ALTERED BODY TEMPERATURE

Introduction

A person’s body temperature is a sensitive indicator of the presence of physiological changes

occurring in the body. There changes can be result of the disease process, a traumatic injury or a therapeutic intervention.
Because of a sensitive nature of a person’s body temperature monitoring the person’s temperature is one
of the common, continue procedure performed on any persons entering health care system.

Meaning of altered body temperature

Abnormal body temperature can be slight such as within low grade fever, cold or life threatening as in severe case of
hypothermia or hyperthermia. Knowledge of factors that can alter normal body temperature is important for the nurse in
finding and testing alteration in thermoregulation.

DEFINITIONS

Temperature: The degree of sensible heat or cold, expressed in terms of a specific scale.

Fever : (also known as pyrexia is a common medical sign characterized by an elevation of

temperature above the normal range of 36.5–37.5 °C (98–100 °F) due to an increase in the body
temperature regulatory set-point.

Types of body temperatures.

Core temperature

The body's core temperature is the temperature of the inner organs like the liver, kidney and heart.
It is more tightly fluctuates around a set point than does the temperature within peripheral.

Shell temperature

It refers to body temperature at the surface that is of the skin and subcutaneous tissue.

REGULATION OF BODY TEMPERATURE

The maintenance of body temperature or thermoregulation is a dynamic system: if heat loss is greater
than heat production then the core temperature drops. Likewise if heat loss is less than heat production then the
core temperature rises. A drop or rise in core temperature is equally dangerous, the situation is ideal when heat
loss and heat production occur at the same rate2. This paper looks at the basic mechanisms by which the body
generates and loses heat, and then discusses the control mechanisms available to the body when remedial action
must be taken to control temperature.
Basic Heat Production

The basal metabolism is the minimal amount of energy the body uses in order to maintain vital
processes3. Generally this expenditure of energy is expressed in terms of heat production per unit of body
surface per day or the Basal Metabolic Rate (BMR). BMR measures the rate at which a quiet, resting, fasting
body breaks down nutrients to liberate energy.

The energy used to produce heat in the body is measured in calories. A calorie is the amount of energy
required to raise the temperature of water from 14 to 15° C. The average man has a BMR of 1,700 calories (7.1
Kilojoules).

An increase in the metabolic rate increases the production of heat. Factors that affect the metabolic rate include:

Exercise – raises the metabolic rate as much as fifteen times above the resting level. In trained athletes this can
be as much as twenty times.

Hormones – the Thyroid hormones (thyroxine and triiodothyromine) are main regulators of BMR. Testosterone
and Human Growth Hormone (HGH) also raise BMR.

Nervous System – under stress, the sympathetic nervous system causes the release of norepinephrine. The SNS
also stimulates the adrenal medulla to release epinephrine and norepinephrine under stress – both hormones
increase the BMR.

Body Temperature – the higher the body temperature the higher the MR. Each 1° C increase, raises the rate of
biochemical reactions by 10%. Thus the temperature increases even further.

Ingestion of Food – the MR increases by as much as 10 – 20% when ingesting food. The rate is higher for
proteins and less for carbohydrates and fats.

Age – the MR of a child, with respect to size, is two times that of an elderly person. The high rates of reactions
are related to growth.

Others – gender (lower MR in females except during pregnancy and lactation), climate (lower MR in the
tropics), sleep (lower MR), and in cases of malnutrition (lower MR).

Basic Heat Loss

Having examined some of the basic heat-generating mechanisms of the body we now look at
some of the heat-loss mechanisms. These are defined using simple terms borrowed from thermodynamics.
Radiation – heat loss via this mechanism occurs through the emission of InfraRed radiation.

Evaporation – is the conversion of a liquid to a vapour. Every gram of water removed from the surface of the
skin removes a great deal of heat from the body (0.58 Kcal) per gram of water. Under normal rest conditions
22% of heat loss occurs through evaporation.

Conduction – is the transfer of heat through physical contact it contributes to about 3% of heat loss.

Convection – is the transfer of heat by movement of liquid or gas between areas of different temperature. Under
normal conditions, at rest, approximately 15% of body heat is lost to the air by convection and conduction.

It is seen that about 40% of heat loss is due to Evaporation, Conduction and Convection, whilst under rest
conditions at 21° C 60% is due to radiation

The Metabolic Thermostat

Having defined the basic mechanisms for heat gain and loss we can now look at what happens when
there is an imbalance between the two.

The hypothalamus is generally recognized as containing the body’s thermostat. It contains a group of
neurons in the anterior portion called the preoptic area. Feedback to this area of the brain is provided by
temperature receptors throughout the body. As temperature rises neurons in the preoptic area increase their
firing rate, as temperature drops the firing rate slows.

Nerve impulses from the preoptic area interact with the heat-losing and heat-promoting centers in the
hypothalamus. The respective centers set in motion the physiological responses to either raise or lower body
temperature when stimulated.

Heat Promotion

If the core temperature drops a negative feedback system comes into play promoting temperature
increase. The thermo receptors in the skin and hypothalamus send signals to the preoptic heat-promoting centre.
In response impulses from the hypothalamus cause the secretion of thyrotropin-releasing hormone (TRH) which
activates several effectors. Most responses are related to sympathetic functions, and these include:

Vasoconstriction – The SNS is stimulated to constrict blood vessels at the periphery, and
warm blood is moved deeper within the body preventing heat loss.

Sympathetic Stimulation – The heat-promoting Centre stimulates the release of epinephrine and
norepinephrine from the adrenal medulla. This increases cellular
metabolism thus increasing heat production (chemical thermogenesis).

Skeletal Muscles – Muscle tone is increased inducing shivering (involuntary thermogenesis).

Thyroid Hormones – An increased production of thyroid hormone increases the MR. Clothing
can be added to aid the heating process.
Heat Loss

If the body temperature rises then nerve impulses are sent to the preoptic heat-losing centre, and the following,
mostly parasympathetic, control mechanisms are induced in the body:

Vasodilatation – blood vessels in the skin vaso-dilate, the skin warms and excess heat goes
into the environment.

Metabolic rate – the metabolic rate is lowered thus lowering the production of heat by the
body.

Perspiration – the high blood temperature stimulates the hypothalamus to activate the
stimulation of sweat glands to produce sweat. The skin is cooled through
evaporation. Clothing can be removed to aid the cooling process.

Causes of altered thermoregulation mechanism

 Extremes in environmental temperature

 Infection
 Strenuous exercise
 Hormones
 Stress
 Exposure to may warm temperature for an extended period

Altered thermoregulation mechanisms

Any condition that influences with normal mechanism of thermoregulation can contribute to altered
body temperature

Nervous system impairment

Tumors or trauma to the brain or spinal cord interfere with nervous system control of
temperature regulation. If the spinal cord is several in the neck above t h e sympathetic outflow from the cord, as
in the quadriplegia patient, the hypothalamus can no longer control the degree of vasoconstriction or
sweating anywhere in the body. Local temperature reflexes originating in the
skin, spinal cord and intra-abdominal receptors can still function full their effectiveness is limited.

Circulatory impairment

Circulatory problems can impede normal temperature regulation. Patient acts peripheral vascular
diseases or neuropathy (decreased blood flow to the nervous) is notable to construct or dilate blood vessels to control heat
loss from the body. Treatment with medication such as antihypertensive agent can also interfere with
vasoconstriction as a regulatory mechanism.

Skin impairment

Damage to large areas of skin can impede the body; ability to regulate body temperature. Severe
burned case carries hyper metabolic state that increases body temperature. In severely burned patient
above normal body temperature, severe brain can cause hyper metabolic state that increases the body
temperature. In severely burned patient above normal body temperature is often present for a few weeks until the core
temperature can be readjusted.

Endogenous pyrogens

Infection caused by bacteria, viruses, fungi and other micro element normal body
temperature. These agents cause the host to produce specific protein called endogenous pyrogen. Endogenous
pyrogen is released from immunologically active phagocyte cells. Some tumor cells are also capable of producing
endogenous pyrogen. Endogenous pyrogen are transported to the brain where they alter the feeling rely of the temperature
sensitive numerous located in the protégé area of the hypothalamus. As are the
but point is increased causing the thermoregulatory center to sense the enistemi of a lower than
derivedthem purulent. Thiscausethe thermoregulatorycentret o seems the extreme of a lower than desired temper
ature. This causes t h e thermoregulatory center to initiate heat conserving and heat producing mech
anism, such as shivering unit the core temperature reaches the new set point (Guyton, 1986).

Exercise

An increase the muscle activity cause increase metabolic rate and an increased in body heat production.
Exercise causes the body temperature to vary according to the strenuous of the activity. Very strenuous exercise
such as long distance running can cause the rectal temperature to 40 degree Celsius (104
degreeFahrenheit)inhealthpeople (Guton, 1986) if the person is already febrile the exercise is cause t h e
temperature to use even hyper.

Stress

Physical and emotional stress can cause the body temperature to rise because
of the hormonal and neural stimulator concurrent unit a state of stress usually such fluctuation in the body temperature
are minor

Altered nutrition

People who are severely nutritional deficit lack normal body fat total as an insulator agent heat
loss. Lack of appetite and inability to eat decrease heat produced through his metabolism of food.

FACTORS AFFECTING THE BODY TEMPERATURE.

Illness, Disease and Trauma

 Fever can be caused by infection or illness; this is the body's way of fighting the infection.
Certain diseases, such as arthritis, hyperthyroidism and leukemia may also cause elevated body
temperature.
 Alternatively, diabetes and hypothyroidism result in lowered body temperatures. Shock and
sepsis may also cause low body temperatures.
 According to WebMD, "severe trauma" such as heart attack and stroke may result in fever.

Exposure

Exposure to extreme heat or cold can change body temperature. Hot weather, especially with high
humidity, can result in heat exhaustion and even heat stroke, which elevates temperature to dangerously high
levels. Sunburn can also cause fever. Exposure to cold temperatures can result in hypothermia, or a body
temperature that is dangerously low.

Hormones

Female hormone levels also affect body temperature. When a woman is ovulating or menstruating, her
body temperature will fluctuate. Women trying to conceive use these changes in body temperature to determine
when they are most fertile.

Alcohol, Drugs and Medications

Alcohol and recreational drugs can also change body temperature. In addition, certain prescribed
medications will alter normal temperatures. Antibiotics elevate body temperature, while others, such as Tylenol,
reduce fever and help to regulate body temperature.

Time of Day

Body temperature is at its lowest point early in the day. As the day progresses, body temperature rises.

Assessing body temperature

The four most common rules for measuring body temperature are oral, rectal,
axially and the tympanic membrane. Each of the sites has advantages anddisadvantages. The body temperature is
usually measured orally. This method reflects changing body temperature more quickly than the rectal method.
If a client has been taking cold or hot food nurses should wait 30 minutes before taking the
temperature orally to ensure that the temperature of the month is not affected by the temperature of the mouth is
not affected by temperature of the food fluid or warm smoke.

Rectal temperature:

Rectal temperature reading are consider to be the most accurate in some agency taking temperature rectally is
contraindicated for client s with myocardial infarction. It is believed that missing thermometer can produce
vagul stimulation which in these can cause myocardial damage. However, not all authorities’ shares this relief.
Relief temperature is usually contraindicated for clients who is undergoing rectal surgery or have diarrhea or disease in rectum.

Axilla temperature:

Axilla is preferred site for measuring temperature in neuronbecause it is accessible and offers no possibility of
rectal perforation. However, some reach indication that the axillary method is in accurate when assesses a fine
and that rectal perforation during temperature measurement is relatively race.

Tympanic membrane

T ym p a n i c m e m b r a n e o r n e a r b y t i s s u e i n t h e e a r c a n a l i n another site for core body tempera

ture. Tympanic membrane temperature readingaverage 1:1 to 1:5 Fahrenheit higher than oral temperature
reading likes the sublingual oral site; the tympanic membrane has an abundant altered blood supply premier
from branches of the external carotid artery. Because temperature sensor applied directly to the tympanic membrane can be
uncomfortable and involve risk of membrane injury or perforation noninvasive infrared thermometers are now used.
TYPES OF THERMOMETER
 Mercury in glass thermometer
 Electronic thermometer
 Chemical disposal thermometer
 Temperature sensitive tape
 Infrared thermometer

Temperature scales
The body temperature is measured in degrees on two scales

Celsius, Fahrenheit Sometimes a nurse needs to convert a Celsius reading to Fahrenheit or vice versa. To
convert from Fahrenheit to Celsius detect 32 from the Fahrenheit reading and then multiple by the
fraction 5/9 that is C= (F-32)*5/9 (Fahrenheit) e.g. When the Fahrenheit reading is 100c= (100-32) * 5/9= (68) * 5/9 = 37.7 degree
Celsius To convert from Celsius to Fahrenheit F= (c*9/5) +32E,g when the Celsius reading is 40F= (40*9/50 + 32= (72) + 32=104

Safety precaution
The nurse is responsible for assessing the client accurately and also maintaining a safe environmental. Safety is a major
consideration when assessing temperature due to the disadvantages of various sites and equipment. Never forces
any type of thermometer into plane. If it does not entry easily is assess the site and co nsider using a
different location or type of thermometer Although the oral site in the most common it should not use if
the client cannot cooperate or there is a rise that they may file the thermometer. The rectal thermometer always
held in a place and never left unattended.

Manifestation of altered thermoregulation

A body temperature above the usual range is called hyperthermia, pyrexia a fever. A core body temperature below the lower limit of
normal is called hypothermia.

HYPERTHERMIA
A body temperature above the usual range is called hyperthermia or fever. A very high fever such as 41 degree
Celsius (105.8 degree Fahrenheit) is called hyperpyrexia.

Types of fever
 Intermittent fever
 Remittent fever
 Relapsing fever
 Constant fever

Intermittent fever

The body temperature alternate at regular interval between periods of fever and periods of
normal or subnormal temperature.
Remittent fever

A wide range of temperature fluctuation (more than 2 degree Celsius (36 degree Fahrenheit) ) occurs over
the 24 hours period all of which are above normal

Relapsing fever

In a short febrile period of a few days are interrupted with periods of 1 or 2 days of normal temperature

Constant fever

The body temperature fluctuates minimally but always remains above normal

Fever with rigors

Rigor is the shaking or excessive shivering that accompanies fever. Fever accompanied with rigors are
seen in conditions like malaria, kala azar, filariasis, urinary tract infections, inflammation of gall bladder,
septicemia, infective endocarditis or inflammation of the inner layer of the heart, abscesses and pneumonia.

Types of and signs of hyperthermia

According to the National Institute on Aging, hyperthermia in the elderly can be classified by the
following categories and signs and symptoms:

 Heat cramps are painful muscle spasms in the abdomen, arms, or legs following strenuous activity.
The skin is usually moist and cool and the pulse rate is normal or rapid. Body temperature remains
in the normal range. A low sodium level may cause heat cramps, but salt replacement should not
be considered without advice from a physician.

NOTE: Use of salt tablets to replace sodium is not recommended due to slow absorption and the
associated risk of: gastric irritation, vomiting and cerebral edema.

 Heat edema is swelling in the ankles and feet during periods of heat.
 Heat syncope is sudden unconsciousness experienced after exertion in the heat. It is caused by
hypotension secondary to cutaneous vasodilatation. The skin appears pale and sweaty but feels
moist and cool. The pulse may be weak, and the heart rate is usually rapid. Blood pressure is
usually less than 100 mmHg systolic. Body temperature may be normal.
 Heat exhaustion is a warning that the body is getting too hot. The person may be thirsty, giddy,
weak, uncoordinated, nauseous, and may be having a profound diaphoresis. The body temperature
is usually normal and the pulse is normal or rapid. The skin is cold and clammy. Although heat
exhaustion is often caused by water and sodium depletion, salt supplements should be taken only
with a physician's consent.
 Heat stroke is a life threatening condition. Persons with heat stroke have a very high mortality rate
so immediate medical attention is needed when symptoms first become evident.

Important signs of heat stroke include:

 Fainting, often an early sign
 Core body temperature over 40C
 A change in behavior, such as confusion, combativeness, or other unusual behaviors
  Absence of sweating, despite the heat
 Dry, flushed skin and a strong rapid pulse changing to a slow weak pulse
 Cool skin due to vascular collapse
 EKG changes consistent with heart damage

Delirium or coma
 Heat stroke can be fatal even after returning to normal temperature. Intravascular coagulation
and multi-organ failure may result from the release of heat shock protein and exaggerated
immune response. Acute renal failure should be anticipate
 Those patients that survive heat stroke often suffer from neurological impairment.

Hyperthermia treatment and prevention

 Treatment of hyperthermia consisting of measures which will rapidly lower core body temperature.
However, care must be taken to avoid causing vasoconstriction or shivering. Vasoconstriction will
impede heat loss and shivering will create heat.
 Once heat stroke has developed, the prognosis is poor, particularly with advanced age. The treatment
goal is to reduce tissue damage by lowering the temperature of vital structures such as the brain, heart
and liver. Tissue damage ensues when core temperature reaches 109F (43C). Cooling treatments can be
internal or external.
 Internal cooling techniques such as ice water gastric or rectal lavage, extracorporeal blood cooling, and
peritoneal or thoracic lavage are effective but they are also difficult to manage and associated with
complications.
 External cooling techniques are usually easier to implement, well tolerated and effective.
 Conductive cooling techniques include direct application of sources such as hypothermic blanket, ice
bath, or ice packs to neck, axillae and groin
 Convective techniques include removal of clothing and use of fans and air conditioning.
 Evaporative cooling can be accelerated by removing clothing and using a fan in conjunction with
misting the skin with tepid water or applying a single layer wet sheet to bare skin.
 Hyperthermia is a condition that is much better prevented than treated in an elderly person. Elderly
patients should be cautioned about the dangers of hot weather. For those elders at very high risk, such
as those living alone without air conditioning or ventilation, temporary relocation to a more protected
environment such as a shelter or community center should be implemented. Nurses can suggest several
specific strategies that can help elderly people avoid hyperthermia during heat waves.

These strategies include:

 Drink 2 to 3 quarts of water daily.

 Avoid exertion or exercise, especially during the hottest part of the day.
 If traveling, allow 2 to 3 weeks in an unusually hot climate before attempting any type of exertion.
 When outside, wear a hat and loose clothing; when indoors, remove as much clothing as needed to be
comfortable.
 Take a tepid bath or shower.
 Use cold wet towels or dampen clothing with tepid water when the heat is extreme.
 Avoid hot, heavy meals.
 Avoid alcohol.
Determine if the person is taking any medications that increase hyperthermia risk; if so, consult with the
patient's physician.

Clinical signs of fever Onset (cold or chill stage)

 Increased heart rate

 Increased respiratory rate and depth
 Shivering
 Pallor, cold skin
 Complaints of feeling cold
 Cyanotic nail beds
 Cessation of sweating
 Course
 Absence of chills
 Skin that feels warm photosensitivity
 Glassy eyed appearance
 Increase pulse and respiratory rate
 Increase thirst
 Mild to severe dehydration
 Drowsiness, restlessness, delirium or convulsions
 Hepatic lesions of the mouth
 Loss of appetite (if fever is prolonged)
 Malaise, weakness and aching muscles
 Effervescence (fever abatement)
 Skin that appears flushed and feels warm
 Sweating
 Decreased shivering
 Possible dehydration

Nursing intervention for client with fever or hyperthermia

 Monitor vital signs
 Assess skin color and temperature
 Monitor white blood cell count, hematocrit value, and other pertinent laboratory reports for
indication of infection or dehydration
 Remove excess blankets when the clients feel warm, but provide extra warmth when the client
feels chilled
 Provide adequate nutrition and fluids (e.g. 2500 -3000 ml per day) to meet the
increased metabolic demands and prevent dehydration.
 Client who sweat profusely can become dehydrated
 Measure intake and output
 Reduce physical activity to limit heat production especially during the flush stage
 Administer antipyretics (drugs that reduce the level of fever) as ordered
 Provide oral hygiene to keep the mucous membrane moist. They can become dry and cracked as
a result of excessive fluid loss
  Provide tepid sponge bath to increase heat loss through conduction
 Provide dry clothing and bed linens

HYPOTHERMIA
Hypothermia is a core body temperature below the normal limit of normal. The three physiological mechanism of
hypothermia are;

1. Excessive heat loss

2. Inadequate heat production to counteract the heat loss
3. Impaired hypothermia thermoregulation

Clinical signs of hypothermia

1. Decreased body temperature, pulse and respiration

2. Severe shivering (initially)
3. Feelings of cold and chills
4. Pale, cool, waxy skin
5. Hypotension
6. Decreased urinary output
7. Lack of muscle coordination
8. Disorientation
9. Drowsiness progressing to coma

Management of hypothermia
Pre hospital Care

 Pre-hospital management focuses on preventing further heat loss, rewarming the body core
temperature, and avoiding precipitating ventricular fibrillation or another malignant cardiac
rhythm. This should be the preeminent concern. Conscious patients can develop ventricular
fibrillation suddenly; pre-hospital workers, particularly those operating in remote search-and-
rescue operations, should avoid inadvertent jerky movement of severely hypothermic patients.
Patients who develop hypothermia-induced dysrhythmia in the field may be beyond
resuscitation. How the hypothermic heart deteriorates into the rhythm of ventricular fibrillation
remains under debate.
 Patients developing hypothermia from cold-water immersion appear to be at high risk of
fibrillation; rescuers probably are justified in instructing such patients to minimize motion and to
await careful extrication.
 Anecdotal reports of sudden cardiac death associated with tracheal intubation appear to be
exaggerated, particularly if a patient is adequately pre-oxygenated.
 Both cardiac pacing and atropine are generally ineffective for Brady arrhythmia.
 Lidocaine is ineffective in preventing hypothermia-induced ventricular dysrhythmias.
 Many authors have advocated prophylactic beryllium in cases of severe hypothermia when
spontaneous conversion to ventricular fibrillation is possible. This recommendation is due to the
success of such therapy both in controlled animal studies and in anecdotal human reports.
Emergency Department Care

 Patients with respiratory failure should be endotracheal intubated and placed on a mechanical
ventilator. Intubation and insertion of vascular catheters should not be delayed but performed
gently while closely monitoring cardiac rhythm for ventricular fibrillation.
 Measure core temperatures using a low-reading esophageal, rectal, or bladder thermometer.
Tympanic thermometers are unreliable in a setting of profound hypothermia and should not be
used. If using a rectal probe, be careful not to insert it into stool.
 Determine whether a cold patient is profoundly or mildly hypothermic. Profoundly hypothermic
patients present with stupor or cardiac dysrhythmia (regardless of the recorded temperature) and a
core temperature of 30°C or lower. Mildly hypothermic patients may be rewarmed in any available
manner (eg, warm blankets, removal of cold, wet clothing) since their risk for cardiac dysrhythmia
is low. Surface rewarming is adequate in these cases, but it is ineffective in very low body
temperatures and carries an additional risk of temperature after drops and shock secondary to
peripheral vasodilation.
 Remove any wet clothing, and replace it with warm, dry materials.
 Profound hypothermia is a true emergency, warranting the same resource-intensive resuscitation
as myocardial infarction. Direct treatment at maintaining or restoring cardiac perfusion;
maximizing oxygenation is indicated for a prolonged period of time until the core temperature is
at least 32°C.
 Do not attempt resuscitation on the patient with a frozen chest where compressions are not
possible.
 Gingerly handle patients identified with profound hypothermia, and take immediate measures to
prevent degeneration of cardiac activity into malignant dysrhythmia.
 Profoundly hypothermic patients who demonstrate cardiac ectopy may be ideal candidates for
bretylium, if available. Administer an initial dose of 5 mg/kg IV (repeated at 10 mg/kg, as needed)
to prevent ventricular fibrillation. Lidocaine is ineffective for treatment of hypothermia-induced
dysrhythmias. While no randomized human trials have been reported, at least 4 animal trials and
2 human case reports support using bretylium for any patient with profound hypothermia. Based
on such evidence, the US Wilderness Emergency Medical Services Institute recommends using
empiric bretylium for profound hypothermia
 Initiate warmed, humidified oxygen; provide heated intravenous saline; and place warmed
blankets or heat lamps around a hypothermic patient.

Nursing interventions for clients with hypothermia

1. Provide a warm environment (room temperature)

2. Provide dry clothing
3. Apply warm blankets (hypothermia blankets)
4. Keep limbs close to body
5. Cover the client’s scalp with a cape turban
6. Supply warm oral or intravenous fluid.
7. Apply warming pads
Hypothermia and its Management in Newborn
Hypothermia in newborn the newborn with a temperature of 36.0-36.4°C (96.8-97.5°F) is under
cold stress (mild hypothermia). A baby with a temperature of 32.0-35.9°C (89.6-96.6°F) has moderate
hypothermia, while a temperature below 32°C (89.6°F) is considered to be severe hypothermia..

Causes and risk factors

Hypothermia of the newborn is mainly due to lack of knowledge. In many hospitals incorrect care
of the baby at birth is the most important factor in causing hypothermia, delivery rooms are not warm enough
and the newborn is often left wet and uncovered after delivery.
The newborn is weighed naked and washed soon after birth. The initiation of breast-feeding is
frequently delayed for many hours, and the baby is kept in a nursery, apart from the mother. In many newborns
these practices will result in hypothermia.

At home, families and Trained Birth Attendants (TBAs) may also not be aware of the importance
of drying and wrapping the newborn immediately after birth. Other risk factors include asphyxia, use of
anesthetic or analgesic drugs during delivery, infection or other illness of the infant and inadequate measures
taken to keep the baby warm before and during transportation.

Signs of Hypothermia
An early sign of hypothermia is feet that are cold to the touch. If prolonged leads to hypothermia,
the baby becomes less active, suckles poorly, impaired feeding and has a weak cry.
In severely hypothermic babies the face and extremities may develop a bright red colour. The baby becomes
lethargic and develops slow, shallow and irregular breathing and a slow heartbeat.
Low blood sugar and metabolic acidosis, generalized internal bleeding (especially in the lungs) and respiratory
distress may occur. Such a level of hypothermia is very dangerous and unless urgent measures are taken, the
baby will die.

Management of hypothermia
Thermal protection of the newborn is the series of measures taken at birth and during the first days
of life to ensure that the baby does not become either too cold (hypothermia) and maintains a normal body
temperature of 36.5-37.5°C (97.7-99.5°F).

Newborns found to be hypothermic must be rewarmed as soon as possible. It is very important to

continue feeding the baby to provide calories and fluid. Breast-feeding should resume as soon as possible.

If the infant is too weak to breast-feed, breast milk can be given by, spoon or cup. It is important
to be aware that hypothermia can be a sign of infection. Every hypothermic newborn should therefore be
assessed for infection.

Management in Hospital

 In hospital a diagnosis of hypothermia is confirmed by measuring the actual body temperature with
thermometer.
 In cases of mild hypothermia the baby can be rewarmed by skin-to-skin contact, in a warm room (at
least 25°C/77°F).
  In cases of moderate hypothermia the clothed baby may be rewarmed by the following measures: under
a radiant heater; in an incubator, at 35-36°C (95-96.8°F); by using a heated water-filled mattress;in a
warm room: the temperature of the room should be 32-34°C/89.6-93.2°Fin a warm cot: if it is heated
with a hot water bottle, these should be removed before the baby is put in.
 The rewarming process should be continued until the baby's temperature reaches the normal range.
 In cases of severe hypothermia studies suggest that fast rewarming over a few hours is preferable to
slow rewarming over several days. Rapid rewarming can be achieved by using a thermostatically-
controlled heated mattress set at 37-38°C (98.6-100.4°F) or an air-heated incubator.
 The "warm chain" is a set of ten interlinked procedures carried out at birth and during the following
hours and days which will minimize the likelihood of hypothermia.
 The room where the birth occurs must be warm (at least 25°C/77°F) and free from draughts.
 At birth, the newborn should be immediately dried and covered, before the cord is cut.
 While it is being dried, it should be on a warm surface such as the mother's chest or abdomen (skin-to-
skin contact).
 If this is not possible, alternative means of preventing heat loss and providing warmth — such as
wrapping, placing the baby in a warm room or under a radiant heater.
 Bathing and weighing the baby should be postponed.

Management at home
 At home, skin-to-skin contact is the best method to rewarm a baby.
 The room should be warm; the baby should be covered with a warm blanket and be wearing a
cap.
 The mother should continue breast-feeding as normal.
 If the baby becomes lethargic and refuses to suckle, these are danger signs and it should be
taken to hospital
 While being transported, the baby should be in skin-to-skin contact with the mother during
transportation.

PREVENTION OF HYPOTHERMIA

 Refrain from bathing the newborn immediately post-delivery.

 When bathing a neonate wash and dry only a small area of the body at a time, keeping the rest of the
infant's body covered.
 The baby should be dried well and then wrapped.
 Avoid unnecessary exposure when attending to baby's needs.
 The mother should keep the baby close to her body to avoid hypothermia.
 In general, newborns need a much warmer environment than an adult.

Frostbite
Is the medical condition where localized damage is caused to skin and other tissues due to extreme
cold? Frostbite is most likely to happen in body parts farthest from the heart and those with large exposed areas.
The initial stages of frostbite are sometimes called "frost nip".
Classification

There are several classifications for tissue damage caused by extreme cold including:

1. Frostnip is a superficial cooling of tissues without cellular destruction.

2. Chilblains are superficial ulcers of the skin that occur when a predisposed individual is repeatedly exposed
to cold
3. Frostbite involves tissue destruction.

STAGES
At or below 0 °C (32 °F), blood vessels close to the skin start to constrict, and blood is shunted away
from the extremities via the action of glomus bodies. The same response may also be a result of exposure to high
winds. This constriction helps to preserve core body temperature. In extreme cold, or when the body is exposed
to cold for long periods, this protective strategy can reduce blood flow in some areas of the body to dangerously
low levels. This lack of blood leads to the eventual freezing and death of skin tissue in the affected areas. There
are four degrees of frostbite. Each of these degrees has varying degrees of pain.[2]

First degree

This is called frostnip and this only affects the surface skin, which is frozen. On the onset, there
is itching and pain, and then the skin develops white, red, and yellow patches and becomes numb. The area
affected by frostnip usually does not become permanently damaged as only the skin's top layers are affected.
Long-term insensitivity to both heat and cold can sometimes happen after suffering from frostnip.

Second degree

If freezing continues, the skin may freeze and harden, but the deep tissues are not affected and remain soft and
normal. Second-degree injury usually blisters 1–2 days after becoming frozen. The blisters may become hard and
blackened, but usually appear worse than they are. Most of the injuries heal in one month, but the area may
become permanently insensitive to both heat and cold.

Third and fourth degrees

If the area freezes further, deep frostbite occurs. The muscles, tendons, blood vessels, and nerves all freeze. The
skin is hard, feels waxy, and use of the area is lost temporarily, and in severe cases, permanently. The deep
frostbite results in areas of purplish blisters which turn black and which are generally blood-filled. Nerve damage
in the area can result in a loss of feeling. This extreme frostbite may result in fingers and toes being amputated if
the area becomes infected with gangrene. If the frostbite has gone on untreated, they may fall off. The extent of
the damage done to the area by the freezing process of the frostbite may take several months to assess, and this
often delays surgery to remove the dead tissue.

Risk factors

Risk factors for frostbite include using beta-blockers and having conditions such as diabetes and peripheral
neuropathy.
Causes

Factors that contribute to frostbite include extreme cold, inadequate clothing, wet clothes, wind chill,
and poor blood circulation. Poor circulation can be caused by tight clothing or boots, cramped positions, fatigue,
certain medications, smoking, alcohol use, or diseases that affect the blood vessels, such as diabetes.[4]

Exposure to liquid nitrogen and other cryogenic liquids can cause frostbite as well as prolonged contact
with the chemical butane (see deodorant burn).

Treatment
Do not make affected area (skin) touch any cold or hot objects? Keep affected area warm. Treatment of
frostbite centers on rewarming (and possibly thawing) of the affected tissue. The decision to thaw is based on
proximity to a stable, warm environment. If rewarmed tissue ends up refreezing, more damage to tissue will be
done. Excessive movement of frostbitten tissue can cause ice crystals that have formed in the tissue to do further
damage. Splinting and/or wrapping frostbitten extremities are therefore recommended to prevent such movement.
For this reason, rubbing, massaging, shaking, or otherwise applying physical force to frostbitten tissues in an
attempt to rewarm them can be harmful.[5] Caution should be taken not to rapidly warm up the affected area until
further refreezing is prevented. Warming can be achieved in one of two ways:

Passive rewarming involves using body heat or ambient room temperature to aid the person's body in
rewarming itself. This includes wrapping in blankets or moving to a warmer environment.[7]

Active rewarming is the direct addition of heat to a person, usually in addition to the treatments included
in passive rewarming. Active rewarming requires more equipment and therefore may be difficult to perform in
the pre-hospital environment.[5] When performed, active rewarming seeks to warm the injured tissue as quickly
as possible without burning them. This is desirable as the faster tissue is thawed, the less tissue damage
occurs.[5] Active rewarming is usually achieved by immersing the injured tissue in a water-bath that is held
between 40-42°C (104-108F). Warming of peripheral tissues can increase blood flow from these areas back to
the bodies' core. This may produce a decrease in the bodies' core temperature and increase the risk of cardiac
dysrhythmias.[8]Surgery

Debridement and/or amputation of necrotic tissue is usually delayed. This has led to the adage "Frozen
in January, amputate in July” with exceptions only being made for signs of infections or gas gangrene.

Research

Evidence is insufficient to determine whether or not hyperbaric oxygen therapy as an adjunctive treatment
can assist in tissue salvage. There have been case reports but few actual research studies to show the effectiveness.

Medical sympathectomy using intravenous reserpine has also been attempted with limited success.[11]

While extreme weather conditions (cold and wind) increase the risk of frostbite it appears that certain
individuals and population groups appear more resistant to milder forms of frostbite, perhaps due to longer term
exposure and adaptation to cold weather environments. The "Hunter's Response" or Axon reflex are examples
of this type of adaptation.
Conclusion
Body temperature alteration is showing basis of infection, so assessing and controlling body temperature is very
important

Bibliography
1. Joyce. M. Black “Medical Surgical Nursing”, 2005;7th edition, Saunders publications
2. [Link]. (2003), “Fundamentals of Nursing” 6th e d p g 4 4 9 - 4 5 3 ,
3. John Rosen's emergency medicine: concepts and clinical practice 7thedition. Philadelphia, PA:
Mosby/Elsevier. p. 1862. ISBN 978-0-323-05472-0.
4. [Link], [Link] retrieved 4/3/10
5. Eric Perez, [Link] Institute of Health. Retrieved May 18,
6. [Link]
7. Murray, M., Pizzorno, J., The Encyclopaedia of Natural Medicine, Little, Brown and Company, UK,
1995.
8. Tortora, G.J., Grabowski, S.R., Principles of Anatomy and Physiology - 8th Edition, Harper Collins, NY,
1996.