vital signs-temp, pr

8/12/2019 Vital Signs-Temp, PR

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Temperature, pulse, respiration, bloodpressure (B/P) & oxygen saturation are themost frequent measurements taken by HCP.

Because of the importance of thesemeasurements they are referred to as VitalSigns. They are important indicators of thebodys response to physical, environmental,and psychological stressors.


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VS may reveal sudden changes in a clientscondition in addition to changes that occurprogressively over time. A baseline set of VS areimportant to identify changes in the patientscondition.

VS are part of a routine physical assessment andare not assessed in isolation. Other factors such asphysical signs & symptoms are also considered.

Important Consideration: A clients normal range of vital signs may differ from the

standard range.


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1. On a clients admission2. According to the physicians order or the institutions policy

or standard of practice

3. When assessing the client during home health visit

4. Before & after a surgical or invasive diagnostic procedure

5. Before & after the administration of meds or therapy thataffect cardiovascular, respiratory & temperature controlfunctions.

6. When the clients general physical condition changesLOC, pain

7. Before, after & during nursing interventions influencing vitalsigns

8. When client reports symptoms of physical distress


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Vital signs


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Body temperature balance between heat produced bythe body & heat lost from the body

Types of Body Temperature

Core Temperature temp. of deep tissues of the body.Measured by taking oral & rectal temp. The normal oraltemp is 37 degrees Celsius (98.7F) w/ a range of 35.837.3 degrees Celsius (96.4 99.1 F). The rectal tempmeasures 0.4 0.5 degrees Celsius (0.7-1F) higher.

Surface Temperature temp of the skin, subcutaneoustissue & fat. Measured by taking axillary temperature.

Body heat is primarily produced by metabolism The heat regulating center is found in the

hypothalamus


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Core temperature temperature of the bodytissues, is controlled by the hypothalamus (controlcenter in the brain) maintained within a narrowrange.

Skin temperature rises & falls in response toenvironmental conditions & depends on bld flow toskin & amt. of heat lost to external environment

The bodys tissues & cells function best between

the range from 36 deg C to 38 deg C

Temperature is lowest in the morning, highestduring the evening.


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Basal Metabolic Rate (BMR) The younger theperson, the higher the BMR; the older the person,the lower the BMR. Therefore, older individuals havelower body temp than younger ones.

Muscle Activity (exrecise, swimming) increasescellular metabolic rate, therefore, increases bodyheat production.

Thyroxin Output increases cellular metabolic rate(chemical thermogenesis). Hyperthyroidism ischaracterized by increased body temp.

Epinephrine, norepinephrine sympatheticstimulation increases rate of cellular metabolismwhich in turn increases body temp.


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Radiation transfer of heat from surface of 1 objectto the surface of another w/o contact between 2objects. Eg. It feels warm in a crowded room.

Conduction transfer of heat from 1 surface toanother. It requires temp. difference between 2surfaces. Eg. Application of moist wash cloth overskin.

Convection dissipation of heat by air currents. Eg.Exposure of skin towards electric fan.

Evaporation continuous vaporization of moisturefrom skin, oral mucosa, respiratory tract (insensibleloss). Eg. Tepid sponge bath increases peripheralcirculation, thereby increasing heat loss by

evaporation


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Age infants body temp is greatly affected by temp ofenvironment.

- Elder individuals are at risk of hypothermia due to

decreased thermoregulatory controls, subcutaneous fats,inadequate fats & sedentary lifestyle.

Diurnal variations Highest temp usually reached between8pm- 12 mn; & lowest temp between 4-6 AM

Exercise strenuous exercise increases metabolic rate Hormones- progesterone, thyroxine, epinephrine &

norepinephrine inc. body temp, estrogen dec. body temp

Stress SNS stimulation inc. BMR thereby inc. body temp


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Glass mercury mercury expands or contracts inresponse to heat. (just recently non mercury)

Electronic heat sensitive probe, (reads in seconds)there is a probe for oral/axillary use (red) & a

probe for rectal use (blue). There are disposableplastic cover for each use. Relies on battery power return to charging unit after use.

Infrared Tympanic (Ear) sensor probe shaped like

an otoscope in external opening of ear canal. Earcanal must be sealed & probe sensor aimed attympanic membrane retn to charging unit afteruse.


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Oral temperature : 36.5 37.5 C

Axillary temperature 35.8 ~37 .0 C

Sublingual temperature 36.7~37.7 C

Rectal temperature36.9~38.1 C

Tympanic temperature: 36.8 37.9 C


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Oral most accessible & convenient method Allow 15 mins to elapse bet. a clients intake of hot /

cold food / smoking & measurement of oral temp.

Shake thermometer down to 35.5 deg Celsius Place thermometer under tongue, directed towards

side. Location ensures contact w/ large vessels undertongue.

Wash thermometer before use, from bulb to stem andafter use, from stem to bulb. ensures medicalasepsis

Take oral temp for 2-3 mins. ensures adequate timefor recording of the temp.


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Oral temperaturecan be taken bymouth using classic

glass mercury-filledor digitalthermometers.


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Oral lesions / surgery

Dyspnea

Cough

Nausea & vomiting Presence of oro-nasal pack, NGT / ET

Seizure-prone

Very young children Unconscious

Restless, disoriented / confused


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Rectal most accurate measurement of temp Assist client to assume lateral position to expose anal

area

Lubricate thermometer before insertionInsertthermometer by 0.5-1.5 inches

Instruct client to take deep breath during insertion ofthermometer

Hold thermometer in place for 2 mins (for neonates:5mins; make sure there is no imperforate anus)

Do not force insertion of thermometer

Note: rectal temp are recommended infrequently nowthat tympanic thermometers are available.


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Temperatures takenrectally (using amercury or digital

thermometer) tend tobe 0.5 to 0.7(Fahrenheit) higherthan when taken by

mouth.


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Anal / rectal conditions or surgeries Eg. Analfissure, hemorrhoids, hemorrhoidectomy

Diarrhea

Quadriplegic clients. Vagal stimulation may occurcausing bradycardia & syncope


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Axillary safest & most non-invasive method oftemp taking

Pat dry the axilla. Rubbing causes friction & will

increase temp in the area Place thermometer in the clients axilla

Place arm tightly across chest to keepthermometer in place for 9 mins (for infants &

children : 5 mins)


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Axillary temperaturescan be taken under thearm. Temperaturestaken by this route

tend to be 0.3 to 0.4(Fahrenheit)lower thanthose temperaturestaken by mouth.


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Tympanic useful for toddlers who squirm atrestraint for rectal route & useful also forpreschoolers who are not yet able to cooperate

for oral temp taking & yet fear invasion of rectaltemp taking


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Intermittent fever temp fluctuates betweenperiods of fever & periods of normal/subnormal temp.

Remittent fever temp fluctuates w/in a widerange over 24 hr period but remains abovenormal range.

Relapsing fever temp is elevated for fewdays, alternated w/ 1-2 days of normal temp.

Constant fever body temp is consistentlyhigh.

Very high temperatures (41-42 deg Celsius)


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Crisis or flush or defervescent stage suddendecline of fever

- indicates impairment of function ofhypothalamus

Lysis gradual decline of fever- indicates that the body is able to maintain

homeostasis.


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Onset (chill / cold stage) of fever

- increased heart rate

- increased resp. rate & depth

- shivering- pale, cold skin

- cyanotic nail bed

- complaints of felling cold

- goose flesh appearance in the skin- cessation of sweating

- rise in body temp.


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Course of Fever- absence of chills

- skin that feels warm

- feeling of being neither hot nor cold- increased pulse & resp. rate- increased thirst

- mild to severe dehydration

- drowsiness, restlessness, delirium &convulsions

- loss of appetite to eat

- malaise, weakness & aching muscles


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Defervescence (fever abatement)

- skin that appears flushed & feelswarm

- sweating

- decreased shivering

- possible dehydration


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Monitor vital signs Assess skin color and temperature.

Monitor WBC, Hct and other pertinent laboratoryrecords.

a. Elevated wbc levels indicate presence of infection.b. Elevated Hct indicates dehydration.

Remove excess blankets when the client feels warm;provide extra warmth when the client feels chilled.

Provide adequate foods and fluids. To provide

additional calories and to prevent dehydration. Measure Intake and Output.

Maintain prescribed IV fluids as ordered by thephysician.


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Provide measures to stimulate appetite and offer well-balanced meals to meet increased metabolic needs.

Promote rest. To reduce body heat production.

Provide cool, circulating air using a fan. To dissipate heat

by convection. Provide dry clothing and bed linens. To ensure comfort.

Provide TSB (Temperature of water 80-98F). To enhanceheat loss by evaporation and conduction.

Frequent changing of clothes is also necessary because ofincreased sweating.

Administer antipyretics as ordered. Temperature of 38.5Cand above usually require administration of antipyretic.


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Fahrenheitdiscovered at around 1700 by a Germanscientist Gabriel Fahrenheit who invented thethermometer by putting water in a thin glass tube.The warmer the temperature, the higher the waterwent up the tube.

Celsius discovered by Swedish professor AndersCelsius who defined a better scale for measuringtemperature. He proposed the scale using the boilingpoint of water as 100 C and the freezing point ofwater as 0 C. This made a lot more sense, and it wascalled the centigrade system. (Centi- means hundredand centigrade means divided into 100 units.)


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Celsius to Fahrenheit

The formula to convert Celsius to Fahrenheit is:

F = 9/5 C + 32

In other words, if C = 100 C (boiling point of water),then

F = (9 x 100)/5 + 32 = 212 F

Fahrenheit to Celsius

The formula to convert Fahrenheit to Celsius is: C = 5(F - 32)/9

In other words, if F = 50 F , then

C = 5*(50 - 32)/9 = 5*(18)/9 = 10 C


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Celsius to Kelvin

Converting from degrees Celsius to Kelvin issimple.

K = C + 273 Thus, if C = 10 C, the Kelvin temperature

would be 283 K.


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Vital signs


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A wave of blood created by contraction of theleft ventricle of the heart

Factors affecting Pulse Rate:- Age: younger people have higher pulse ratethan older ones

- Sex / Gender: Females have higher PR after

puberty- Exercise

- Medications: digitalis, beta-blockers dec. PR,epinephrine & atropine inc. PR


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Factors affecting Pulse Rate:- Hemorrhage

- Stress

- Position changes


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Left ventricle contracts causing a wave of bld to surgethrough arteries called a pulse. Felt by palpating arterylightly against underlying bone or muscle.

Carotid, brachial, radial, femoral, popliteal, posteriortibial, dorsalis pedis

Assess: rate, rhythm, strength can assess by usingpalpation & auscultation.

Pulse deficit the difference between the radial pulse and theapical pulse indicates a decrease in peripheral perfusion

from some heart conditions ie. Atrial fibrillation.


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Peripheral place 2nd, 3rd& 4th fingers lightly on skin wherean artery passes over an underlying bone. Do not use yourthumb (feel pulsations of your own radial artery). Count 30seconds X 2, if irregular count radial for 1 min. and thenapically for full minute.

Apical beat of the heart at its apex or PMI (point ofmaximum impulse) 5thintercostal space, midclavicular line,

just below lt. nipple listen for a full minute Lub-Dubs

Lub close of atrioventricular (AV) valves tricuspid &

mitral valves Dub close of semilunar valves aortic & pulmonic valves


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Rate N 60-100, average 80 bpm Tachycardia greater than 100 bpm

Bradycardia less than 60 bpm

Rhythm the pattern of the beats (regular or irregular)

Strength or size or amplitude, the volume of bld pushed against the wall ofan artery during the ventricular contraction

weak or thready (lacks fullness)

Full, bounding (volume higher than normal)

Imperceptible (cannot be felt or heard)

0----------------- 1+ -----------------2+--------------- 3+ ----------------4+

Absent Weak NORMAL Full Bounding


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Age Heart Rate (Beats/min)

Infants 120-160

Toddlers 90-140

Preschoolers 80-110

School agers 75-100

Adolescent 60-90

Adult 60-100


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Tension or elasticity, the compressibilityof the arterial wall, is pulse obliterated byslight pressure (low tension or soft)

Stethoscope Diaphragm high pitched sounds, bowel, lung & heart

sounds tight seal

Bell low pitched sounds, heart & vascular sounds, apply

bell lightly (hint think of Bell with the L for Low)


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The normalpulse forhealthy adultsranges from 60

to 100 beatsper minute.


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The pulse rate mayfluctuate andincrease with

exercise, illness,injury, andemotions. Girlsages 12and older

andwomen, ingeneral, tend tohave faster heartrates than do boys

and men.


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Athletes, suchas runners,may have heartrates in the

40's andexperience noproblems.


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You feel the beatsby firmly pressing

on the arteries,which are locatedclose to the surfaceof the skin at

certain points ofthe body.


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The pulse can befound on the side ofthe lower neck, onthe inside of theelbow, or at thewrist.


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Place thetips ofyour index andmiddle fingersjustproximal to thepatients wrist onthe thumb side,orienting them so

that they are bothover the length ofthe vessel.


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Push lightly at first,adding pressure ifthere is a lot ofsubcutaneous fat or

you are unable todetect a pulse. Ifyou push too hard,you might occlude

the vesselandmistake your ownpulsefor that of thepatient.


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Measure the rate ofthe pulse (recordedin beats perminute). Count for30 secondsandmultiply by 2 (or 15seconds x 4).


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If the rate isparticularly slow orfast, it is probablybest to measure fora full 60 secondsinorder to minimizethe error.


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Is the timebetween beatsconstant?.Irregularrhythms, arequite common.


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Does the pulse volumefeel normal? Thisreflects changes in stroke volume. Inhypovolemia, the pulse volume is relatively

vital signs-temp, pr

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