NUR141#2

• Infection
• Shivering
• Stress
• Exercise

Generated in core of body and circulated to peripherial surface by circulating blood

Hypothalamus

• conserve heat (goosebumps, decreases surface area)
• Increase heat loss (sweat)
• produce heat (shiver)

• – Rectum
• - Tympanic Membrane
• – Esophagus
• – Pulmonary Artery
• – Urinary Bladder

• – Oral
• – Axillae
• – Skin

• Temperature Range : 36 – 38 degrees C or 96.8 – 100.4 F
• Average oral/tympanic:37 C (98.6 F)
• Average rectal: 37.5 C (99.5 F)
• Average axillary: 36.5 C (97.7 F)

• Age and Sex- old and babies,females fluctuate because of hormones,
• Exercise-increases need for energy in cells
• Stress
• Circadian Rhythms

• Hyperthermia (high temp because of environment)
• Hypothermia (severely low temp because of environment)

• Hypothermia-below 35 C or 95 F
• Afebrile-normal body temp
• Pyrexia-with fever 38 C or 100.4 F
• Hyperpyrexia- Above 41 C or 105.8 F

• Remittent- fluctuating above normal but never comes down to normal
• Constant-constant temp
• Relapsing-returns to normal for at least 24 hrs then recurs
• Intermittent-alternating between febrile and afebrile

Electronic, Tympanic, Glass, Disposable, Temperature-Sensitive (patches or tape), Automated Monitoring Devices, Temporal Artery Thermometers

Exercise, smoking, chewing gum, infection, drinking

• – MONITOR!
• – Administer antipyretic meds (Dr’s prescription)
• – Limit physical activity
• – Reduce external covering
• – Keep clothing and bed linen dry
• – Encourage Intake of Oral Fluids/Food
• – Encourage or provide Oral care
• – Control environmental temperature
• - (do not induce shivering)

• “Normal” (60-100beats/min)
• Tachycardia_ (>100beats/min)
• Bradycardia (<60beats/min)

• – 0 = Absent
• - 1+ = Thready
• – 2+ = Weak
• – 3+ = Normal
• – 4+ = Bounding

Irregular = Dysrhythmia

• 1.Radial
• 2. Temporal-side of head
• 3. Carotid-neck
• 4. Brachial-elbow
• 5. Radial-wrist
• 6. Femoral-groin
• 7. Popliteal-behind knees, harder to find palpitations
• 8. Posterior tibial-inner aspect of ankle
• 9. Dorsalis Pedis (Pedal)-top of foot

• Need stethoscope to listen
• 5th intercostal space/left mid-clavicular, off apex of heart

(lub-dub) opening and closing of valves S1 (lub-opening of tricuspid) S2 (dub-closed tricuspid, open bicuspid)

Pulse deficit (Apical rate – radial rate)

• Eupnea 12-20 breaths/min
• Tachypnea > 24 breaths/min
• Bradypnea < 10 breaths/min

• Hyperventilation-increased rate of breathing, deeply
• Hypoventilation-decreased rate and decreased depth
• Cheyne-Stokes- deep rapid breathing with periods of apnea (drug over doses, act of dying)
• Biot’s- same as Cheyne Stokes only a little more irregular

95-100%

30

Coordinated functioning of the muscular skeletal and nervous systems

• Erect posture
• Use the biggest and strongest muscles
• Use internal girdle and long midriff
• Work as closely as possible to the object
• Use the weight of the body as a force
• Slide, roll, push or pull rather than lift
• Spread -feet apart, flex knees
• Face in same direction of where you are moving
• Work on level surface;
• move bed flat then move patient, move bed back into place.

50-51 lbs.

• Self Image
• Healthy functioning of each body system.

• Physiological-build up of secretions in lung, skin breakdown,
• Psychological-depression, decreased appetite, muscle atrophy, urinary (increased calcium from immobile bones)
• Developmental

• Paresis- impaired or weak muscle strength
• Hemiparesis-impaired or weak muscle strength on one side
• Paralysis-inability to move
• Hemiplegia-inability to move one side of the body
• Paraplegia- inability to move lower extremities
• Quadriplegia-inability to move lower and top extremeties

• Ball and socket-shoulder and hip, flexion-extension, abduction adduction, rotation
• Condyloid joint-wrist- flexion-extension, abduction, adduction
• Gliding joint- carpal bones of wrist and tarsal bones of feet
• Hinge joint- only flexion –extension e.g. elbow knee and ankle
• Saddle joint-side to side, back and forth (thumb)

• active –by patient
• passive- nurse does, no increase in muscle tone

Active-Assisted- both nurse and patient

• follow proper body mechanics
• provide privacy and warmth
• make eye contact with patient
• ROM to the point of resistance but not pain

• flexion/lateral flexion
• extension/hyperextension
• rotation/circumduction
• internal/external rotation
• abduction/adduction
• supination/pronation
• opposition of thumb to fingers
• dorsiflexion/plantar flexion
• inversion/eversion

Pillows, mattresses, adjustable beds, trapeze bars, hand rolls, trochanter rolls, hand-wrist splints, high top sneakers;

• Low or Semi-Fowler’s-30 degree
• Fowler’s-45-60 degree
• High Fowler’s-90 degree, breathing problems or dysnea, aspiration precautions
• Protective Supine-laying on back, pillow head, calves, arm
• Protective Sidelying- pillow behind back, between knees,one in front
• Protective Prone- under stomach, shins,
• Protective Sims- not on back not on front, knee up and over a pillow

• Dangling-seated on the side of the bed with legs dangling, orthostatic hypertension, prevents fainting, gives body a chance to adjust blood pressure
• nonskid- footwear/Safe environment
• Gait belt-goes around middle of patient
• Walk on affected/weak side slightly behind patient

Crutches, cane, walker

• the walker should extend from the floor to the patient’s hipjoint
• elbows should be flexed 30’
• Proper use
• – For stability
• – Affected side

• elbows should be flexed 30’
• Proper use: hold on opposite side of affected side

• support of body weight should come primarily on the hands and arms while using the crutchesnot in the axillary area where pressure can damage nerves
• Need to be properly fitted