Measurement of Cardinal Symptoms

MEASUREMENT OF CARDINAL SYMPTOMS (TTV) Types of Cardinal Symptoms 1. TEMPERATURE / BODY TEMPERATURE 1.1 Definition It is defined as the degree of heat in the body.Body temperature is an indication of health or illness which is described by the degree of heat produced by the body.The temperature for cell metabolism is set at 370C. Normal individual 36-370C.Skin temperature is not the same as internal organ temperature. 1.2 Central Temperature The deepest body temperature is determined by 3 factors, namely: a. Own heat production. b. Environmental isolation. c. Blood flow speed. 1.3 Heat Production 1.3.1 Food Metabolism And Activity Heat is produced through food metabolism. Metabolic speed - BMR. Adding activity such as exercise will increase BMR and increase heat production. 1.3.2 Thyroxine Production Increases Cold - Hypothalamus - Thyrotropine - Ex. Thyroid - Thiroxine - Increased metabolic rate of body cells Increased heat production. 1.4 Heat Release RADIATION Transfer of heat from one surface to another without contact. CONDUCTION Transfer of high temperature heat to low temperature through contact. CONVECTION The movement of hot air from near the body is removed by replacing it with cold air. EVAPORATION Release of heat by evaporation, for example: respiratory tract, sweat, amniotic fluid. 1.5 Balance of Heat Production and Heat Released The main organs of temperature regulation: HYPOTHALAMUS. 1.5.1 ANTERIOR HYPOTHALAMUS Warm body/fever - Anterior hypothalamus - Dilatation of capillaries on the surface of the body - Lots of blood going to the capillaries on the surface of the body - Lots of sweat. 1.5.2 POSTERIOR HYPOTHALAMUS Cold body - Cold blood - Posterior hypothalamus - Vasoconstriction body surface capillaries - Little blood to the body surface - No sweat secretion. 1.6 Factors Affecting Temperature AGE: Temperature changes with age. TIME OF DAY CHANGES: Temperature changes 2-3 times0C - High at 20.00-23.00, Low at 04.00-06.00 WIB. SEX: Ovulation - temperature increases by 0.3 – 0.50C - Increased BMR. EMOTIONS: Emotions rise - temperature rises - and vice versa. ACTIVITY TRAINING: Muscular activity - temperature will increase. 1.7 Measuring Body Temperature - There are 3 methods, namely: oral, rectal and axillary. - Rectal temperature 0.40C is higher than oral. - Axillary temperature 0.60C below oral temperature. - NORMAL orally 36.4 - 37.20C, average 370C. - NORMAL per rectum 37 – 37.80C, average 37.50C. - NORMAL per axilla 35.8 - 370C, average 36.70C 1.8 Physical Assessment of Signs of Fever Beginning of Signs of an Attack 1. There are complaints of cold. 2. Shivering or muscle contractions. 3. An increase in cardiac rate is reflected by an increase in pulse. 4. Cold, pale skin due to peripheral vasoconstriction. 5. Contraction of the villous arrectors is indicated by standing hair. 6. Reduced sweating. 7. In children: very high temperature - convulsions. Signs During a Fever 1. Weakness and pain in parts of the body. 2. Headache, irritability, confusion, restlessness due to CNS irritation. 3. Anorexia, nausea and vomiting. 4. Client complains of hot & cold. 5. The skin feels hot to the touch. 6. Peripheral vasodilation, red face. 7. Dehydration of mucous membranes. 8. Long fever - loss of weight. Termination Sign 1. Diaphoresis. 2. Temperature drops. 3. Possible dehydration. Intervention 1. Shivering - Give a blanket. 2. Diaphoresis - Improve room circulation. 3. Prevent dehydration - Increase fluid intake. 4. Record intake & output. 5. Monitor TTV.