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Prepared byMARY ANN A. CUBON,RN,RM,MANThe taking of vital signs is a common nursing function/intervention we usually do any health setting. It is the fundamental step or the 1st step in the physical assessment/examination to establish baseline values of the clients cardiorespiratory integrity. Baseline values are important for subsequent measurements to compared with. VS are regulated through various homeostatic mechanisms and they fall within certain normal ranges/standards. So that any changes/variations from normal findings may indicate potential problems with the clients health status.

1Vital SignsAlso known as cardinal signs are a persons temperature, pulse, respiration and blood pressure, abbreviated as T, P, R and BP.Are indicators of vital body functions and reflects a persons present health status as compared to accepted normal standards.

The taking of VSs therefore refers to measurement of the clients TPR and BP.

VS taking is part of nursing care in any setting. Although it may be delegated to other healthcare personnel, it is the nurses responsibility to ensure accuracy of data and to report abnormal findings. So that if for example a patient has chest pain or dizziness or has unexpected changes in his VS, the nurse should double-check the findings and further assess the patient. And when assessing or taking the VS, it should be done thoroughly and scientifically.2Times to Assess Vital Signs On admission to a health care agency to obtain baseline data

Based on agency/institutional policy and procedures

Anytime there is a change in patients condition or reports symptoms such as chest pain or feeling hot or faint.

Before and after any surgical or invasive procedure

Before and after the administration of a medication that could affect the respiratory or cardiovascular systems (Ex: before giving a digitalis preparation)

Before and after any nursing intervention that could affect the vital signs (Ex: ambulating a client who has been on bed rest, after enema, BT)Or when to take the VS3Body TemperatureThe balance between the heat produced and the heat lost from the body, and is measured in heat units called degrees. Normal Range (oral temperature) of an adult: 36.7 C - 37 C (98 -98.6 F)

The body continually produces heat as a by-product of metabolism. Meaning, heat is produced in the bodys cells thru food metabolism that results in the release of energy. This energy is converted to energy forms that can be used directly by the body. And one form of this energy is thermal energy for regulation of body temp. Energy is measured in terms of HEAT. When the amount of heat produced by the body equals amount of heat lost, the person is in HEAT BALANCE.

4Two types of body temperature1. Core temperature is the temperature of the deep tissues of the body, such as the abdominal cavity and pelvic cavity. It remains relatively constant, 37C.2. Surface temperature temperature of the skin, subcutaneous tissue and fat and it rises and falls in response to the environment.Core Temperature the temperature of the deep tissues of the body such as the cranium, abdominal cavity and the pelvic cavity; relatively remains constant (370C or 98.60F)Surface Temperature temperature of the skin, the subcutaneous tissue, and fat

Heat Balance the amount of heat produced by the body equals amount of heat lost

5Factors Affecting Heat Production/LossHeat productionHeat lossBasal metabolism/BMRRadiationMuscular activity (shivering)ConductionThyroxine & Epinephrine (stimulating effects on metabolic rate)ConvectionTemperature effect on cells (fever)EvaporizationAs long as heat production and heat loss are properly balanced (heat balance), the body temperature remains constant.6Basal Metabolic Rate/BMR - rate of energy use in the body needed to maintain essential activities such as breathing. Metabolic rates decrease with age. In general, the younger the person, the higher the BMR.

Muscle activity including shivering, increases the metabolic rate thereby increases heat production.

Thyroxine output. Increased thyroxine output increases the rate of cellular metabolism throughout the body thus increasing the bodys temperature.

Thyroxine/T4 (derived from tyrosine) is a hormone of the thyroid gland influences the metabolic rate.74. Epinephrine, norepinephrine, and sympathetic stimulation/stress response. These hormones immediately increase the rate of cellular metabolism in many body tissues. Epinephrine and norepinephrine directly affect liver and muscle cells, thereby increasing cellular metabolism.

5. Fever increases the cellular metabolic rate and thus increases the body's temperature further.

Mechanisms of Heat Loss1. Conduction transfer of body heat to a cooler object in direct contact with the body.the amount of heat transferred depends on the temperature difference and the amount and duration of the contact.Ex: Bathing a client in cool or tepid water will lower the clients temperature. The body transfers heat to an ice pack placed on the forehead. A newborn placed on a cold counter/table after deliveryMechanisms of Heat Loss2. ConvectionIs the flow of heat from the body surface to cooler surrounding air.Dispersion/dissemination of heat by air currents or motion.Ex: The use of fans blows current of cool air across the surface of a warm body enhances heat loss by air.

Movement of heat away from the bodys surface.

10Mechanisms of Heat Loss3. RadiationTransfer of body heat to a cooler object not in contact with the body. transfer is in the form of infrared rays or by electromagnetic waves.Ex: Body heat is transferred to a hanging curtain/draft, cabinets and other furniture.

transfer of heat from the surface of one object to the surface of another without contact between the two objects.The body gives of waves of heat from uncovered surfaces

11Mechanisms of Heat Loss4. EvaporationThe loss of heat through conversion of a liquid to a vapor/gas.Ex: Body fluid in the form of perspiration and moisture from the respiratory tract/lungs evaporates.Insensible water loss is the continuous, and unnoticed water loss Insensible heat loss

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Factors Affecting Body Temperature Age- infants and elderly are greatly influenced by the temperature of the environment due to inadequate diet, loss of subcutaneous fat, lack of activity, and reduced thermoregulatory control.

Diurnal variations/circadian rhythms body temperature normally change throughout the day, varying as much as 1.0C between the early morning and the late afternoons. This is due to environmental and physiologic processes/ events that occur at 24-hour intervals. Body temp during early morning is usually lower (about 1.0C) than in the late afternoon and early evening.Point of highest body temp is usually reached between 4:00- 6:00 PM.Lowest point is reached during sleep between 4:00 - 6:00 AM.

Exercise- hard work or strenuous exercise can increase body temperature to as high as 38.3C to 40C (101F to 104F) measured rectally.Nurses should be aware of the factors that can affect a client's body temperature so that they can recognize normal temperaturevariations and understand the significance of body temperature measurements that deviate from normal.Circadian Rhythms body temp during early morning is usually lower than in the late afternoon and early evening. = this predictable fluctuations recurs next day.13Range of oral temperatures during 24 hours for a healthy young adult

Body temp during early morning is usually lower (about 1.0C) than in the late afternoon and early evening. Point of highest body temp is usually reached between 4:00- 6:00 PM. Lowest point is reached during sleep between 4:00 - 6:00 AM.

Body temp during early morning is usually lower (about 1.0C) than in the late afternoon and early evening.Point of highest body temp is usually reached between 4:00- 6:00 PM.Lowest point is reached during sleep between 4:00 - 6:00 AM.

14Hormones Progesterone secretion at the time of ovulation raises body temperature by about 0.3C to 0.6C (0.5F to 1.0F) above basal temperature.

Stress- highly stressed or anxious client have an elevated temperature due to the stimulation of the sympathetic nervous system causing an increase production of epinephrine and norepinephrine, thereby increasing metabolic activity and heat production.

Environment - extremes in environmental temperatures can affect a person's temperature regulatory systems.In a warm room --- body temp will be elevated; if client has been outside in cold weather --- body temp will be low.

Regulation of Body TemperatureThe system that regulates body temp has 3 parts:Sensors or sensory receptors (mostly in the skin)Cold receptors skin has more cold receptorsWarm receptorsHypothalamus: Thermoregulatory CenterEffector system: sweat glands, skin, muscles, subcutaneous tissues, fat, deep organs like brain, liver, heart. vasoconstriction, muscle shivering, piloerection = coldvasodilation, sweating/perspiring = warmVasodilation widening of blood vesselsVasoconstriction narrowing of blood vesselsPiloerection/Goosebumps hair standing on endSensory Receptors in the skin can sense if the body is getting overheating or too cold. When body heat rises, the sensors in the hypothalamus detect the heat, and send out/ transmit signals or impulses to the temperature by triggering perspiring, vasodilation of blood vessels and the inhibition of heat production. The opposite of which occurs when the body heat is low and the cold sensors are stimulated, the hypothalamus transmits impulses to stimulate heat production through vasoconstriction of blood vessels, muscle shivering, and piloerection or hair standing. When pilomotor muscles of the skin contract in response to cold, piloerection occurs, reducing the size of the surface area to minimize heat loss.16Terms and Definitions for Types of Fever2 Alterations in body temperature:Pyrexia/Hyperthermia/Fever - a body temperature above the usual range (36.7 C - 37C). Hypothermia- a body temperature below the lower limit of normal.

Hyperpyrexia a very high fever, such as 41 C (105.8F)Febrile - a client who has a fever.Afebrile a client who has no fever17

Types of FeverIntermittent: The body temperature alternates regularly between periods of fever and periods of normal or subnormal temperature.

Remittent: The body temperature fluctuates several degrees (> 2C) above normal, but does not reach normal between fluctuations.

Constant: The body temperature remains consistently elevated and fluctuates less than 2C (3.6).

Crisis: The fever returns to normal suddenly.

Lysis: The fever returns to normal gradually. Intermittent fever seen in malariaRemittent seen in pts with colds19Fever spike: A temperature that rises to fever level rapidly following a normal temperature and then returns to normal within a few hours.

Relapsing: A short febrile periods of a few days interspersed with periods of 1 or 2 days of normal temperature. The body temperature returns to normal for at least a day, but then the fever recurs.Relapsing fever: bacterial blood infection20Nursing Interventions for Clients with FeverMonitor vital signs.Assess skin color and temperature: flushed skin, warm to touchMonitor pertinent laboratory reports for indications of infection or dehydration.Remove excess blankets when the client feels warm, but provide extra warmth when the client feels chilled.Provide adequate nutrition and fluids (e.g., 2,500-3,000 ml per day) to meet the increased metabolic demands and prevent dehydration.Measure intake and output.Reduce physical activity to limit heat productionAdminister antipyretics (drugs that reduce the level of fever) as ordered.Provide oral hygiene to keep the mucous membranes moist.Provide a tepid sponge bath/TSB to increase heat loss through conduction.Provide dry clothing and bed linens.Nursing Care for Clients with HypothermiaProvide warm environmentProvide dry clothingApply warm blanketsKeep limbs close to bodyCover the clients scalp: newbornsSupply warm oral or intravenous fluidsApply warming padsAssessing Body TemperatureThe most common sites for measuring body temperature are:Oral RectalAxillaryTympanic membraneSkin/temporal artery.

Each of the sites has advantages and disadvantages.

Advantages and Disadvantages SITEADVANTAGESDISADVANTAGESMOUTHEasy access and convenientGlass thermometer can break if bitten.Painful if mouth is inflamed or injured.Not recommended for confused, comatose, uncooperative patients, and small children.Commonly used because of rich blood supply.Comfortable for most people.Inaccurate if client has just ingested hot/cold food or fluid or smoked.Could injure the mouth following oral surgery. Oral: must wait 15 mins to measure temp after food or fluid ingestion. Measuring device is in contact with the oral mucous membrane.

24SITEADVANTAGESDISADVANTAGESRECTUMCommon site when oral not available.

Believed most reliable or accurate because it reflects core temperature.Inconvenient and more unpleasant for clients; difficult for client who cannot turn to the side.Requires lubricant.Frightening to infants and small children.Could injure the rectum following rectal surgery.Must be held in place for safety.Presence of stool may interfere with thermometer placement. If the stool is soft, the thermometer may be embedded in stool rather than against the wall of the rectum.Rectal temp is higher than oral temp bcoz of the seal created by the anal sphincter, which decreases contact with environmental air.25SITEADVANTAGESDISADVANTAGESAXILLASafe and noninvasiveEasy to use on newborns and confused patients.Least invasiveThe thermometer must be left in place a long time to obtain an accurate measurement.Least desirable for adult like to be affected by environmental temperatures because the axilla is moreTYMPANIC MEMBRANEEasy to use, readily accessible and safe for all ages.Does not require position change.Can be uncomfortable and involves risk of injuring the membrane if the probe is inserted too far.Reflects the core temperature Repeated measurements may vary; right and left membranes can differVery fast; reading obtained in as few as 10 seconds.Presence of cerumen/ear wax can affect the reading.May cause pain for patients with otitis or ear infection.Core temperature: tympanic membrane lies very close to external carotid artery.26SITEADVANTAGESDISADVANTAGESSKIN/TEMPORAL ARTERYSafeNoninvasiveVery fastRequires electronic equipment that may be expensive or unavailablePresence of perspiration in the head requires variation in techniqueExpensive

Types of thermometerGlass thermometers can be hazardous due to its mercury content which is toxic to humans. Mercury is a toxic metal for humans. Low doses of mercury compounds can have serious neuro developmental effects and can damage the cardiovascular, immune and reproductive systems whereas high doses could be fatal.

1. Mercury/Glass thermometer Electronic thermometers are available for oral and rectal use.It can provide a reading in only 2 to 60 seconds. The equipment consists of a battery-operated portable electronic unit, a probe that the nurse attaches to the unit, and a probe cover, which is usually disposable.A reading is complete through a light , tone or beep.2. Electronic thermometers The tape contains liquid crystals that change color according to temperature.When applied to the skin, (forehead, abdomen), the temperature digits on the tape respond by changing color after the length of time specified by the manufacturer (15 seconds).It does not indicate the core temperature.3. Temperature-sensitive tapeUses infrared technology to measure the tympanic membrane temperature.The infrared thermometer makes no contact with the tympanic membrane, only at the external opening of the ear canal, where it senses body heat in the form of infrared energy given off by a heat source, which in the ear canal is the tympanic membrane. The reading is complete through a light ,tone or beep.

4. An infrared (tympanic) thermometer Pull the pinna of the ear up and back for placement of a tympanic thermometer in a child over 3 years of age; down and back for children under age 3.Placement of a tympanic thermometer

Temporal artery thermometers determine temperature using a scanning infrared thermometer that compares arterial temperature in the temporal artery of the forehead to the temperature in the room and calculates the heat balance to approximate the core temperature of the blood in the pulmonary artery. The probe is placed in the middle of the forehead and then drawn laterally to the hairline. If the client has perspiration on the forehead, the probe is also touched behind the earlobe so the thermometer can compensate for evaporative cooling.

Temperature ScalesThe body temperature is measured in degrees on two scales:Celsius (centigrade) and Fahrenheit.

To convert from Fahrenheit to Celsius: deduct 32 from the Fahrenheit reading and then multiply by the fraction 5/9; that is:C = (Fahrenheit temperature - 32) x 5/9

For example, when the Fahrenheit reading is 100:C = (100 - 32) x 5/9 = (68) x 5/9 = 37.8C

To convert from Celsius to Fahrenheit: multiply the Celsius reading by the fraction 9/5 and then add 32; that is:F = (Celsius temperature x 9/5) + 32

For example, when the Celsius reading is 40:F = (40 X 9/5) + 32 = (72 + 32) = 104FA centigrade-calibrated scale ranges from 34 - 42, and a Fahrenheit-calibrated scale ranges from 94 - 108F. Conversions from one scale to another are based on the formula that 0C is equal to 32F. 34QUIZ 11Normal pulse range for the adult at rest.2-5 Four factors that may significantly change body temperature.6 When is the point of highest body temperature usually reached?7 A term that describes a fast heart rate.8It is considered the thermoregulatory center of the body.9-12 Give at least 4 common sites for counting the pulse rate.13 What do you call the sounds you usually hear when taking the blood pressure?14 It is referred to as the respiratory center of the body.15A term that describes an abnormally slow respiration.16The bell head of the stethoscope should be placed over which artery to measure blood pressure in the arm?17It is a quick, inexpensive, noninvasive method of assessingoxygenation or arterial blood oxygen saturation.18Which route in taking the body temperature is not indicated for a patient who just took in a cup of hot coffee?19-20 Convert: 100.6F C

1) 60 100 beats normal pulse rate adults2) Basal Metabolic Rate/BMR factors body temp3) Muscle activity4) Thyroxine output5) Fever6) 4 AM 6PM Highest body temp reached7) tachycardia name fast heart rate8) hypothamalus thermoregulatory center of the body9) 10)11)12)13) Medulla respiratory center of the body14) Bradypnea abnormally slow respiration15) 16) 17)18)19)20)