Professional Documents
Culture Documents
Shurouq Qadose
17/2/2008
Vital signs are temperature, pulse, respiration,
blood pressure and pain. A change in vital signs
may indicate a change in health.
Pyrexia
A body temperature above the usual range is called
pyrexia, hyperthermia, or fever.
Hyperpyrexia; is a very high fever usually above 41
°C and survival is rare when the temperature
Reaches 44 °C and death due to damaging effects
on the respiratory center.
The client who has a fever is referred to as febrile;
the one who does not is afebrile.
The signs and symptoms of fever: loss of
appetite, headache, hot, dry skin, flushed face,
thirst and general malaise. Young children or
other people with high fevers may experience
periods of delirium or seizures.
Nursing Interventions for Client's with
fever:
• Monitor vital signs
• Assess skin color and temperature
• Monitor WBC, HCT, and other laboratory reports for
indications of infection or dehydration
• Remove excess blanket when the client feels warm,
but provide extra warmth when the client feels
chilled.
• Measure intake and output
• Provide adequate nutrition and fluid
• Reduce physical activity to limit heat production.
• Administer antipyretic
• Provide oral hygiene to keep the mucous
membrane moist.
• Provide a tepid sponge bath to increase heat
loss through conduction.
• Provide dry clothing and bed linens.
Hypothermia; is a core body temperature below
the lower limit of normal. The three
physiologic mechanisms of hypothermia are:
• Excessive heat loss
• Inadequate heat production to counteract heat
loss
• Impaired hypothalamic thermoregulation
The clinical signs of hypothermia:
–Decreased body temperature, pulse, and
respiration
–Severe shivering
–Feelings of cold and chills
–Pale, cool skin
–Hypotension
–Decreased urinary output
–Lack of muscle coordination
–Disorientation
–Drowsiness progressing to coma
–Frostbite(nose, fingers, toes)
Nursing Interventions for Client's with Hypothermia
»Provide a warm environment
»Provide dry clothing
»Apply warm blanket
»Keep limbs close to body
»Cover the client's scalp with a cap
»Supply warm oral or intravenous
fluids
»Apply warming pads
Assessing Body Temperature
Temperature scales
The body temperature is measure in degreed on
two scales: Celsius (centigrade) and
Fahrenheit.
C= (Fahrenheit temperature – 32) * 5/9
F = (Celsius temperature * 9/5) +32
Pulse