基础护理学：第八章生命体征的观察与护理-体温

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第八章

生命体征的观察与护理

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体温（T）脉搏（P）呼吸（R）血压（Bp）是生命维持的基本征候，是机体内在活动的客观反映，是衡量机体状况的指标，合称为生命体征。生

命

体

征CompanyLogoHotTipHowdoIincorporatemylogotoaslidethatwillapplytoalltheotherslides?

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第

一

节

体温的观察与护理CompanyLogoHotTipHowdoIincorporatemylogotoaslidethatwillapplytoalltheotherslides?

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教学目标：1、了解正常体温的生理性变化2、掌握异常体温的观察及护理3、掌握体温的测量方法CompanyLogoHotTipHowdoIincorporatemylogotoaslidethatwillapplytoalltheotherslides?

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一、什么是体温？二、体温是怎样产生的？三、体温的正常值是多少？四、哪些因素可能引起体温的变化？？CompanyLogoHotTipHowdoIincorporatemylogotoaslidethatwillapplytoalltheotherslides?

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体表温度(shelltemperature)

体核温度(coretemperature)体温机体深部的平均温度CompanyLogoHotTipHowdoIincorporatemylogotoaslidethatwillapplytoalltheotherslides?

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体热-维持体温三磷酸腺苷-机体利用糖、脂肪、蛋白质1、温度的产生CompanyLogoHotTipHowdoIincorporatemylogotoaslidethatwillapplytoalltheotherslides?

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2、热的产生：内脏、肌肉进食、交感神经兴奋、环境温度增加禁食、肌肉活动减少、抵抗力下降产热增加产热减少CompanyLogo皮肤

（70%）呼吸（29%）排泄散热器官CompanyLogoHotTipHowdoIincorporatemylogotoaslidethatwillapplytoalltheotherslides?

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散热辐射蒸发对流传导散热散热方式CompanyLogoHotTipHowdoIincorporatemylogotoaslidethatwillapplytoalltheotherslides?

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行为性调节生理性调节体温的调节CompanyLogoHotTipHowdoIincorporatemylogotoaslidethatwillapplytoalltheotherslides?

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下丘脑体温调节枢，控制产热和散热效应器活动，将体温维持在一个调定点生理性调节3、体温的调节CompanyLogoHotTipHowdoIincorporatemylogotoaslidethatwillapplytoalltheotherslides?

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根据环境温度与个人对冷热的感觉进行调节行为性调节2、体温的调节CompanyLogoHotTipHowdoIincorporatemylogotoaslidethatwillapplytoalltheotherslides?

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温度：℃（摄氏温度）℉（华氏温度）℃与℉的换算公式：℃=(℉-32)×5/9℉=℃×9/5+32正常体温（二）CompanyLogoHotTipHowdoIincorporatemylogotoaslidethatwillapplytoalltheotherslides?

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成人体温平均值及正常范围部位平均温度正常范围

腋温36.5℃36.0-37.0℃口温37.0℃

36.3-37.2℃

直肠

37.5℃36.5-37.7℃CompanyLogoHotTipHowdoIincorporatemylogotoaslidethatwillapplytoalltheotherslides?

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其他年龄性别昼夜因素药物影响（三）体温生理性变化CompanyLogoHotTipHowdoIincorporatemylogotoaslidethatwillapplytoalltheotherslides?

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二、异常体温的观察和护理体温过高-发热

机体在致热源作用下，体温调节中枢的调定点上移而引起调节性体温升高，当体温上升超过正常值的0.5℃或一昼夜体温波动在1℃以上时，称为发热。CompanyLogoHotTipHowdoIincorporatemylogotoaslidethatwillapplytoalltheotherslides?

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生物性病原，如细菌、病毒、立克次体、原虫、寄生虫等感染感染性体温调节中枢功能紊乱、吸收热、变态反应性发热、内分泌与代谢障碍非感染性1、体温过高的原因CompanyLogoHotTipHowdoIincorporatemylogotoaslidethatwillapplytoalltheotherslides?

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2、临床分度：以口腔温度为例：人体最高的耐受温度为40.6~41.4℃，直肠温度持续升高超过41℃，可引起永久性的脑损伤，高达43℃很少存活。部位摄氏度

华氏度低热

37.3-38.0

99.1-100.4中等热 38.1-39.0

100.6-102.2高热 39.1-41.0

102.4-105.8超高热

≥41

≥105.8CompanyLogoHotTipHowdoIincorporatemylogotoaslidethatwillapplytoalltheotherslides?

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3、发热的临床过程：体温上升期高热持续期体温下降期渐升骤升渐降骤降产热散热寒战、疲乏皮肤血管收缩：皮肤苍白、干燥无汗、畏寒。心率加快，呼吸加深加快、头痛食欲不振，易惊厥皮肤血管舒张：皮肤潮红，灼热，伴有水分丢失：口干、尿少。皮肤血管舒张：大量出汗、皮肤潮湿，有脱水情况。CompanyLogoHotTipHowdoIincorporatemylogotoaslidethatwillapplytoalltheotherslides?

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4.

热型：各种体温曲线的形状称为热型

稽留热

弛张热

间歇热

不规则热CompanyLogoHotTipHowdoIincorporatemylogotoaslidethatwillapplytoalltheotherslides?

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稽留热体温持续在39-40℃左右，达数日或数周，24h波动范围不超过1℃。多见于肺炎、伤寒等CompanyLogoHotTipHowdoIincorporatemylogotoaslidethatwillapplytoalltheotherslides?

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弛张热：体温持续高于正常，24h体温波动在1℃以上，多见于败血症、风湿热、化脓性疾病等CompanyLogoHotTipHowdoIincorporatemylogotoaslidethatwillapplytoalltheotherslides?

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间歇热：高热与正常体温交替有规律地反复出现，多见于疟疾等CompanyLogoHotTipHowdoIincorporatemylogotoaslidethatwillapplytoalltheotherslides?

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不规则热：

体温在24小时中变化不规则，持续时间不定。多见于流行性感冒、肿瘤性发热

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5、高热患者的护理1降温2密切观察病情3补充营养和水分4休息5口腔护理6皮肤护理7安全护理8心理护理CompanyLogoHotTipHowdoIincorporatemylogotoaslidethatwillapplytoalltheotherslides?

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（二）体

温

过

低由于各种原因引起的产热减少或散热增多导致体温低于正常范围。体温低于35℃-体温不升CompanyLogoHotTipHowdoIincorporatemylogotoaslidethatwillapplytoalltheotherslides?

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程度

℃

。F轻度 32-35

89.6-95中度 30-32

86-89.6重度 ＜30

＜86致死温度 23-25

73.4-771.

体温过低的分级临床表现：皮肤苍白、四肢冰冷、呼吸缓慢、血压降低、感觉迟钝甚至昏迷CompanyLogoHotTipHowdoIincorporatemylogotoaslidethatwillapplytoalltheotherslides?

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护理学基本理论随时做好抢救准备工作5.密切观察生命体征

2.加强营养使产热增加3.保暖1.病因护理4.2、体

温

过

低的护理CompanyLogoHotTipHowdoIincorporatemylogotoaslidethatwillapplytoalltheotherslides?

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三、体温计的种类与构造：水银体温计、电子体温计、可弃式体温计、感温胶片CompanyLogoHotTipHowdoIincorporatemylogotoaslidethatwillapplytoalltheotherslides?

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肛表腋表口表水银贮槽真空毛细管凹陷处

1.水

银

体温计刻度是35~42℃,每1℃之间分成10小格，每小格为

0.1℃，在37℃刻度处则以红色标记以示醒目。CompanyLogoHotTipHowdoIincorporatemylogotoaslidethatwillapplytoalltheotherslides?

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采用电子感温探头来测量体温，测得的温度直接由数字显示，直观读数，测温准确，灵敏度高。2.电子体温计CompanyLogoHotTipHowdoIincorporatemylogotoaslidethatwillapplytoalltheotherslides?

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4.感温胶片

5.其他红外线体温计奶嘴式电子体温计CompanyLogoHotTipHowdoIincorporatemylogotoaslidethatwillapplytoalltheotherslides?

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3.可弃式体温计测温时将测温表置于患者舌下1min取出后当颜色点从白色变成蓝色时，最后的蓝点位置即为所测温度。CompanyLogoHotTipHowdoIincorporatemylogotoaslidethatwillapplytoalltheotherslides?

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四、测体温的方法【目的】判断体温有无异常。动态监测体温变化，分析热型。协助诊断，为预防、治疗、康复、护理提供依据。CompanyLogoHotTipHowdoIincorporatemylogotoaslidethatwillapplytoalltheotherslides?

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【评估】病人年龄、性别、病情、意识、治疗等情况。影响体温测量的因素。病人心理状况，合作程度。CompanyLogoHotTipHowdoIincorporatemylogotoaslidethatwillapplytoalltheotherslides?

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【计划】1.操作者的准备：2.用物准备：3.病人准备：4.环境准备CompanyLogoHotTipHowdoIincorporatemylogotoaslidethatwillapplytoalltheotherslides?

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【实施】1.操作步骤（1）备齐用物携至床旁，核对解释（2）选择合适的测量方法测量腋温测量口温测量肛温CompanyLogoHotTipHowdoIincorporatemylogotoaslidethatwillapplytoalltheotherslides?

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测口温测肛温测腋温特点最方便，但易引起交叉感染准确，但不方便安全易接受，但准确性不高部位舌下热窝肛门内3～4cm腋窝时间3min3min10min禁忌婴幼儿、昏迷、精神异常、口鼻疾病手术、张口呼吸腹泻、直肠或肛门手术、心肌梗死患者腋下有创伤、手术及腋下出汗较多、肩关节手术、消瘦体温的测量CompanyLogoHotTipHowdoIincorporatemylogotoaslidethatwillapplytoalltheotherslides?

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