
Lubricant
Appropriate chart
Appropriate thermometer (that is, low-reading thermometer if client suspected of being hypothermic)
Modesty sheet/towel to protect client’s dignity
Procedure
Rationale
Screen the bed/close door
Promotes comfort and dignity; minimizes
embarrassment
Assist client into lateral position with upper
leg flexed; keep majority of client covered;
expose anal area only
For patient comfort and dignity
Apply lubricant to a tissue and dip end of
thermometer into lubricant
Minimizes trauma to rectal mucosa
during insertion. Using tissue avoids
contamination of tube/container
Ask client to relax and take deep breaths
With non-dominant hand separate client’s
buttocks to expose anus
Relaxes anal sphincter for ease of
insertion
Insert the thermometer no more than 5 cm
into the rectum and hold the thermometer
in place. Allow the thermometer time to
register (minimum two minutes). Note the
reading
To prevent trauma



To allow adequate time for the thermometer to register
Wipe client’s anal area with a soft tissue;
remove gloves and dispose in clinical waste
bag
To promote comfort and prevent crossinfection
Assist the client into a comfortable position
and record on measurement chart
To promote client comfort and adhere to
legislation surrounding record keeping
Report any significant change or abnormality
To ensure prompt attention
Clean thermometer, adhering to local policy
To minimize the risk of cross-infection
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Tympanic measurement

Equipment
Electronic tympanic thermometer (check for patency)
Speculum covers (disposable – one for each client)
Appropriate chart for recording

Identify factors that may affect the reading, for example the presence of cerumen (ear wax), recent facial/aural surgery (potential for injury and should therefore be avoided), hearing aid, or ear infection (the area willbe very sensitive and therefore should be avoided; the risk of cross-infection would also be significant were this site to be used).
Procedure
Rationale
Assist client into comfortable position, with
head turned towards one side, making sure
client has not recently been laid on that side
Client comfort; ear canal easily viewed. If
client has been laid on that side, reading
may be higher
Remove tympanic thermometer from
charging base. Place disposable speculum
cover over the probe until it locks in place
For safety; prevents cross-infection
between clients
Gently pull ear pinna backwards, upwards
and outwards. Insert speculum into ear
canal snugly to make a seal, pointing
towards the nose
Straightens the external auditory canal;
allows maximum exposure of the
tympanic membrane
Depress the scan button on the handheld
unit. Leave thermometer in place until a
signal (usually a bleep) is heard and the
temperature reading can be seen on the
digital display
Causes infra-red energy to be detected
from the tympanic membrane
Remove speculum carefully from ear. Discard
speculum cover into appropriate disposal
bag/receptacle by pressing ejection button
Client comfort; safety; prevents crossinfection
Return handheld unit to charging base
Automatically causes digital reading to
disappear and prevents damage to
sensor. Some units also have a built-in
security device in that the unit will cease
to function after a given amount of time
if not replaced on the base station
Record result noting any significant change
and report accordingly
To ensure continuity of care and prompt
attention if necessary


NB Some manufacturers recommend moving the speculum in a rocking or figure-of-eight motion to detect maximum tympanic membrane heat radiation. However, this must be undertaken with great care and is not a recommended course of action for the novice. If in doubt seek guidance.
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Oral measurement

Procedure
Rationale
Assist client into a comfortable position, explain
procedure, and gain consent
For information-giving and client
comfort
Hold mercury thermometer at eye level, rotating
slightly to ensure mercury line is visible. Check
mercury is low enough to record the temperature.
If not, shake it down in a downward direction,
taking care not to hit any nearby objects
For accuracy of measurement.



To prevent breakage
Cover thermomenter with a disposable cover
To reduce infection risk
Place thermometer under the client’s tongue beside the frenulum
To ensure correct reading
Advise client not to talk, to keep lips closed
to form a seal and, if fully co-operative, ask
them to hold the thermometer in situ.
Leave in place for a minimum of seven
minutes
To keep thermometer in place. If the
client is unable to hold the thermometer
in situ consider using another route.
To allow adequate time for the thermometer
to register
Remove thermometer, remove cover, read
at eye level, record results and report any
significant change
To ensure continuity of care and prompt
attention if necessary
Clean thermometer according to local policy
To minimize cross-infection


Using a digital thermometer
Follow the procedure outlined above but wait for the signal that signifies that the highest temperature has been reached.
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Axillary measurement

Procedure
Rationale
Wash hands using effective techniques
To prevent cross-infection
Collect appropriate equipment
Remember that only electronic or mercury thermometers are suitable for axillary measurement
Hold mercury thermometer at eye level,
rotating slightly to ensure mercury line is
visible. Check mercury is low enough to
record the temperature. If not, shake it
down in a downward direction, taking care
not to hit any nearby objects
For accuracy of measurement




To prevent breakage
Explain procedure and ensure client has
understood
Promotes client co-operation and
informed consent
Screen the bed or close door. Assist client
to comfortable position and move clothing
away from shoulder
Promotes comfort, maintains client’s
privacy, prevents embarrassment,
exposes axillary area
Place the thermometer in the centre of the
client’s axilla
To ensure good contact with the skin
when the arm is lowered
Rest the client’s arm across the chest,
advising them to remain as still as possible
To avoid thermometer moving out of
position
Leave in position until electronic
thermometer signals, or 7–8 minutes for
mercury thermometers
To ensure accuracy of measurement
Remove thermometer, read and record
result, noting any significant changes
To ensure continuity of care and meet
legislative requirements
Remove disposable cover and clean
thermometer, adhering to local policy
To prevent cross-infection
Report any abnormal findings
To ensure client receives appropriate care
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Monitoring temperature

Monitoring a client’s body temperature is essential to establish current health status, identify actual or potential problems, facilitate medical and nursing intervention, and monitor client progress.

Equipment:
Appropriate thermometer (digital, tympanic, rectal, or mercury) paying due regard to the age of the client, their level of ability to co-operate, local clinical guidelines and contemporary evidence
Designated chart for recording
Protective covers/probe covers
Equipment for disposal, cleansing and disinfection
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Assessing an individual’s ability to maintain body temperature

The reader is reminded that the assessment of body temperature is part of a holistic nursing assessment and should not be undertaken in isolation without reference to or consideration of the client’s other activities of living.

Specific points to consider when assessing an individual’s body temperature include:

• Physical
Actual physiological measurement (ºC)
Assessment of possible routes (oral, rectal, axillary, tympanic, surface)
excluding those that are injured, uncomfortable, infected or inappropriate Metabolic rate
Shivering
Body excretions (air, urine, faeces)
Hormonal influences (women have a slightly higher temperature than men at particular times in the menstrual cycle)
Circadian rhythm
Gender (see hormonal influences above)
Age, infants and older people are more susceptible to temperature
changes in the environment
Has the client recently had a hot or cold drink?
Is the client obese or very thin?
Have they recently been smoking?

• Psychological
Emotion
Stress
Anxiety
Behaviour including ability to put on/take off clothing appropriately, and degree of compliance
Confusion (mercury thermometers should not be used for clients who are confused as they may try to bite or swallow the thermometer)

• Sociocultural
Climate
Exercise
Housing/shelter
Smoking
Drugs
Environmental
Room temperature
Severe heat
Severe cold
Exposure
Food and drink
Time of day

• Politico-economic
Occupation
Poor housing, heating
Poor diet
Lack of finances for adequate heating

• Past history
Past medical history
Recent exposure to infection/illness
Recent holiday abroad
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Methods of temperature measurement

Clinical mercury thermometers
Traditional mercury thermometers have been used for many years in clinical settings and may be used in the mouth, the axilla or the rectum. Although they are familiar to nurses and clients, their use has declined in recent years due to the potential hazards of mercury spillage and broken glass. There is also controversy surrounding accuracy of measurement and the length of time a mercury thermometer needs to be left in place. Types available include oral, rectal and subnormal (those that record
below 35ºC), and disposable covers are readily available to reduce the risk of cross-infection.

Electronic thermometers
These have become more popular in recent years and are often purchased for use in the home. An internal probe is connected to a power supply that has a display unit and bleeps when the maximum temperature is reached. They can be used in the mouth, the axilla or the rectum and should be covered with a clean disposable probe cover for each patient. They take significantly less time to register an accurate temperature than traditional thermometers and have therefore become increasingly popular. Though incurring a more significant cost they are considered a much safer product.

Tympanic thermometers
These are placed in the ear canal and heat is detected as infra-red energy from the tympanic membrane. It is a rapid way of measuring temperature, only taking a few seconds, but there is some controversy over the accuracy of measurement. They are probably the most widely used devices used in hospitals today.

Chemical disposable thermometers
These may be used in the mouth or the axilla. They are usually plastic strips which are impregnated with thermo-sensitive chemicals that change colour with increasing temperature. As these are disposable there is no risk of cross-infection.

Disposable strips
These are widely available from retail pharmacies and consist of individually wrapped strips for single use only. The strip is applied to the forehead until a reading can be visualized on the strip. Whilst they can give a broad indication of whether the individual is hot or cold they are the least accurate and only really serve as a very basic guide as to whether more professional attention is needed.
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Normal body temperature

The following levels may vary slightly in different textbooks, but the following is intended to offer a simple, useful guide.

Normal range = 36–37ºC
Pyrexia = 38–40ºC
Hyperpyrexia = 40.1ºC and above
Heat stroke = Usually occurs around 41–42ºC
Death = 43ºC and above
Hypothermia = 35ºC and below
Death = 20ºC

The range of normal through to abnormal body temperature is shown in Figure 9.2.
Figure 9.2 Range of body temperatures
The sites that can be used to monitor temperature are:
• the axilla (axillary)
• the mouth (orally)
• the tympanic membrane (inner ear, aural)
• the rectum (rectally)
• the skin.

Great care should be taken when selecting the site. Whilst the rectal route is considered the most accurate because of its proximity to the core of the body it is obviously the least convenient, the most invasive and carries a number of risks not least the potential to perforate the rectum. It is therefore the least-used site but the best option when a very accurate measurement is required, for example in cases of hypothermia.

For many years the mouth has been the most commonly used site in adults, but care must be taken to ensure that the thermometer is placed firmly in the pocket to the side of the frenulum below the tongue and that the client is fully orientated and co-operative; confused or disorientated clients may bite or try to swallow it. This site is therefore not recommended in children unless they are fully compliant, nor should it be used for measuring the temperature of breathless patients or patients who suffer from epilepsy. When using this site it is also important to check that the client has not just had a hot or cold drink as this can significantly affect the measurement.

The axilla and groin are useful and less dangerous but are less efficient, particularly in clients who are obese or very thin, as good skin contact is essential for accurate measurement.

The tympanic membrane has become by far the most common site for taking temperatures, as it is easily accessible, least invasive and most speedy. Accuracy does, however, rely on the operator fully occluding the aural canal.

Whichever route is selected, continuity is important, as the measurement can vary by between 0.5 and 4.0ºC depending on the site used.
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Common terminology of Maintaining body temperature

Apyrexia - A normal body temperature
Body temperature - Represents the balance between the heat produced by the body and the heat lost
Circadian rhythm - Sleep cycle (body temperature is lower at different times of the sleep cycle)
Conduction - The transmission of heat from one object to another
Convection - The transmission of heat by movement of the heat through a liquid or gas
Core temperature - The temperature of the deep tissues and organs within the cranial, thoracic and abdominal cavities
Evaporation - To lose heat through moisture, i.e. sweating
Frenulum - The thin membrane anchoring the tongue to the soft palate
Heat stroke - A potentially serious condition produced by prolonged exposure to excessive temperatures, which can lead to coma and death
Homeostasis - Maintenance of a constant but dynamic internal environment
Hyperpyrexia - A very high body temperature
Hypothermia - A very low body temperature
Metabolic rate - The speed at which the body’s internal mechanisms are functioning
Pyrexia - A high body temperature
Surface temperature - Temperature of the skin surface (rises and falls in response to the environment)

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Maintaining body temperature

Most of the time adults are unaware of their body temperature because it usually remains at a constant, comfortable level. A special regulating centre in the brain, the hypothalamus, carefully balances the amount of heat produced and the amount lost by the body by, for example, making us sweat or shiver. Control of temperature in this way is part of maintaining homeostasis of the body. Adults are therefore referred to as being ‘homeothermic’, that is, able to maintain their core body temperature at a constant level regardless of the external temperature (see Figure 9.1). As can be seen their skin temperature can be several degrees higher or lower than the core temperature without affecting overall body function.

Figure 9.1 Variations in core and skin temperatures
In infants and children, however, the control centre is not fully developed. This therefore means that there is a potential for wide variations in body temperature; this is why it is crucial that parents or carers monitor constantly the temperature of infants and children and make adjustments to their clothing and environment on their behalf.

Normal body temperature is subject to variation over the 24-hour day, in keeping with the circadian rhythm (sometimes known as diurnal variation). It starts to rise at about 06.00 hours until 11.00 hours. After 11.00 hours it levels out until about 17.00 hours, by which time it may have risen 0.5–0.7ºC from early morning. It then starts to fall again in the early hours of the morning, when body temperature is at its lowest. This is why when we undertake night duty we usually feel quite cold around 03.00 hours and often feel the need to have a warm drink, eat or go for a walk round the ward or department.

The factors that may affect body temperature include:
• physical, for example illness, infection, gender, age, metabolic rate
• psychological such as emotion, stress and anxiety
• sociocultural including exercise, activity, recreational drugs
• environmental, for example time of day, severe heat or cold
• politico-economic, for instance lack of finances for heating or occupation.
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Collection of a specimen of vomit

If a client is vomiting profusely and has not responded to treatment, whilst very rare, you may be asked to collect a specimen for microscopy, culture and sensitivity (M,C&S) or to test for the presence of blood. Testing for blood can be done quite simply by dipping a urinalysis strip in the bowl. Specimens for M,C&S should be collected in a sterile universal container and dispatched to the laboratory immediately, though this test is not considered particularly accurate as stomach contents quite often contain bacteria which may or may not be pathogenic.

What is perhaps more important is that you reassure the client and support them by ensuring that:
• The client is not left alone and has a ready supply of bowls and tissues.
• Their dignity is maintained by providing privacy.
• Filled receptacles are monitored and disposed of promptly.
• The client receives appropriate and adequate anti-emetic medication.
• The client is offered a mouthwash or if necessary assisted in restoring their oral hygiene.
• Any soiled clothing or bed linen is replenished immediately.

In this chapter we have outlined some of the more fundamental aspects of elimination. As you become more senior and more experienced, it is all too easy to forget the importance of these activities to clients in the everyday hub of a busy clinical environment, and, in doing so, delegate them to less qualified and experienced personnel who may not approach them with the same level of awareness, care or compassion as yourself. Therefore it is essential to constantly remind yourself that these are, indeed, crucial daily activities that promote health and well-being, but they require tact and diplomacy, as well as expediency, if clients are to receive a high standard of care.
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Monitoring vomitus

Monitoring a client’s vomiting pattern along with the amount and consistency of the vomit can help in determining the nature of their condition as well as assisting in helping us determine a client’s potential for malnutrition and dehydration, and subsequently their replacement needs. It is therefore essential that this be documented accurately on the client’s fluid balance chart, before being disposed of in keeping with the universal precautions and any abnormality reported and documented in the client’s care record.

When observing vomit it is important that you note the amount, form, consistency, colour, frequency, whether it is accompanied by nausea or pain, and whether it is related to the ingestion of food or medication. Greenish brown fluid indicates the presence of bile. If the vomit is brown and foul-smelling like faeces, this is indicative of an intestinal obstruction in the large bowel. The presence of blood in the vomit is termed haematemesis and may be bright red, indicating fresh blood from the stomach or upper gastro-intestinal tract, or resemble dark brown ‘coffee grounds’, suggesting that it has been partially digested.

Projectile vomiting (that is, vomit emitted with force), can occur at any age. Whilst it is not uncommon in children, particularly if they eat too much too quickly, it should be reported along with any other findings as again this may indicate an obstruction or other disorder.

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Rectal examination

Occasionally some clients may require a digital rectal examination to determine whether or not they are constipated or whether they have any other rectal or faecal abnormality. Guidelines from the Royal College of Nursing (2000) suggest that only a specialist nurse should undertake this procedure. It is therefore outside the remit of student nurses and other untrained health care professionals. It is recommended that you consult your local policy for further information and guidance.

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Collection of specimen of faeces

Any persistent alteration in a client’s bowel habits needs to be investigated as it may indicate a serious disorder. Therefore, the nurse may be required to collect a specimen of faeces, which will be sent to the laboratory for investigation. Single specimens may be collected for microscopy, culture and sensitivity if an infection is suspected, to determine the micro-organisms. Three consecutive specimens may be requested if we are looking for blood not detectable by the human eye (faeces for occult blood, FOB) or, if the client is passing pale, bulky stools, we sometimes collect all faecal output for three consecutive days (faecal fat collection). It is therefore important to ascertain which type of specimen is required and assess the client’s ability to co-operate beforehand.

Equipment:
Bedpan (and sundries as necessary)
Appropriate specimen container duly labelled with client’s details, date and accurate time of collection
Completed specimen forms
Plastic bag
Category-3 stickers if client is considered a high risk
Gloves
Procedure
Rationale
Explain the procedure to the client and ensure understanding and ability to participate, as necessary
To gain the client’s consent and co-operation
Provide client with a clean bedpan
To reduce the risk of contaminating the specimen
Place the bedpan on the toilet/ commode
To ensure privacy for the client
Wash hands and put on gloves and disposable apron before handling the bedpan containing the specimen
To minimize the risk of cross-infection
Examine the specimen in the sluice using the spoon incorporated in the lid of the sample container
To identify any obvious abnormalities. To prevent contamination
Fill the specimen bottle to at least onethird full
To obtain a usable amount of specimen
If segments of tapeworm are seen these should be included in the faecal sample and sent to the laboratory
For identification
Dispose of the bedpan and/or contents appropriately
To minimize infection risks
For infants and clients who are incontinent, faeces can be obtained directly from a nappy or pad by scraping it with the scoop of the collecting vessel
To obtain specimen, reduce possible difficulty
and reduce potential embarrassment in older clients
Remove gloves and apron and wash hands
To reduce the risk of cross-infection
Ensure the specimen container is clearly labelled and placed in a specimen bag. This should be accompanied by a specimen request form
For correct identification of the specimen














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Monitoring bowel actions

Bowel habits are variable between individuals and are influenced by lifestyle, eating habits and mental state. The average adult will pass 100–150 g of faeces once per day; change in this pattern and change in the nature of faeces passed can indicate disease. The health care professional will therefore need to monitor the bowel action of clients where actual or potential problems are indicated.

Normal faeces is made up of 75 per cent water and 25 per cent solid constituents (cellulose, dead epithelial cells, bacteria, mucus and bile pigments). Skatole and indole arise from bacterial decomposition and give faeces it characteristic odour. Faecal matter is normally brown in colour, soft in consistency and cylindrical in form.

The carer should observe the client’s faeces to identify any changes, and this should be documented in the client’s records or on a stool chart along with frequency of passage and appearance of the faeces. The Bristol Stool Chart is a useful classification system that has been developed to assist us in recording the stool type and can be found on the Internet. This information can assist in diagnosis and treatment and can inform care planning.

Constipation is the commonest problem that can occur. This is the passage of hard stools less frequently than the client’s normal pattern. Conversely, the term diarrhoea is used when faeces contains excess water and the frequency of defecation is markedly increased. Alternating constipation and diarrhoea is suggestive of irritable bowel syndrome but can indicate a partial obstruction.

Other less common abnormalities are:
• pale, putty-coloured faeces, indicative of problems in the biliary system
• presence of pus or excessive mucus, suggesting infection or inflammation
• black and tarry stools (meleana) with a characteristic smell of altered blood, suggestive of bleeding somewhere in the large bowel
• fresh blood in the faeces, which can indicate haemorrhoids or other abnormality
• black stools also occur as a result of taking iron tablets
• parasites
• foreign bodies, particularly in children, who may for example have swallowed a coin or placed something in their rectum.

All of these abnormalities usually require further investigation; therefore, a faecal specimen will be required.
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Collecting a catheter specimen of urine

A catheter specimen of urine is taken for bacteriological examination when there are symptoms of a urinary tract infection. It is an aseptic technique, to reduce the risk of contaminating the sample. Urine should be obtained from a specific port on the drainage bag – never by disconnecting the closed circuit. Nurses need to familiarize themselves with the sampling ports on the drainage ports.

Equipment:
20 ml syringe
21G needle
Universal container
Gate clamp
Microbiology form
Alcohol swabs
Receiver
Gloves
Apron
Sharps box
Procedure
Rationale
Explain to the client why the specimen is
required, and provide privacy
To gain co-operation, obtain consent and
respect dignity
Clamp the drainage tubing just below the sampling
port until sufficient urine is collected
To achieve sufficient urine for analysis
Never clamp the catheter
May damage the catheter
Collect equipment
Organization of equipment helps the procedure
to run smoothly
Wash hands and put on gloves
To minimize the risk of contamination
Swab the sample port with a 70 per cent
alcohol swab and allow the port to dry
To reduce the risk of infection
Insert the needle into the port at an angle
of 45 degrees
To avoid going straight through the
tube and therefore increasing the risk of
needlestick injury
If no needle is required, insert the syringe
firmly into the centre of the sample port
and continue
Follows recommendations of
manufacturer
Withdraw the required amount of urine.
Remove the needle from the port. Remove
the top of the specimen pot and fill it with
urine
To obtain specimen
Dispose of needle and syringe immediately
in a sharps box
To reduce the risk of needlestick injury
Swab the sample port with a 70 per cent
alcohol swab and allow the port to dry
To reduce the risk of infection
Unclamp the catheter, remove gloves and
dispose of equipment safely. Wash hands
and make the client comfortable
To reduce the risk of injury and infection
Label the specimen container and transfer
it to the laboratory with the request form
For identification of the client
Specimens should be transferred within one
hour of sampling whenever possible
If transfer is delayed then specimens
should be stored in a refrigerator at 4oC.
Storing them at room temperature for
longer than two hours will affect the result
Document in the client’s nursing records the
date and time that the specimen was collected
To communicate this information to others



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