ADVANCED NURSING PRACTICE

SEMINAR ON

ALTERED BODY TEMPERATURE

Submitted to submitted by

Mrs Raji Raju Ms Sumy saji

Associate professor first year M.sc nursing

Vijaya College of nursing Vijaya College of nursing

Kottarakkara kottarakkara

Submitted on: 23- 04- 2018

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 ALTERED BODY TEMPERATURE
I. INTRODUCTION

Body temperature reflects the balance between the heat produced and the heat loss from the
body .Abnormal body temperature can be slight, such as low grade fever or life threatening, as in
severe cases of hypothermia or hyperthermia. The nurse is often the person to monitor client’s
temperature, to identify deviations and to report significant findings to the physician, so that
appropriate therapy can be institute.

The temperature within the deep tissues of the body (core temperature) is normally
maintained within a range of 36.0°C to 37.5°C (97.0°F to 99.5°F).12 Within this range, there are
individual differences and diurnal variations; internal core temperatures reach their highest point
in late afternoon and evening and their lowest point in the early morning hours .Virtually all
biochemical processes in the body are affected by changes in temperature. Metabolic processes
speed up or slow down, depending on whether body temperature is rising or falling. Body
temperature reflects the difference between heat production and heat loss. Body heat is generated
in the tissues of the body, transferred to the skin surface by the blood, and then released into the
environment surrounding the body. The thermoregulatory center in the hypothalamus functions
to modify heat production and heat losses as a means of regulating body temperature.

II. BODY TEMPERATURE -DEFINITION

In human the traditional normal value for the temperature is 37degree Celsius various parts of
the body art at various temperature.

1. A fever is indicated when body temperature rises about one degree or more over the normal
temperature of 98.6°F, (American Academy of Family Physicians.)
2. The body temperature is the difference between the amount of heat produced by the body
process and the amount of heat loss to the external environment.

Heat produced-Heat loss=Body temperature

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III. TYPES OF BODY TEMPERATURE
 CORE TEMPERATURE
It is the temperature of the interior body tissue below the skin and subcutaneous tissue .The
sites of measurement of core temperature are rectum, tympanic membrane, esophagus,
pulmonary artery, urinary bladder.
 SHELL TEMPERATURE
It refers to boy temperature at the surface of that is of the skin and subcutaneous tissue. .The
sites of measurement of shell temperature are skin, axillae, and oral.
 Oral;37*c (98.6F)
 Rectal;37.5*c(99.6F)
 Tympanic;37.5*c(99.5F)
 Axillary;36.5*c(97.6F)
IV. FACTORS AFFECTING BODY TEMPERATURE

Many factors affect the body temperature .changes in body temperature within an acceptable
range occur when the relationship between the heat production and the heat loss is altered by
physiology or behavioral variables.

 Age
Major factors affecting the body temperature is the age. For example at birth the newborn leaves
a warm, relatively constant environment and enters one in which temperature fluctuates widely.
Their head should always be protected because of the increase surface area of head, 30% of body
heat is lost through head. This thermoregulation system remains unstable till puberty. Even the
older people also become sensitive to temperature extremes because of decreased
thermoregulation control. Among old persons changes in body temperature may be because of
inadequate dietary intake, loss of subcutaneous fat, decreased activity level etc.
 Exercise
Muscle activity requires in increased blood supply and an increased fat and carbohydrate
breakdown that cause increase in heat production. Increase in utilization of carbohydrates and fats
ultimately leading to increased metabolic rate and further to heat production .Any form of exercise

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increase the heat production and thus the body temperature. prolonged strenuous exercise, such
as long distance running ,can temporarily raise body temperatures up to 41*c(105.8f).
 Hormone level

Woman generally experience greater fluctuations in body temperature than men. Hormonal
variations during the menstrual cycle cause body temperature fluctuations.
Decrease progesterone

Decrease body temperature

During ovulation
Increased progesterone

Increased body temperature

Even during menopause, woman experiences intense body heat and sweating (known as hot
flashes) because of instability of vasomotor control.

 Basal metabolism
Accounts for the heat produced by the body at absolute rest. The average basel metabolic rate
depends on the body surface area. Thyroid hormones also affect the BMR. By promoting the
breakdown of the body glucose and fat, thyroid hormones increase the rate of chemical reactions
in almost all the cells of body. When large amount of thyroid hormones are secreted, the BMR
can increase 100% than normal. Absence of thyroid hormones can cut the BMR in half, causing
the decrease in heat production. Stimulation of the sympathetic nervous system by norepinephrine
and epinephrine also increase the metabolic rate of body tissues. Men have a higher BMR than
women.
 Circadian rhythm
Body temperature normally changes (0.9-1.8) 0.5-1*c during a 24 hour period. The temperature
is usually lowest between 1.00 - 4.00am.During the daytime the body temperature rises steadily
up to 6pm and then declines to early morning levels.
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 Stress
Physical and emotional stress increase body temperature through stimulation of sympathetic
nervous system due to increase in production of epinephrine and nor epinephrine therapy
increasing metabolic activity and heat production. A client who is anxious could have an elevated
body temperature for that reason.
 Environment
Extremes of environment can affect a person’s temperature regulatory systems. If temperature is
assessed in a warm room, a client may be unable to regulate body temperature by heat loss
mechanisms and the body temperature will be elevated .similarly if the client has been outside in
extremely cold weather without suitable clothing the body temperature may be low.
V. REGULATION OF BODY TEMPERATURE
A. NEURAL CONTROL
Body temperature is controlled by the hypothalamus .The hypothalamus detects minor changes in
body temperature and maintains the body temperature within the critical level referred as set point.
Neurons in both the pre optic anterior hypothalamus receive two kinds of signals; one from
peripheral nerves that reflect warmth /cold receptors and the other from the temperature of the
blood bathing the region .These two types of signals are integrated by the thermoregulatory center
of hypothalamus to maintain normal body temperature. When these neurons detect the
temperature of blood is too warm, signals radiate to the heat loss center located in the anterior
portion of the hypothalamus which is mainly composed of parasympathetic nerves that when
stimulated initiate mechanism to decrease body heat .
If cold detected signals are sent to the heat promoting Centre in the posterior hypothalamus which
operates mainly through sympathetic nervous system which stimulates mechanism to produce
body heat .in a neutral environment, the metabolic rate of humans constantly produces more heat
than is necessary to maintain the core body temperature at 37c.

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 B. VASCULAR CONTROL
The circulatory systems functions as a transportation mechanism responsible for carrying heat
from body core to the skin surfaces from where it is transferred to the air through radiation,
evaporation, conduction, and convection.in order to cool the body the superficial blood vessels
dilate which leads to increased blood flow to the skin and is controlled by peripheral nervous
system produces vasoconstriction when body needs to conserve heat.

HEAT PRODUCTION

Heat is produced in body by metabolism, which is the chemical reaction in all body cells. Food is
the primary fuel source for metabolism .As metabolism increases heat production increases and
as it decreases less heat is produced .heat production occurs during rest ,voluntary and involuntary
shivering and no shivering thermo genesis.
 Rest;Best metabolism accounts for the heat produced by the body at absolute rest. The average
basal metabolic rate depends on the body surface area. Thyroid hormones also affect the BMR

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 by promoting the breakdown of body glucose and fat they increase the chemical reactions in
almost all the cells of the body stimulation of sympathetic nervous system by nor epinephrine
and epinephrine also increase the metabolic rate of body tissues. These chemical mediators
cause blood glucose to fall which stimulates cells to manufacture glucose. The male sex
hormone testosterone increases BMR .men have higher BMR than woman.
 voluntary movements
Voluntary movements such as muscular activity during exercise require additional energy. The
metabolic rate can increase up to 2000 times normal during exercise.
 shivering
It is an involuntary body response to temperature differences in the body. The skeletal movement
during the shivering requires significant energy. Shivering can increase heat production up to 4-5
times greater than normal .the heat is produced assists in equalizing the body temperature, and the
shivering ceases.
 non shivering themogenesis
It occurs primary in neonates, because neonates cannot shiver, a limited amount of vascular brown
tissue present at birth is metabolized for heat production.

HEAT LOSS

Heat loss and heat production occurs simultaneously .The skins structure and exposure to the
environment result in constant, normal Heat loss trough radiation, conduction, convection, and
evaporation.
 Radiation (60%)

It is the transfer of heat from the surface of one object to the surface of another
without direct contact between the two. Radiation occurs because heat transfers through
electromagnetic waves. Heat radiates from skin to any surrounding cooler object. Radiation
increases as the temperature difference between the object increases. Example; A nude person in
room with normal temperature will loss body heat in to environment.

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 Conduction (3%)
It is the transfer of heat from one object to another with direct contact. When a warm skin
touches a cooler object, heat is lost .when the temperature of two objects is same the conductive
heat loss stops. Here contact with other object is present. Heat is lost to other objects that are
cooler than skin.
The nurse increases the conductive heat loss when applying an ice pack or bathing a client with
cool water .applying several layers of clothing reduces conductive loss. The body gains heat by
conduction when contact is made with materials warmer than skin temperature.
E.g.; hydrotherapy, sponge bath decrease body temperature through conduction
 Convection (15%)
It is the transfer of heat away by air movement. Heat is conducted to air molecules directly in
contact with skin. Air currents carry away the warm air.as the air current velocity increases,
convective heat loss increases. Heat is first conducted to air molecules directly in contact with
skin .a fan promotes heat loss through convection .convective heat loss increase when moistened
skin comes into contact with slightly moving air.
 Evaporation (22%)
It is the transfer of heat energy when a liquid is changed to a gas. The body continuously loose
heat by evaporation. 600- 900ml a day evaporates from the skin and lungs, resulting in water and
heat loss. This is normal loss considered insensible water loss and does not play a major role in
temperature regulation. When the body temperature rises, the anterior hypothalamus signals the
sweat glands to release sweat. Sweat evaporates from the skin surface resulting in heat loss.

C.SKIN IN TEMPERATURE REGULATION

The skin’s role in temperature regulation includes insulation of the body, vasoconstriction and
temperature sensation. The skin, subcutaneous tissue and fat keep heat inside the body .In the
human body the internal organs produce heat and during exercise and increased sympathetic
stimulation. The amount of heat produced is greater than the usual core temperature. Blood flows
from the internal organs carrying heat to the body surface. The skin is well supplied with the blood
vessels, the areas of hands, feet, and ears.

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The skin is well supplied with heat and cold receptors .As the cold receptors are plentiful the skin
functions primarily to detect cold surface temperatures. When the skin becomes chilled, its sensors
send information to the hypothalamus. This initiates shivering to increase body heat production,
inhibition of sweating, and vasoconstriction

D.BEHAVIOURAL CONTROL

Humans voluntarily act to maintain comfortable body temperature when exposed to temperature
extremes. The ability of person to control body temperature depends on degree of temperature
extreme. The person’s ability to sense feeling comfortable or uncomfortable, thought processes
or emotions. Thermoregulation depends upon;

 Degree of temperature extreme

 Client’s capacity to have comfortable or uncomfortable feelings about temperature.
 Emotions of client
 Activity level of client.

Body temperature control is difficult if any of these abilities are absent .infants can sense
uncomfortable warm conditions but need assistants in changing their environments. Older adults
may need help in detecting cold environments and minimizing heat loss. Illness a decreased level
of consciousness or impaired through processes result in an inability to recognize the need to
change behavior for temperature control.

E. MECHANISMS ACTIVATED BY COLD

o Increased heat production by increase in BMR, muscle activity, thyroxin output, epinephrine,
nor epinephrine and sympathetic stimulation, fever.
o Decreased heat loss by cutaneous vasoconstriction, curling up.

F. MECHANISMS ACTIVATED BY HEAT

o Increased heat loss by cutaneous vasodilation, sweating, increased respiration

o Decreased heat production; manifested by anorexia, apathy, illness.
VI. EQUIPMENT FOR TEMPERATURE RECORDING

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Thermometer is used for measuring body temperature; the main types are,

1. Mercury- in glass thermometer

2. Electronic thermometer
3. Disposable thermometers
1. Mercury- in glass thermometers
The mercury in glass thermometer is a glass tube sealed at one end, with a mercury- filled bulb at
the other end. Exposure of bulb to heat causes the mercury to expand and rise in the enclosed tube.
The length of the thermometer is marked with Fahrenheit or centigrade caliberations.
2. Electronic thermometers
The electronic thermometer consists of a rechargeable battery- powered display unit, a thin wire
rod, and a temperature processing probe covered by a disposable plastic sheath. Separate
unbreakable probes are available for oral and rectal use. The oral probe can be used for axillary
temperature measurement. Within 20 to 50 seconds of insertion, a reading appears on the display
unit. A beep sound is heard when the peak temperature reading has been measured.
3. Disposable thermometers

Disposable single use thermometers are thin strips of plastic with a temperature sensor at one end.
They are used for oral and axillary temperatures, particularly with children. They are useful when
caring for clients on protective isolation to avoid the need to take electronic instruments into client
rooms. They are inserted the same way as an oral or axillary thermometer and used only once.
Chemical dots on the thermometer change color to reflect the temperature reading. The
thermometer is removed after 60 seconds and read after waiting for 10 seconds to ensure that the
temperature reading has been stabilized. Researches have shown that disposable single use
thermometers tend to overestimate or underestimate true temperature readings. As a result, the
device is only recommended for screening purposes in adults. When an abnormal temperature is
suspected, the temperature should be confirmed with an electronic thermometer.

VII. SITES OF TEMPERATURE MEASUREMENT

The main sites for temperature measurements are

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1. Mouth
2. Axilla
3. Skin
4. Rectum
5. Tympanic membrane
1) MOUTH
Advantages
 Accessible requires no position change
 Comfortable for the client
 Provides accurate surface temperature reading.
 Reflects rapid change in core temperature.

Disadvantages

 Affected by ingestion of fluids or foods, smoke and oxygen delivery.

 Should not be used for clients who have had oral surgery, trauma, history of epilepsy, or
shaking chills.
 Should not be used with infants, small children, or confused, unconscious or
uncooperative clients.
 Risk of body fluids exposure.
2) AXILLA
Advantages
 Safe and expensive
 Can be used with newborns and uncooperative clients.
Disadvantages
 Long measurement time.
 Requires fever continuous positioning by nurse.
 Lags behind core temperature during rapid temperature changes
 Requires exposure of thorax

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  Not recommended to detect in infants and young children.
3) SKIN
Advantages
 Inexpensive
 Safe and noninvasive
 Can be used for neonates
 Provide continuous reading
 Does not require a disturbing client
 Easy to read

Disadvantages

 Lags behind other sites during temperature changes, especially during hyperthermia
 Adhesion can be impaired by diaphoresis or sweat
 Can be affected by environmental temperature
 Unreliable during chill phase of fever
4) TYMPANIC MEMBRANE
Advantages
 Minimal client positioning required
 Very rapid measurement
 Can be obtained without disturbing or waking up the client
 Unaffected by oral intake of foods, fluids, smoking
 Can be used in newborns to reduce handling and heat loss

Disadvantages

 More variability of measurement than with other core temperature devices

 Requires removal of hearing aids before measurement

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  Expensive
 Should not be used with clients who have surgery of the ear or tympanic membrane
 Cannot obtain continuous measurement
5) RECTUM
Advantages
 Argued to be more reliable when oral temperature cannot be obtained

Disadvantages

 May lag behind core temperature during rapid temperature changes

 Should not be used for routine vital signs in newborns
 Risk for body fluid exposure
 Requires positioning and may be a source of client embarrassment and anxiety

TYPES OF ALTERATIONS IN TEMPERATURE

1. FEVER (PYREXIA)

DEFINITION

Fever is an elevation of body temperature that exceeds normally daily variation and occurs in
conjunction with an increase in the hypothalamic set point for 37*c-39*c (shabeer. p. Basheer)

CAUSES

 Hot environment
Extremes of environment can affect a person’s temperature regulatory systems. If temperature
is assessed in a warm room, a client may be unable to regulate body temperature by heat loss
mechanisms and the body temperature will be elevated.
 Excessive exercise
Muscle activity requires in increased blood supply and an increased fat and carbohydrate
breakdown that cause increase in heat production.
 Neurogenic factor

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 Neurogenic factors like injury to hypothalamus may cause alterations in temperature.
 Dehydration after excessive diuresis
 As an undesired side effect of a therapeutic drug
 Infectious diseases and inflammation

CLINICAL SIGNS OF FEVER

 Respiratory system: shallow and rapid breathing

 Circulatory system: increased pulse rate and palpation
 Alimentary system: Dry mouth, loss of appetite, indigestion, nausea, vomiting, constipation
or diarrhea
 Urinary system: diminished urinary output, burning micturition, high colored urine
 Nervous system: Headache, restlessness, insomnia, delirium
 Musculoskeletal system: malaise, fatigue, body pain, joints pain

CLASSIFICATION OF FEVER

a. Intermittent fever
The temperature curve returns to normal during the day and reaches its peak in the evening;
Example; in septicemia.
b. Remittent fever
The temperature fluctuates but does not return to normal. Example; TB, viral diseases, bacterial
infections.
c. Sustained fever
The temperature remains elevated with little fluctuation.
d. Relapsing fever

Periods of fever are interspersed with period of normal temperature.

 Tertian; when paroxysm occurs on 1st and 3rd days

 Quatrain; fever associated with paroxysm on first and fourth day. Example; in malaria

PATHOGENESIS OF FEVER

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a. Pyroxenes
Pyroxenes is any substance that causes fever .exogenous pyroxenes are divided from outside the
patient; most are microbial products , toxins or microorganisms .e.g.; lip polysaccharide end toxin
produced by all gram negative bacteria. Enterotoxins of gram positive like staphylococcus aureous
and group. A and B staphylococcal toxins.
b. Phylogenic cytokines
Cytokines are small proteins that regulate immune, inflammatory and hematopoietic processes.in
absence of microbial infection, inflammation, trauma, tissue necrosis or antigen antibody
complexes can induce the production of progeny cytokines which individually or in combination
trigger the hypothalamus to raise the set point to febrile levels. The cellular source of cytokines
are primary monocytes, neutrophils, lymphocytes, although many other types of cells can
synthesize these molecules.
c. Elevation of hypothalamic set point by cytokines
During fever, levels of prostaglandin E2 (PGE2) are elevated in hypothalamic tissue. Cytokines
pass from circulation to brain. The endogenous and exogenous pyroxenes interact with the
endothelium of hypothalamus and raise set point of febrile cells.
d. Production of cytokines in central nervous system.
Several viral diseases produce active infection in the brain. Glial or neuronal cells synthesize
interleukins TNF. Therefore central nervous systems production of cytokines raises hypothalamic
set point.

Exogenous pyrogenes (viruses, bacteria, fungi, pyrogenic steroids) enter the body

Activating leukocytes to produce interleukin 1 which is released into the bloodstream

Causing the thermoregulatory center in the brain to reset to higher set point

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 Activating physiologic effectors to cold (shivering)

Generating heat and causing fever

GRADES OF FEVER

 Low grade fever -37.1 -38.2*c

 High grade fever -38.2 -40.5*c
 Hyper pyrexia - >40.5*c

PHASES OF FEVER

1. Chill phase
The body’s heat producing mechanism attempts to increase the core temperature, the client
experiences cold and may shiver. Goods flush caused by contraction of erector Pilli muscles in an
attempt to trap air around body hairs, is evident .skin becomes pale and cool due to
vasoconstriction.

2. Fever phase

It occurs when fever reaches the new higher set point .the clients skin feels neither hot or nor cold.
Cellular degeneration leads to fluid and electrolyte losses. If fluid volume deficit has occurred the
client may experience thirst. Complaints of aching muscles, general malaise, and weakness can
be there due to increase of protein catabolism .Client may be drowsy or restless. An uncontrolled
fever can make the patient delirious and to suffer from convulsions and to suffer from convulsions
due to cerebral nerve cell irritation.

3. Flush or crisis
During this phase the client experiences prophase diaphoresis, decreased shivering and possible
fluid volume deficit. The client’s skin appears flushed and warm to touch because of
vasodilatation.

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DIAGNOSIS OF FEVER
 History collection
It is in the diagnosis of a febrile illness that a meticulous history is more important. It mainly
include; a careful occupational history should include exposure to animals, toxic fumes and
potential infectious agents. A history of the geographic areas in which the patient has lived and
travel history include locations during military service. A careful family history include
information on family members with tuberculosis, other febrile or infectious diseases, or unusual
familial symptomatology such as fever, bone pain or aneamia.
 Physical examination
All the vital signs are relevant. The temperature may be taken orally or rectally. Special attention
should be paid to the skin, lymph nodes, eyes, nail beds, cardio vascular system, chest, abdomen,
musculo skeletal system, and nervous system.
 Laboratory tests
The workup should include a complete blood count; differential cunt, urinanalysis, electrolytes,
blood urea nitrogen, and creatinine levels should be measured
MANAGEMENT OF FEVER
 Oral aspirin and acetaminophen are equally effective in reducing fever. Aspirin blocks
prostsglandin synthesis in the hypothalamus and elsewhere in the body. Acetaminophen acts
on the heat regulating center in the hypothalamus.
2. HYPERTHERMIA

Hyperthermia is characterized by an unchanged setting of the thermoregulatory center in

conjunction with an uncontrolled increase in body temperature that exceeds the body’s ability to
lose heat.

CAUSES OF HYPERTHERMIA SYNDROMES

1) Heat Stroke;

Caused by thermoregulatory failure in association with an environment may be categorized

as exceptional and non-exceptional.

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 Exceptional; it occurs in younger individuals who exercise in higher than normal heat or
humidity, dehydration.
 Non exceptional; it is caused by anti-cholinergic including antihistamines, anti parkinsonian
drugs, diuretics, phenothiazines. It occurs in either very young or elderly during heat waves,
bedridden patients, elderly and taking drugs confined to poorly ventilated and non AC
environment.
2) Drug induced hyperthermia
Due to increase use of psychotropic drugs .monoamine oxidize inhibitors, tricycle antidepressants,
amphetamines, phencyclidine, lysergic acid diethylamide or cocaine.
3) Malignant
Occurs in individuals with inherited abnormality of skeletal muscle sarcoplasmic reticulum that
cause rapid increase in intracellular calcium level in response to halothane and other inhalation
anesthetics or to succinylcholine . In this there is elevated body temperature, increased muscle
metabolism, muscle rigidity, rhabdomyolysis, acidosis and cardiovascular instability and is often
fatal.
4) Serotonin syndrome
seen in selective serotonin uptake inhibitors(SSRIs), MAO’s and serotonergic medications have
overlapping features including hyperthermia but distinguished by presence of diarrhea, tremors,
myoclonus rather than lead pipe rigidity.
5) Endocrinopathy
Thyrotoxicosis and pheochromo cytoma can lead to increased thermogenesis.
6) Central nervous system damage
Cerebral hemorrhage, status epileptics hypothalamic injury can cause hyperthermia.

CLINICAL FEATURES
Hyperthermia include heat exhaustion and heat stroke. At both these levels, heat gain occurs at a
greater rate than heat loss.

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Symptoms related to heat exhaustion include weakness, fatigue, headache, giddiness, anorexia,
nausea, vomiting, diarrhea, and skeletal muscle cramps.
Heat stoke is severe and some times of fatal conditions. It is characterized by hot, dry skin, and
the absence of sweating, although a person with heat stroke still produce sweat.other
manifestations include confusion, seizures and coma. Sinus tachycardia and hypotension are
common.

DIAGNOSIS

 History collection
History of use of over the counters Medications, or treatment such as surgical /dental procedures.
Nature of prosthetic materials or dental procedures. occupational history, exposure to animals ,
infectious agents , febrile or infected individuals in the home , work place geographic areas patient
travelled , use of tobacco, iv drugs, trauma, animal bites, immunization, family history of TB,
arthritis, infectious diseases, anemia.
 Physical examination
Vital signs, check skin, lymph nodes, eyes, nail beds, cardio vascular system, chest, abdomen,
musculoskeletal system, should be examined carefully.
 Laboratory tests
If a patient reveals more than a simple viral illness or pharyngitis then lab testing is done;
o Clinical pathology:

complete blood count, differential leukocyte count, Neutrogena is present in some viral infections,
drug reactions, systemic lupus erythematous, typhoid, Blood smear for malarial pathogens, ESR.
Urinalysis. Any abnormal fluid accumulation like pleural fluid, peritoneum, joint is examined.
Bone marrow biopsy for histopathology studies as well as culture in infiltration of marrow by
pathogens or tumor cells. Stool for occult blood, inspection for ova, parasites.

o Chemistry:

Electrolytes, blood glucose, blood urea nitrogen, creatinine, liver function test.

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o Microbiology:

Smears and cultures of specimen from throat, urethra, anus, cervix, vagina. When there are no
localized findings or when findings suggest the involvement of pelvis, GIT. If respiratory infection
then sputum evaluation (Gram staining, staining for AFB culture). Culture of blood, abnormal
fluid collection, urine if fever reflects more than uncomplicated viral illness. CSF examined and
cultured if meningismus, severe headache or change in medical status is there.

 Radiology
A chest x-ray is part of evaluation for any significant febrile illness.

MEDICAL MANAGEMENT

It is important to distinguish between fever and hyperthermia since hyperthermia can be fatal and
doesn’t respond to antipyretics.

1) Pharmacological management
 Acetaminophen; adult: 325-650mg, oral, 4 -6 hrs.
Children: 10 -15mg/kg body weight, 4- 6 hrs.
 Ibuprofen (NSAID); adult: 200- 400 mg, PO, 6 hrs.
Children; 5mg/kg body wt. for temp. <102.5F.
 Indomethacin and naproxen (NSAID)
 Aspirin
Adult: 325-650mg PO, q6hrs

Children: 10 -20 mg, q, 6hrs.

 Gluco corticosteroid: potent antipyretic inhibit PGE2 synthesis.

 Mepridine , morphine sulphate, chlorpromazine.
 To manage severe rigors: treatment of underlying cause , nutrition , rest, physical cooling,
tepid bath, hypothermia blankets
2) Nursing management of fever and hyperthermia
 Monitor vital signs

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 Assess skin color and temperature
 Monitor white blood cell count, hematocrit value and other pertinent laboratory reports for
indication of infection or dehydration
 Measure intake and output.
 Reduce physical activity to limit heat production
 Administer antibiotics as ordered
 Provide dry clothing and bed linens.
 Provide tepid sponge bath to increase heat loss through conduction.
3) HYPOTHERMIA
Hypothermia is a state in which the core body temperature is lower than 35 degree Celsius or 95
degrees Fahrenheit. At this temperature many of the compensatory mechanism to conserve heat
begin to fall.
CLASSIFICATION
a) Primary hypothermia
It is a result of the direct exposure of a previously healthy individual to the cold.
b) Secondary hypothermia
It is hypothermia that results due to a complication of a serious systemic disorder.
c) Accidental hypothermia
It results from unintentional exposure to cold or wet and windy climate with an ambient
temperature less than 16 degree Celsius.
d) Induced hypothermia
It is deliberate lowering of temperature to a range of a 78- 90F to reduce oxygen need during
surgery and in hypoxia , to reduce blood pressure and to alleviate hyperthermia by administering
drugs that depress the hypothalamic or by encasting the client in a cooling blanket.
CAUSES
 Exposure to cold environment in winter months and colder climates
 Occupational exposure or hobbies that entail extensive exposure to cold for e.g. hunters,
sailors, and climbers.

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 Endocrine dysfunction: hypothyroidism, adrenal insufficiency, hypoglycemia.
 Neurologic injury from trauma, cerebral vascular accident, sub arachnoid hemorrhage.

RISK FACTORS

 Age extremes: elderly, neonates.

 Outdoor exposure: occupational, sports – related, inadequate exposure.
 Drugs and intoxicants: ethanol, phenothiazine, barbiturates, anesthetics, neuromuscular
blockers and others.
 Endocrine related: hypoglycemia, hypothyroidism, adrenal insufficiency, and hypopituitarism.
 Neurologic related: stroke, hypothalamic disorder, Parkinson’s disease, spinal cord injury.
 Burns and exfoliate dermatologic disorder

CLINICAL MANIFESTATIONS

Hypothermia leads to physiological changes in all organ systems.

a) Mild hypothermia
 Temperature; 35 – 32c
 CNS- Decreased cerebral metabolism, amnesia, apathy, dysarthria, impaired judgment.
 CVS- Tachycardia, vasoconstriction, increase in cardiac output, and blood pressure.
 RESPIRATORY SYSTEM- Tachypnea, bradypnea, decline in oxygen consumption,
bronchospasm
 RENAL AND ENDOCRINE- Diuresis, increase in metabolism with shivering.
 NEUROMUSCULAR- Increased pre shivering muscle tone, fatiguing, ataxia.
b) Moderate hypothermia
 Temperature; <32.2 – 28c
 CNS-EEG abnormalities, decreasing level of consciousness, pupillary dilatation,
hallucinations.
 CVS- Decreased in pulse and cardiac output, increased atrial and ventricular arrhythmias,
prolonged systole.

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 RESPIRATORY SYSTEM- Hypoventilation, 50% decrease in carbon dioxide per 8*c drop in
temp, Absence of protective airway reflexes, 50% decrease in oxygen consumption.
 RENAL AND ENDOCRINE- 50% increase in renal blood flow impaired insulin action.
 NEUROMUSCULAR – Hyporeflexia, diminishing shivering induced thermogenesis, rigidity.
c) Severe hypothermia
 Temperature; -<28c
 CNS- Loss of cerebrovascular auto regulation , decline in cerebral blood flow , coma, loss of
reflexes,
 RESPIRATORY SYSTEM- Pulmonic congestion and edema, apnea.
 RENAL AND ENDOCRINE- Decreased in renal blood flow, extreme oliguria.
 NEUROMUSCULAR- No motion

DIAGNOSIS

Hypothermia is confirmed by measuring the core temperature, at two sites, rectal probes should
be placed to a depth of 15 cm and not adjacent to cold faces. A simultaneous esophageal probe
should be placed 24cm below the larynx. It may lead to falsely high during heated inhalation
therapy.

MANAGEMENT

1. MONITORING
The ABC’s of basic life support are a priority .The patient’s vital signs, central venous pressure,
urine output, arterial blood gas levels, blood chemistry determinations (BUN, creatinine, glucose,
electrolytes ), and chest X-Rays are evaluated frequently .Body temperature is monitored with an
esophageal ,bladder, or rectal thermostat. Continuous ECG monitoring is performed because cold
induced myocardial irritability leads to conduction disturbances, especially ventricular
fibrillation. An arterial line is inserted and maintained to record BP and facilitate blood sampling.
2. REWARMING
Rewarming methods include active core (internal) rewarming, active external rewarming and
passive or spontaneous rewarming.

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 3. CORE- REWARMING
Methods include cardiopulmonary by-pass, warm fluid administration, and warm humidified
oxygen by ventilator, and warmed peritoneal lavage. Core rewarming is recommended for severe
hypothermia i.e. poikilothermia. Monitoring for ventricular fibrillation as the patient passes
through 31c-32c (88- 90*f) is essential.
4. PASSIVE EXTERNAL REWARMING

It includes the use of warm blankets or over the bed heaters. Passive rewarming of the extremities
increases blood flow to the acidosis, anaerobic extremities.

5. SUPPORTIVE CARE
 External cardiac compression
 Defibrillation of ventricular fibrillation. It is ineffective in patients with temperatures lower
than 88F.
 Administration of warm intravenous fluids o correct hypotension and maintain urine output
and core rewarding
 Administration of sodium bicarbonate to correct metabolic acidosis
 Gastric tube insertion to prevent dilation secondary to decreased bowel motility.
 Indwelling catheter to facilitate cold induced diuresis.
 NURSING INTERVENTIONS
 Provide extra covering and monitor temperature
 Cover head properly
 Keep patients linen dry
 Control environmental temperature
 Provide extra heat source
 Carefully assess for hyperthermia or burn.
4) FEVER OF UNKNOWN ORGIN
Fever of unknown origin was defined by peterson and Benson in 1961 as
Temperature of >38 .3c in severe occasions(>101 degree Fahrenheit)
A duration of fever of >3 weeks
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 Failure to reach a diagnosis despite 1 week of inpatient investigation.

CLASSIFICATION OF FUO

a) Classic FUO
 Temperature of >38 .3c in severe occasions(>101 degree Fahrenheit)
 A duration of fever of >3 weeks
 Failure to reach a diagnosis despite 1 week of inpatient investigation.
Example; infections, malignancy, inflammatory diseases, drug fever
b) Nosocomial FUO
A temperature of >=38.3*c develops on several occasions in a hospitalized patient who is
receiving acute care and in whom infection was not present at time of admission. For e.g. septic
thrombophlebitis, sinusitis, drug fever.
c) Neutropenic FUO
A temperature of >=38.3*c develops on several occasions in a patient whose neutrophil count is
<500/micro liter or is expected to fall to that level in 1-2 days.
d) HIV – associated FUO
A temperature of >= 38.3*c develops on several occasions over a period of >4 weeks for
outpatients or > 3days for hospitalized patients with HIV infection.

CAUSES OF FUO

 Infections
 Localized phylogenic infections: appendicitis, cholecystitis, Dental abscess.
 Intravascular infections: bacterial endocarditis.
 Systemic bacterial infections: typhoid fever.
 Mycobacterium infections: tuberculosis.
 Viral infections: dengue, hepatitis A, B, C, D, and E,HIV infection
 Neoplasms
 Malignant: colon cancer, gall bladder carcinoma, leukemia, renal cell carcinoma.
 Benign: castle man’s disease.

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 Habitual hyperthermia
 Exaggerated circadian rhythm
 Collagen vascular
 Rheumatic fever, rheumatic arthritis, systemic lupus erythematous.
 Granulomatous disease
 Crohn’s disease
 Miscellaneous conditions
 Drug fever, gout, tissue infarction or necrosis.
 DIAGNOSIS
 History collection
It is in the diagnosis of a febrile illness that a meticulous history is more important. A careful
occupational history should include exposure to animals; toxic fumes; potential infectious agents;
possible antigens; or other febrile or infected individuals at home, workplace or school. A careful
family history should include information on family members with tuberculosis, other febrile or
infectious diseases, or unusual familial sympatomatology such as deafness, urticarial, fevers, bone
pain or aneamia.
 Physical Examination
The temperature may be taken orally or rectally, but the site used should be consistent. Axillary
temperatures are notoriously unreliable. Special attention should be paid to the skin, lymph nodes,
eyes, nail beds, cardio vascular system, chest, abdomen, musculoskeletal system and nervous
system.
 Laboratory tests

The workup should include a complete blood count; a differential count, urinanalysis. Electrolyte,
glucose, blood urea nitrogen, and creatinine levels should be measured.

TREATMENT

 Oral aspirin and acetaminophen are equally effective in reducing fever. Aspirin blocks
prostaglandin synthesis in the hypothalamus and elsewhere in the body.

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 Non steroidal anti-inflammatory drugs such as indomethacin and ibuprofen are also excellent
antipyretics.
 Physical cooling with sponging, fans, cooling blankets, and even ice baths can be used in
conjunction with administration of appropriate pharmacologic agents.
5) FROST BITE
Frost bite is the condition in which the tissue temperature drops below zero degree Celsius. It is
trauma from exposure to freezing temperatures and actual freezing of the tissue fluids in the cell
and intracellular spaces. It results in cellular and vascular damage. Body parts more frequently
affected by frostbite include the digits of feet and hands, tip of nose, and earlobes.
PREDISPOSING FACTOR
Contact with thermal conductors such as metal or volatile solutions, constrictive clothing or shoes,
immobility, careless application of cold packs, vaso constrictive medications, Raynaud’s
phenomenon.
PATHOPHYSIOLOGY
In pre freeze phase plasma leaks out
and micro vascular constriction develops

The freeze phase begins with extra cellular

Extra cellular crystallization

Water exits the cells and causes intracellular

Dehydration, hyper osmolality and cellular shrinkage

Damaged tissue releases thromboxame

A2 and prostaglandin which produce platelet

Aggregation and vasoconstriction.

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 The microvasculatue begins to collapse

Tissue ischemia and necrosis

CLASSIFICATION OF FROST BITE

1) First degree frost bite: causes only anesthesia and erythematic.

2) Second degree frost bite: appearance of superficial vesiculation surrounded by edema leads
to very cold extremities.
3) Third degree frost bite: hemorrhagic vesicles due to serious microvasculature injury which
further leads to cyanosis.
4) Fourth degree frost bite: damage in sub cuticular, muscular and osseous tissue.

SYMPTOMS

The injured area is white or mottled blue white, waxy and firm to the touch. There is tingling and
redness followed by pallor and numbness of the affected area .There are three degrees: transitory
hyperemia following numbness, formation of vesicles and gangrene. The affected area is
insensitive to touch.

DIAGNOSIS

 Angiography and MRI: To assess the potency of large vessels.

 Ultrasonography and thermography: To evaluate perfusion after rewarming.

MANAGEMENT OF FROST BITE

 Before thawing
Remove the client from cold environment. Stabilize core temperature and treat hypothermia.
Protect the frozen part and do not apply friction or massage.
 During thawing

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Provide parental analgesia e.g. ketorolac .Immerse part in 37- 40c circulating water containing an
antiseptic soap for10 45 minutes. Encourage patient to gently move the part. Provide ibuprofen
40mg PO.
 After thawing
Gently dry and protect the part and elevate it. Apply pledges between toes; if macerated. If clear
vesicles are intact aspirate the fluid or the fluid will reabsorb in days; if broken then debride and
dress with antibiotic.

RESEARCH ABSTRACT

1. Effect of controlled room temperature on oral and axillary

body temperature among healthy young people
Prabhjot Saini, Sandeep Kaur, Bindu K, Jasbir Kaur Nursing and Midwifery Research
Journal, Vol-10, No.4, October 2014 166 Keywords Healthy young people,

Oral temperature, Axillary body temperature, Controlled room temperature. Introduction The
health status of a person is indicated by vital signs. These are temperature, pulse, respiration and
blood pressure falling within a certain range. A change in vital signs might indicate a change 1 in
health. Temperature is a physical property of matter that quantitatively expresses common notions
of hot and cold. It is the measurement of body heat and is balance Correspondence at Prabhjot
Saini Associate Professor DMCH College of Nursing, Ludhiana Abstract: Temperature is a
physical property of matter that quantitatively expresses common notions of hot and cold. It is the
measurement of body heat and is balance between heat produced and heat lost from the body.
There are individual variations of the temperature as well as normal changes occurring during the
day, and with the external environment. The purpose of this study was to assess the effect of
controlled room temperature on oral and axillary body temperature among healthy young people.
Seventy six B.Sc. Nursing students of DMCH College of Nursing, Ludhiana were selected by
simple random sampling technique (lottery method) as per inclusion and exclusion criteria. The
study subjects were exposed to normal room temperature (27°C) for 30 minutes and three

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successive oral and axillary body temperature readings were recorded at 15 minutes interval by
digital thermometer. The study subjects were then subjected to controlled AC room temperature
(20°C and 30°C) for 30 minutes and the procedure of recording three successive oral and axillary
body temperature readings at 15 minutes interval was followed. The study findings revealed that
there was significant mean difference of 1°F between oral and axillary body temperature of a
healthy person at room temperature of 27°C (p < 0.001) as well as mean difference of 0.9°F
between oral and axillary body temperature at controlled room temperature of 20°C and 30°C (p
< 0.001). It was concluded that there was significant difference in both oral and axillary body
temperature 27°C, 20°C to 30°C room temperature.

2. INDIVIDUAL DIFFERENCES IN NORMAL BODY TEMPERATURE:

LONGITUDINAL BIG DATA ANALYSIS OF PATIENT RECORDS

BMJ 2017; 359 doi: https://doi.org/10.1136/bmj.j5468 (Published 13 December 2017) Cite this
as: BMJ 2017;359:j5468

Authors

Ziad Obermeyer,( assistant professor), Jasmeet K Samra, (research analyst),Sendhil Mullainathan,

(professor)

Abstract

Objective; To estimate individual level body temperature and to correlate it with other measures
of physiology and health.

Design; Observational cohort study.

Setting; Outpatient clinics of a large academic hospital, 2009-14.

Participants; 35 488 patients who neither received a diagnosis for infections nor were prescribed
antibiotics, in whom temperature was expected to be within normal limits.

Main outcome measures Baseline temperatures at individual level, estimated using random effects
regression and controlling for ambient conditions at the time of measurement, body site, and time

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factors. Baseline temperatures were correlated with demographics, medical comorbidities, vital
signs, and subsequent one year mortality.

Results In a diverse cohort of 35 488 patients (mean age 52.9 years, 64% women, 41% non-white
race) with 243 506 temperature measurements, mean temperature was 36.6°C (95% range 35.7-
37.3°C, 99% range 35.3-37.7°C). Several demographic factors were linked to individual level
temperature, with older people the coolest (–0.021°C for every decade, P<0.001) and African-
American women the hottest (versus white men: 0.052°C, P<0.001). Several comorbidities were
linked to lower temperature (eg, hypothyroidism: –0.013°C, P=0.01) or higher temperature (eg,
cancer: 0.020, P<0.001), as were physiological measurements (eg, body mass index: 0.002 per
m/kg2, P<0.001). Overall, measured factors collectively explained only 8.2% of individual
temperature variation. Despite this, unexplained temperature variation was a significant predictor
of subsequent mortality: controlling for all measured factors, an increase of 0.149°C (1 SD of
individual temperature in the data) was linked to 8.4% higher one year mortality (P=0.014).

Conclusions Individuals’ baseline temperatures showed meaningful variation that was not due
solely to measurement error or environmental factors. Baseline temperatures correlated with
demographics, comorbid conditions, and physiology, but these factors explained only a small part
of individual temperature variation. Unexplained variation in baseline temperature, however,
strongly predicted mortality.

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