1. Assess body temperature for changes when exposed to pyrogens (endogenous or exogenous substances that cause fever) or to extreme hot or cold external environments because such environments may indicate the cause of an infection.
2. Assess the client for the most appropriate site to check his temperature in order to obtain an accurate reading.
3. Confirm that the client has not consumed hot or cold food or beverage nor smoked for 15 to 30 minutes before the measurement because these activities may alter the oral reading.
4. Assess for mouth breathing and tachypnea because both can cause an inaccurate oral readin5. Assess for oral herpetic lesions because herpes viruses are extremely contagious and require implementation
of Standard Precautions of the Centers for Disease Control and Prevention. Clients with herpetic lesions should have their own glass thermometer to prevent transmission to others.
5. Assess for oral herpetic lesions because herpes viruses are extremely contagious and require implementation of Standard Precautions of the Centers for Disease Control and Prevention. Clients with herpetic lesions should have their own glass thermometer to prevent transmission to others. Four types of thermometers are commonly in used : mercury-in-glass, electronic, tympanic, and disposable
. The most inexpensive, the mercury thermometer , consists of a glass tube at one end with a mercury-filled bulb at the other. Exposure of the bulb to heat causes the mercury to expand and rise in the enclosed tube. These thermometers may be calibrated in either Fahrenheit or Celsius and may be used measure oral, axillary, or rectal temperature.
The tympanic thermometer is very popular in all clinical settings. Taking the client's temperature with this device requires less than 5 seconds and is very easy. The device works when the temperature-sensitive probe, covered with a disposable sheath, is inserted into the client's ear; the probe measures the temperature of the blood flowing near the tympanic membrane. This provides an accurate measurement of core body temperature. Like the electronic thermometer, tympanic thermometers may be programmed to measure temperature in either Fahrenheit or Celsius.
The electronic thermometer consists of a battery-powered display unit, a thin wire cord, and a remperature-sensitive probe. The probe must be covered with a disposable sheath before use. The probes are color coded (blue or white for oral and red for rectal) for proper use. The advantage of the electronic thermometer over the mercury thermometer is speed The electronic thermometer calculates and displays the temperature on a digital screen within 15 to 30 seconds. Many electronic thermometers have a switch on the unit to permit the measurement of temperature in either Fahrenheit or Celsius.
This device requires less than 5 seconds and is very easy. The device works when the temperature-sensitive probe, covered with a disposable sheath, is inserted into the client's ear; the probe measures the temperature of the blood flowing near the tympanic membrane. This provides an accurate measurement of core body temperature. Like the electronic thermometer, tympanic thermometers may be programmed to measure temperature in either Fahrenheit or Celsius.
Disposable, single-use thermometer strips are thin strips of plastic with chemically impregnated paper. They are frequently used for temperature evaluation in children. Chemical dots on the strip change color, representing the highest temperature. The strips are configured so that the examiner can identify the highest colored dot and correlate that with the temperature reading.
BLOOD PRESSURE MEASUREMENT
Purpose: To measure the arterial blood pressure.
Blood pressure measurement requires three pieces of equipment: the sphygmomanometer, the cuff, and the stethoscope. Together they may be used to measure blood pressure.
There are three types of sphygmomanometers. Two types, aneroid and mercury, attach to a blood pressure cuff bladder and require manual cuff inflation. A stethoscope must be used in conjunction with these devices to actually assess the blood pressure. The third type is electronic and assesses the blood pressure without the use of a stethoscope.
1. An aneroid sphygmomanometer is a glass-enclosed circular gauge containing a needle that registers in millimeter calibrations. The gauge is attached to the blood pressure cuff bladder . This gauge needs periodic calibration to ensure accurate measurement.
2. A mercury sphygmomanometer is an upright manometer tube containing mercury. The pressure created in the bladder of the cuff moves the column of mercury up against the force of gravity. Millimeter calibrations mark the height of the mercury column .
electronic sphygmomanometer operates by
sensing circulating blood flow vibrations and converting these vibrations into
electric impulses. These impulses in turn are translated to a digital readout.
The readout generally consists of blood pressure, mean arterial pressure, and
pulse rate. The device is not capable of determining quality of the pulse, such
as rhythm or intensity. The device may be programmed to repeat the measurements
on a scheduled periodic basis and
to alarm if the measurements are outside of the precalculated limits. This is especially useful for clients requiring frequent blood pressure monitoring. No stethoscope is required when the electronic device is used .
Blood pressure cuffs are either disposable and made of a latex substance or reusable and made of a textured fabric . The type of cuff used depends on the clinical situation. All cuffs have a bladder that inflates during blood pressure measurement and a cuff that secures the bladder on the arm. When selecting a blood pressure cuff it is important to select the correct size for the client. Ideally the bladder of the cuff should be 40%, or one third to one half, of the circumference of the limb. On most cuffs, range lines are indicated to assess proper size. When a correctly sized cuff is applied, the cuff edge should lie between the range lines . Adult cuffs come in two widths. The standard cuff (4 2/3 to 5 1/6 inches) is adequate for most adults. If the adult is large or obese, an oversized cuff (6 to 6 1/3 inches) may be used. If the adult has an extremely obese arm, a thigh cuff can be used. For children, there are many different sizes of cuffs. The width of the cuff should cover two thirds of the child's or infant's upper arm. For both children and adults, if the cuff is too wide, it will underestimate the blood pressure; if it is too narrow, it will overestimate the blood pressure.