基礎(chǔ)護(hù)理學(xué)：第八章生命體征的觀察與護(hù)理-體溫

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第八章

生命體征的觀察與護(hù)理

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體溫（T）脈搏（P）呼吸（R）血壓（Bp）是生命維持的基本征候，是機體內(nèi)在活動的客觀反映，是衡量機體狀況的指標(biāo)，合稱為生命體征。生

命

體

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第

一

節(jié)

體溫的觀察與護(hù)理CompanyLogoHotTipHowdoIincorporatemylogotoaslidethatwillapplytoalltheotherslides?

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教學(xué)目標(biāo)：1、了解正常體溫的生理性變化2、掌握異常體溫的觀察及護(hù)理3、掌握體溫的測量方法CompanyLogoHotTipHowdoIincorporatemylogotoaslidethatwillapplytoalltheotherslides?

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一、什么是體溫？二、體溫是怎樣產(chǎn)生的？三、體溫的正常值是多少？四、哪些因素可能引起體溫的變化？？CompanyLogoHotTipHowdoIincorporatemylogotoaslidethatwillapplytoalltheotherslides?

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體表溫度(shelltemperature)

體核溫度(coretemperature)體溫機體深部的平均溫度CompanyLogoHotTipHowdoIincorporatemylogotoaslidethatwillapplytoalltheotherslides?

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體熱-維持體溫三磷酸腺苷-機體利用糖、脂肪、蛋白質(zhì)1、溫度的產(chǎn)生CompanyLogoHotTipHowdoIincorporatemylogotoaslidethatwillapplytoalltheotherslides?

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2、熱的產(chǎn)生：內(nèi)臟、肌肉進(jìn)食、交感神經(jīng)興奮、環(huán)境溫度增加禁食、肌肉活動減少、抵抗力下降產(chǎn)熱增加產(chǎn)熱減少CompanyLogo皮膚

（70%）呼吸（29%）排泄散熱器官CompanyLogoHotTipHowdoIincorporatemylogotoaslidethatwillapplytoalltheotherslides?

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散熱輻射蒸發(fā)對流傳導(dǎo)散熱散熱方式CompanyLogoHotTipHowdoIincorporatemylogotoaslidethatwillapplytoalltheotherslides?

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行為性調(diào)節(jié)生理性調(diào)節(jié)體溫的調(diào)節(jié)CompanyLogoHotTipHowdoIincorporatemylogotoaslidethatwillapplytoalltheotherslides?

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下丘腦體溫調(diào)節(jié)樞，控制產(chǎn)熱和散熱效應(yīng)器活動，將體溫維持在一個調(diào)定點生理性調(diào)節(jié)3、體溫的調(diào)節(jié)CompanyLogoHotTipHowdoIincorporatemylogotoaslidethatwillapplytoalltheotherslides?

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根據(jù)環(huán)境溫度與個人對冷熱的感覺進(jìn)行調(diào)節(jié)行為性調(diào)節(jié)2、體溫的調(diào)節(jié)CompanyLogoHotTipHowdoIincorporatemylogotoaslidethatwillapplytoalltheotherslides?

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溫度：℃（攝氏溫度）℉（華氏溫度）℃與℉的換算公式：℃=(℉-32)×5/9℉=℃×9/5+32正常體溫（二）CompanyLogoHotTipHowdoIincorporatemylogotoaslidethatwillapplytoalltheotherslides?

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成人體溫平均值及正常范圍部位平均溫度正常范圍

腋溫36.5℃36.0-37.0℃口溫37.0℃

36.3-37.2℃

直腸

37.5℃36.5-37.7℃CompanyLogoHotTipHowdoIincorporatemylogotoaslidethatwillapplytoalltheotherslides?

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其他年齡性別晝夜因素藥物影響（三）體溫生理性變化CompanyLogoHotTipHowdoIincorporatemylogotoaslidethatwillapplytoalltheotherslides?

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二、異常體溫的觀察和護(hù)理體溫過高-發(fā)熱

機體在致熱源作用下，體溫調(diào)節(jié)中樞的調(diào)定點上移而引起調(diào)節(jié)性體溫升高，當(dāng)體溫上升超過正常值的0.5℃或一晝夜體溫波動在1℃以上時，稱為發(fā)熱。CompanyLogoHotTipHowdoIincorporatemylogotoaslidethatwillapplytoalltheotherslides?

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生物性病原，如細(xì)菌、病毒、立克次體、原蟲、寄生蟲等感染感染性體溫調(diào)節(jié)中樞功能紊亂、吸收熱、變態(tài)反應(yīng)性發(fā)熱、內(nèi)分泌與代謝障礙非感染性1、體溫過高的原因CompanyLogoHotTipHowdoIincorporatemylogotoaslidethatwillapplytoalltheotherslides?

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2、臨床分度：以口腔溫度為例：人體最高的耐受溫度為40.6~41.4℃，直腸溫度持續(xù)升高超過41℃，可引起永久性的腦損傷，高達(dá)43℃很少存活。部位攝氏度

華氏度低熱

37.3-38.0

99.1-100.4中等熱 38.1-39.0

100.6-102.2高熱 39.1-41.0

102.4-105.8超高熱

≥41

≥105.8CompanyLogoHotTipHowdoIincorporatemylogotoaslidethatwillapplytoalltheotherslides?

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3、發(fā)熱的臨床過程：體溫上升期高熱持續(xù)期體溫下降期漸升驟升漸降驟降產(chǎn)熱散熱寒戰(zhàn)、疲乏皮膚血管收縮：皮膚蒼白、干燥無汗、畏寒。心率加快，呼吸加深加快、頭痛食欲不振，易驚厥皮膚血管舒張：皮膚潮紅，灼熱，伴有水分丟失：口干、尿少。皮膚血管舒張：大量出汗、皮膚潮濕，有脫水情況。CompanyLogoHotTipHowdoIincorporatemylogotoaslidethatwillapplytoalltheotherslides?

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4.

熱型：各種體溫曲線的形狀稱為熱型

稽留熱

弛張熱

間歇熱

不規(guī)則熱CompanyLogoHotTipHowdoIincorporatemylogotoaslidethatwillapplytoalltheotherslides?

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稽留熱體溫持續(xù)在39-40℃左右，達(dá)數(shù)日或數(shù)周，24h波動范圍不超過1℃。多見于肺炎、傷寒等CompanyLogoHotTipHowdoIincorporatemylogotoaslidethatwillapplytoalltheotherslides?

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弛張熱：體溫持續(xù)高于正常，24h體溫波動在1℃以上，多見于敗血癥、風(fēng)濕熱、化膿性疾病等CompanyLogoHotTipHowdoIincorporatemylogotoaslidethatwillapplytoalltheotherslides?

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間歇熱：高熱與正常體溫交替有規(guī)律地反復(fù)出現(xiàn)，多見于瘧疾等CompanyLogoHotTipHowdoIincorporatemylogotoaslidethatwillapplytoalltheotherslides?

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不規(guī)則熱：

體溫在24小時中變化不規(guī)則，持續(xù)時間不定。多見于流行性感冒、腫瘤性發(fā)熱

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5、高熱患者的護(hù)理1降溫2密切觀察病情3補充營養(yǎng)和水分4休息5口腔護(hù)理6皮膚護(hù)理7安全護(hù)理8心理護(hù)理CompanyLogoHotTipHowdoIincorporatemylogotoaslidethatwillapplytoalltheotherslides?

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（二）體

溫

過

低由于各種原因引起的產(chǎn)熱減少或散熱增多導(dǎo)致體溫低于正常范圍。體溫低于35℃-體溫不升CompanyLogoHotTipHowdoIincorporatemylogotoaslidethatwillapplytoalltheotherslides?

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程度

℃

。F輕度 32-35

89.6-95中度 30-32

86-89.6重度 ＜30

＜86致死溫度 23-25

73.4-771.

體溫過低的分級臨床表現(xiàn)：皮膚蒼白、四肢冰冷、呼吸緩慢、血壓降低、感覺遲鈍甚至昏迷CompanyLogoHotTipHowdoIincorporatemylogotoaslidethatwillapplytoalltheotherslides?

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護(hù)理學(xué)基本理論隨時做好搶救準(zhǔn)備工作5.密切觀察生命體征

2.加強營養(yǎng)使產(chǎn)熱增加3.保暖1.病因護(hù)理4.2、體

溫

過

低的護(hù)理CompanyLogoHotTipHowdoIincorporatemylogotoaslidethatwillapplytoalltheotherslides?

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三、體溫計的種類與構(gòu)造：水銀體溫計、電子體溫計、可棄式體溫計、感溫膠片CompanyLogoHotTipHowdoIincorporatemylogotoaslidethatwillapplytoalltheotherslides?

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肛表腋表口表水銀貯槽真空毛細(xì)管凹陷處

1.水

銀

體溫計刻度是35~42℃,每1℃之間分成10小格，每小格為

0.1℃，在37℃刻度處則以紅色標(biāo)記以示醒目。CompanyLogoHotTipHowdoIincorporatemylogotoaslidethatwillapplytoalltheotherslides?

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采用電子感溫探頭來測量體溫，測得的溫度直接由數(shù)字顯示，直觀讀數(shù)，測溫準(zhǔn)確，靈敏度高。2.電子體溫計CompanyLogoHotTipHowdoIincorporatemylogotoaslidethatwillapplytoalltheotherslides?

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4.感溫膠片

5.其他紅外線體溫計奶嘴式電子體溫計CompanyLogoHotTipHowdoIincorporatemylogotoaslidethatwillapplytoalltheotherslides?

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3.可棄式體溫計測溫時將測溫表置于患者舌下1min取出后當(dāng)顏色點從白色變成藍(lán)色時，最后的藍(lán)點位置即為所測溫度。CompanyLogoHotTipHowdoIincorporatemylogotoaslidethatwillapplytoalltheotherslides?

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四、測體溫的方法【目的】判斷體溫有無異常。動態(tài)監(jiān)測體溫變化，分析熱型。協(xié)助診斷，為預(yù)防、治療、康復(fù)、護(hù)理提供依據(jù)。CompanyLogoHotTipHowdoIincorporatemylogotoaslidethatwillapplytoalltheotherslides?

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【評估】病人年齡、性別、病情、意識、治療等情況。影響體溫測量的因素。病人心理狀況，合作程度。CompanyLogoHotTipHowdoIincorporatemylogotoaslidethatwillapplytoalltheotherslides?

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【計劃】1.操作者的準(zhǔn)備：2.用物準(zhǔn)備：3.病人準(zhǔn)備：4.環(huán)境準(zhǔn)備CompanyLogoHotTipHowdoIincorporatemylogotoaslidethatwillapplytoalltheotherslides?

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【實施】1.操作步驟（1）備齊用物攜至床旁，核對解釋（2）選擇合適的測量方法測量腋溫測量口溫測量肛溫CompanyLogoHotTipHowdoIincorporatemylogotoaslidethatwillapplytoalltheotherslides?

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CompanyLogoHotTipHowdoIincorporatemylogotoaslidethatwillapplytoalltheotherslides?

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測口溫測肛溫測腋溫特點最方便，但易引起交叉感染準(zhǔn)確，但不方便安全易接受，但準(zhǔn)確性不高部位舌下熱窩肛門內(nèi)3～4cm腋窩時間3min3min10min禁忌嬰幼兒、昏迷、精神異常、口鼻疾病手術(shù)、張口呼吸腹瀉、直腸或肛門手術(shù)、心肌梗死患者腋下有創(chuàng)傷、手術(shù)及腋下出汗較多、肩關(guān)節(jié)手術(shù)、消瘦體溫的測量CompanyLogoHotTipHowdoIincorporatemylogotoaslidethatwillapplytoalltheotherslides?

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