Nursing Care of a Family When a Child Has a Metabolic Nclex Questions

Introduction

Aim

Definition of Terms

Temperature Ranges

Assessment

At Risk Patient Groups

Management

Special Considerations

Companion Documents

Links

Evidence Tabular array

References

Introduction

Temperature management remains a pregnant component of hospital care for all neonatal and paediatric patients. Body temperatures exterior normal ranges may be indicative of underlying disease processes or clinical deterioration, and should be identified within a timely mode. Maintaining a stable body temperature inside normal ranges assists in optimising metabolic processes and actual functions. Therefore, minimising environmental factors within the infirmary setting which may effect in unnecessary body temperature fluctuations is further of import.

Aim

To assistance healthcare professionals in undertaking the advisable assessment and potential management of neonatal and paediatric body temperatures, at The Imperial Children's Hospital.

Definition of Terms

• Normothermia: Body temperature inside normal values.
  Exact normal temperature ranges differ between individuals and tin can be influenced by some genetic and chronic medical weather. It is of import to define the baseline for individual patients in lodge to identify abnormal body temperature deviations.
  
• Pyrexia: An elevated body temperature due to an increase in the body temperature's fix point. This is usually caused past infection or inflammation. Pyrexia is besides known as fever or febrile response.
  Some causes of fevers practise not crave medical treatment, whilst other causes need to be identified and treated.
  
• Hyperthermia: An elevated body temperature due to failed thermoregulation. This occurs when the trunk produces and/or absorbs more than heat than it tin misemploy.
  
• Estrus stroke: A presentation of severe hyperthermia. Thermoregulation is overwhelmed by excessive metabolic product and ecology heat, in combination with dumb heat loss. This is uncommon within an inpatient setting.
  
• Low temperature: A lowered body temperature, where the body loses heat faster than it can produce heat.
  
• Hypothermia: An abnormally depression trunk temperature, where the body temperature drops below a safe level. Both low temperatures and hypothermia tin can be caused past environmental factors, metabolic complications, illness processes, or can be medically induced.
  

Temperature Ranges

Classification	Neonates	Paediatrics*
Low temperature (or hypothermia)	<36.5⁰C	<36⁰C
Normothermia	36.v - 37.5⁰C	36 - 37.5⁰C
Low form fever (or normothermia)	37.6 - 37.9⁰C	37.6 - 37.9⁰C
Fever (or hyperthermia)	≥ 38⁰C	≥ 38⁰C

*Significant variation of suggested temperature values and ranges exists inside current literature. The values presented in this tabular array are derived from a collaboration of multiple sources and expert opinions, and should be utilized as a guideline only. Verbal normal temperature ranges differ between individuals. It is important to ascertain an individual'southward baseline in gild to identify abnormal torso temperature deviations, and to evaluate these in the context of other vital signs and overall patient presentation.

Please annotation, any delirious child who appears seriously unwell should have a thorough assessment and their treating medical team notified, irrespective of the degree of fever.
In infants <iii months, hypothermia or temperature instability tin can be signs of serious illness.

Assessment

Trunk temperature should be measured on admission and four hourly with other vital signs, unless clinically indicated for more frequent measurements.
Trunk temperatures falling outside normal ranges should exist monitored and farther managed where appropriate until normothermia is accomplished.

When assessing body temperatures, it is of import to consider patient-based and environmental-based factors, including prior administration of antipyretics and contempo environmental exposures.
Torso temperature should always be evaluated in the context of other vital signs and overall patient presentation.

Methods of torso temperature measurements:

Due to temperature variation between body sites, ideally the same route should be used for ongoing patient observations, as to let for accurate temperature trend evaluation. Certificate the road used in EMR.

0-3 months: Axillary Road
Axillary digital thermometer is the preferred method for this age group, in about cases.

   Process:

1. Place thermometer tip in the centre of the armpit over the axillary avenue, ensuring pare is dry out and intact prior to probe placement.
   
2. Place the patient's arm securely against their body.
   
3. Plow thermometer on. For a more accurate reading, expect >3 minutes with thermometer in situ before obtaining a measurement.

0-3 months: Rectal Road (if requested)
In special cases, a rectal temperature may exist required for a more than accurate cess of body temperature.
This should be performed only if approved past medical staff, with ANUM involvement.
Rectal measurements should be avoided within the oncology population and in patients with low platelets, coagulopathy, or perineal trauma and pelvic area surgery, due to the increased risk of bowel perforation.

   Procedure:

1. Place plastic sheath over thermometer.
   
2. Dab a pocket-sized corporeality of lubricant on end of thermometer.
   
3. Carefully insert thermometer 2cm into the infant'southward anus (1cm for pre-term babe). Over-insertion may crusade bowel perforation.
   
4. Turn thermometer on.
   
5. Wait for 5 seconds post Celsius sign flashing before taking a recording.
   
6. Remove and clean thermometer with alcohol.

>3 months: Tympanic Road
Tympanic thermometer is the preferred method for this historic period group.

   Procedure:

1. Gently insert probe into ear canal until the culvert is entirely sealed off, ensuring the tip is facing the eardrum.
   
2. Press the thermometer button and wait for the beeps.
   
3. If ears have been covered (eg. headphones/beanie), remove items and wait until ear canal is cooled before taking measurement. If a patient'due south ear canals are too pocket-sized to properly insert the tympanic probe, consider an axillary thermometer road instead.
   

Notes:
If the patient has been exposed to cold conditions, allow for adequate fourth dimension for patient to equilibrate to room temperature before measuring trunk temperature.
Both axillary and tympanic routes measure temperatures lower than truthful cadre body temperature.
Temperature measurement frequency may differ in sub-speciality areas, such as within the Emergency Department, critical care and peri-operative areas. Please refer to specific section guidelines for farther information.

At Hazard Patient Groups

The following patient populations are at an increased risk of existence unable to maintain normothermia:

• Neonates and young infants
  
• Peri and post-operative patients
  
• Burns patients
  
• Trauma patients
  
• Neurologically compromised patients
  

Management

Preventative Approaches

A patient's surrounding environs tin greatly impact their ability to maintain an otherwise stable body temperature. Acknowledging and minimising environmental influences on thermoregulation is of import for all paediatric patients, especially the neonatal and at take a chance patient populations.

The table below outlines approaches nurses, clinicians and families can utilise towards minimising preventable heat transfer from patients to their surroundings.

Way	Definition	Clinical Scenario	Preventative Direction
Evaporation	Heat loss occurring during conversion of liquid to vapour	Sweat, incontinence Wet or oozing dressings	Go on patient dry Remove wet clothing, supercede wet dressings if appropriate
Convection	Transfer of estrus from the body surface to the surrounding air via air electric current	Air drafts in room	Relocate patient abroad from draughts, close door
Conduction	Transfer of heat from one solid object to some other solid object in direct contact	Common cold blankets, cold weighing scales	Cover cold surfaces with pre-warmed towel or coating
Radiations	Transfer of rut to cooler solid objects not in direct contact with the trunk	Nearby cold windows or walls	Relocate patient away from cold surfaces Close blinds on window

Neonatal Management

Paediatric Direction

Notes:

• Sepsis: Early recognition and initial management of sepsis in neonates and paediatrics is paramount, and if left untreated can pb to severe morbidities and mortality.  For farther information on sepsis recognition and direction of neonates and paediatrics, please see *Link: SEPSIS- cess and management, RCH CPG*
  
• Bair Hugger devices: If using a forced air warming device, the temperature of the device should not exist gear up to >32⁰C in the inpatient setting. The patient'southward temperature should be rechecked at a minimum of every thirty minutes or if the patient is <6 months, a minimum of every 15 minutes whilst forced air warming in use, every bit patients are at a gamble of overheating. Check that the blanket is connected to the device correctly as patients are at take a chance of burns.
  
• If applicative, refer to individual department guidelines for direction of specific patient populations, eg. Delirious Neutropenia pathway. Encounter Special Considerations section below.
  

Special Considerations

The following patient populations may require more specific interventions and/or differing management when body temperature falls outside traditionally normal values:

• Delirious Neutropenic patients
  
• Therapeutic hypothermic patients
  
• Therapeutic hypothermic neonates
  
• Patients with chronic weather causing lower baseline body temperatures
  Some patient populations have conditions that affect their basal metabolic rates and thus, have unique normal temperature ranges. Information technology is important to define these private'southward normal temperature fluctuations in social club to identify abnormal readings and manage accordingly.
  
• Perioperative and Postoperative Patients
  
  • Preoperatively
    
    • Ensure temperature is taken on admission and patients are accordingly dressed and warm preoperatively.
    • Provide a warm blanket as appropriate.
    • Consider forced air warming (Bair Hugger) for patients undergoing extensive surgery.
      
  • Recovery
    
    • Ensure temperature is taken on admission to PACU
      
    • Initiate active warming via forced air warming (Bair Hugger) if neonatal patient temperature is <36⁰C (if not in Ohio/Isolette) or paediatric patient temperature is <35.5⁰C.
      
    • Temperature should exist taken every 5 minutes whilst a patient is receiving active warming.
      
    • If overheating or burns occur, stop active warming and seek anaesthetic review (treating or in charge). Cool patient if advisable. Certificate event via EMR and consummate VHIMS.
      
    • Discharge temperature is ≥36.6⁰C for neonatal patients and ≥36⁰C for paediatric patients.  Ensure clinical indicators are completed and active warming interventions are documented in EMR.
      
    • Patients with chronic atmospheric condition which cause lower baseline trunk temperatures should return to their baseline prior to transfer to ward. This baseline temperature should exist discussed with parents/caregivers and communicated to the receiving ward or day surgery.
      
    • If the post-operative temperature is <36⁰C but ≥35.five⁰C, the patient is rousable and all other vital signs are stable and within normal range, they can exist transferred to the ward.  If clinically indicated, forced air warming can be made available for ward to go on to employ. This should be discussed with parents/caregivers and communicated to albeit ward.

Companion Documents

• Nursing Assessment (CPG (Nursing))
  https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Nursing_assessment/
  
• Febrile Kid (country-broad CPG):
  https://www.rch.org.au/clinicalguide/guideline_index/febrile_child/
  
• SEPSIS (land-wide CPG):
  https://www.rch.org.au/clinicalguide/guideline_index/SEPSIS_assessment_and_management/
  
• Febrile Neutropenia (land-wide CPG):
  https://www.rch.org.au/clinicalguide/guideline_index/Fever_and_suspected_or_confirmed_neutropenia/

Additional Useful Links

RCH Kids Health Info Fact Sheet on Fever in Children
https://www.rch.org.au/kidsinfo/fact_sheets/fever_in_children/

Evidence Table

Temperature Direction Nursing Guideline Testify Table 2019. 

References

• Asher, C., & Northington, 50. K. (2008). Position statement for measurement of temperature/ fever in children. Journal of Pediatric Nursing, 23(iii), 234-236. doi: 10.1016/j.pedn.2008.03.005
  
• Barbi, Due east., Marzuillo, P., Neri, E., Naviglio, S., & Krauss, B. S. (2017). Fever in Children: Pearls and Pitfalls. Children, four(9), 81-99. doi:ten.3390/children4090081
  
• Bharti, P., Chauhan, Chiliad., & Ahmed, One thousand. (2017). Comparison of rectal, infra-red tympanic and infra-red skin temperature in term neonates. International Archives of Integrated Medicine, 4(3), 43-49. Retrieved from https://search-ebscohost-com.ezp.lib.unimelb.edu.au/login.aspx?direct= truthful&db=a9h&AN=122002190&site=eds-live&scope=site
  
• Davie, A., & Amoore, J. (2010).  Best practice in the measurement of torso temperature. Nursing Standard, 24(42), 42-49.  doi: 10.7748/ns2010.06.24.42.42.c7850
  
• Derieg, S. (2017). An overview of perioperative intendance for paediatric patients. The Journal of Perioperative Nursing in Australia, thirty(3), 23-29. doi:x.26550/303/23-29
  
• Dougherty, 50., Lister, Due south., & West-Oram, A. (2015). Observations. In The Royal Marsden Transmission of clinical nursing procedures, 9th ed. (pp. 534-540). Westward Sussex, United kingdom of great britain and northern ireland: The Royal Marsden NHS Foundation Trust.
  
• El-Radhi A.S. (2018). Measurement of body temperature. In El-Radhi A. (Ed.) Clinical Transmission of Fever in Children (pp. 69-84). Retrieved from https://doi.org/10.1007/978-iii-319-92336-9_4
  
• Freer, Y., & Lyon, A. Temperature monitoring and control in the newborn baby. (2011). Paediatrics and Child Wellness, 22(4), 127-130. doi:10.1016/j.paed.2011.09.002
  
• Hay, A. D., Costelloe, C., Redmond, N. M, Montgomery, A. A., Fletcher, Thou., Hollinghurst, Southward., & Peters, T. J. (2008). Paracetamol plus ibuprofen for the treatment of fever in children (PITCH): randomised controlled trial. British Medical Journal, 337(7672), 729-733. doi:x.1136/bmj.a1302
  
• Işler, A., Aydin, R., Güven, Ş. T., & Günay, S. (2014). Comparison of temporal artery to mercury and digital temperature measurement in pediatrics. International Emergency Nursing, 22(3), 165-168. doi:x.1016/j.ienj.2013.09.003
  
• Knobel, R. B. (2014). Fetal and neonatal thermal physiology. Newborn and Infant Nursing Reviews, 14(two), 45-49. doi: 10.1053/j.nainr.2014.03.003
  
• Leduc, D. Wood, S. (2013).Position statement: temperature measurement in paediatrics. Canadian Paediatric Lodge. Retrieved from https://www.cps.ca/en/documents
  
• National Institute for Health and Clinical Excellence (NICE). (2013). Feverish illness in children: cess and initial management in children younger than 5 years. London: Majestic College of Obstetricians and Gynaecologists. Retrieved from https://www.overnice.org.uk/guidance/cg160
  
• Oguz, F., Yildiz, I., Varkal, M. A., Hizli, Z., Toprak, S., Kaymakci, One thousand., … Unuvar, E. (2018). Axillary and tympanic temperature measurement in children and normal values for ages. Pediatric Emergency Intendance, 34(three), 169-173. doi:10.1097/PEC.0000000000000693
  
• Printz, V., Hobbs, A. Thousand., Teuten, P., & Paul, South. P. (2016). Clinical update: cess and management of febrile children. Customs Practitioner, 89(6), 32-37.
  
• Trevisanuto, D., Testoni, D., & de Almeida, One thousand. F. (2018). Maintaining normothermia: why and how? Seminars in Fetal & Neonatal Medicine, 23(5), 333-339.  doi:ten.1016/j.siny.2018.03.009
  
• Weiss, S. L., & Pomerantz, W. J. (2019). Septic shock in children: rapid recognition and initial resuscitation (offset hour). Up to Date. Retrieved from https://www.uptodate.com/contents/septic-shock-in-children-rapid-recognition-and-initial-resuscitation-first-hour

 Please remember to read the disclaimer.

The development of this nursing guideline was coordinated by Elizabeth Cooke, RN, ED, and approved by the Nursing Clinical Effectiveness Committee. Updated August 2019.

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Source: https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Temperature_management/

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