Temperature, pulse, respiration, blood pressure (B/P) & oxygen saturation are the most frequent measurements taken

by HCP. Because of the importance of these measurements they are referred to as Vital Signs. They are important indicators of the bodys response to physical, environmental, and psychological stressors.

VS may reveal sudden changes in a clients condition in addition to changes that occur progressively over time. A baseline set of VS are important to identify changes in the patients condition. VS are part of a routine physical assessment and are not assessed in isolation. Other factors such as physical signs & symptoms are also considered. Important Consideration:
A clients normal range of vital signs may differ from the standard range.

1. 2. 3. 4. 5.

6. 7. 8.

On a clients admission According to the physicians order or the institutions policy or standard of practice When assessing the client during home health visit Before & after a surgical or invasive diagnostic procedure Before & after the administration of meds or therapy that affect cardiovascular, respiratory & temperature control functions. When the clients general physical condition changes LOC, pain Before, after & during nursing interventions influencing vital signs When client reports symptoms of physical distress

Vital signs

Body temperature balance between heat produced by the 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 oral temp is 37 degrees Celsius (98.7F) w/ a range of 35.8 37.3 degrees Celsius (96.4 99.1 F). The rectal temp measures 0.4 0.5 degrees Celsius (0.7-1F) higher. Surface Temperature temp of the skin, subcutaneous tissue & fat. Measured by taking axillary temperature. Body heat is primarily produced by metabolism The heat regulating center is found in the hypothalamus

Core temperature temperature of the body tissues, is controlled by the hypothalamus (control center in the brain) maintained within a narrow range. Skin temperature rises & falls in response to environmental conditions & depends on bld flow to skin & 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, highest during the evening.

Basal Metabolic Rate (BMR) The younger the person, the higher the BMR; the older the person, the lower the BMR. Therefore, older individuals have lower body temp than younger ones. Muscle Activity (exrecise, swimming) increases cellular metabolic rate, therefore, increases body heat production. Thyroxin Output increases cellular metabolic rate (chemical thermogenesis). Hyperthyroidism is characterized by increased body temp. Epinephrine, norepinephrine & sympathetic stimulation increases rate of cellular metabolism which in turn increases body temp.

Radiation transfer of heat from surface of 1 object to the surface of another w/o contact between 2 objects. Eg. It feels warm in a crowded room. Conduction transfer of heat from 1 surface to another. It requires temp. difference between 2 surfaces. Eg. Application of moist wash cloth over skin. Convection dissipation of heat by air currents. Eg. Exposure of skin towards electric fan. Evaporation continuous vaporization of moisture from skin, oral mucosa, respiratory tract (insensible loss). Eg. Tepid sponge bath increases peripheral circulation, thereby increasing heat loss by evaporation

Age infants body temp is greatly affected by temp of environment. - Elder individuals are at risk of hypothermia due to decreased thermoregulatory controls, subcutaneous fats, inadequate fats & sedentary lifestyle. Diurnal variations Highest temp usually reached between 8pm- 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

Glass mercury mercury expands or contracts in response 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 disposable plastic 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. Ear canal must be sealed & probe sensor aimed at tympanic membrane retn to charging unit after use.

Oral temperature : 36.5 37.5 C Axillary temperature 35.8 ~37 .0 C Sublingual temperature 36.7~37.7 C

Rectal

temperature 36.9~38.1 C

Tympanic temperature: 36.8 37.9 C

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 under tongue. Wash thermometer before use, from bulb to stem and after use, from stem to bulb. ensures medical asepsis Take oral temp for 2-3 mins. ensures adequate time for recording of the temp.

Oral temperature can be taken by mouth using classic glass mercury-filled or digital thermometers.

Oral lesions / surgery Dyspnea Cough Nausea & vomiting Presence of oro-nasal pack, NGT / ET Seizure-prone Very young children Unconscious Restless, disoriented / confused

Rectal most accurate measurement of temp

Assist client to assume lateral position to expose anal area Lubricate thermometer before insertionInsert thermometer by 0.5-1.5 inches Instruct client to take deep breath during insertion of thermometer 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 now that tympanic thermometers are available.

Temperatures taken rectally (using a mercury or digital thermometer) tend to be 0.5 to 0.7 (Fahrenheit) higher than when taken by mouth.

Anal / rectal conditions or surgeries Eg. Anal fissure, hemorrhoids, hemorrhoidectomy Diarrhea Quadriplegic clients. Vagal stimulation may occur causing bradycardia & syncope

Axillary safest & most non-invasive method of temp 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 keep thermometer in place for 9 mins (for infants & children : 5 mins)

Axillary temperatures can be taken under the arm. Temperatures taken by this route tend to be 0.3 to 0.4 (Fahrenheit) lower than those temperatures taken by mouth.

Tympanic useful for toddlers who squirm at restraint for rectal route & useful also for preschoolers who are not yet able to cooperate for oral temp taking & yet fear invasion of rectal temp taking

By ear a special thermometer can quickly measure the temperature of the ear drum, which reflects the body's core temperature.

Pyrexia body temperature above normal range - also known as hyperthermia or fever Hyperpyrexia very high fever, 41 deg Celsius & above Hypothermia - core body temperature of less than 350C. - may be caused by excessive heat loss, inadequate heat production / impaired hypothalamic function

Intermittent fever temp fluctuates between periods of fever & periods of normal/ subnormal temp. Remittent fever temp fluctuates w/in a wide range over 24 hr period but remains above normal range. Relapsing fever temp is elevated for few days, alternated w/ 1-2 days of normal temp. Constant fever body temp is consistently high. Very high temperatures (41-42 deg Celsius)

Crisis or flush or defervescent stage sudden decline of fever - indicates impairment of function of hypothalamus Lysis gradual decline of fever - indicates that the body is able to maintain homeostasis.

Onset (chill / cold stage) of fever

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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.

- 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

Course of Fever

Defervescence (fever abatement) - skin that appears flushed & feels warm - sweating - decreased shivering - possible dehydration

Monitor vital signs Assess skin color and temperature. Monitor WBC, Hct and other pertinent laboratory records. 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 the physician.

Provide measures to stimulate appetite and offer wellbalanced 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 enhance heat loss by evaporation and conduction. Frequent changing of clothes is also necessary because of increased sweating. Administer antipyretics as ordered. Temperature of 38.5C and above usually require administration of antipyretic.

Fahrenheit discovered at around 1700 by a German

scientist Gabriel Fahrenheit who invented the thermometer by putting water in a thin glass tube. The warmer the temperature, the higher the water went up the tube. Celsius discovered by Swedish professor Anders Celsius who defined a better scale for measuring temperature. He proposed the scale using the boiling point of water as 100 C and the freezing point of water as 0 C. This made a lot more sense, and it was called the centigrade system. (Centi- means hundred and centigrade means divided into 100 units.)

Kelvin - was determined based on the Celsius scale, but with a starting point at absolute zero. Temperatures in the Kelvin scale are 273 degrees less than in the Celsius scale. Thus absolute zero is -273 C and the boiling point of water 100 C is 373 K or 373 kelvins.

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

Celsius to Kelvin Converting from degrees Celsius to Kelvin is simple. K = C + 273 Thus, if C = 10 C, the Kelvin temperature would be 283 K.

Vital signs

A wave of blood created by contraction of the left ventricle of the heart Factors affecting Pulse Rate: - Age: younger people have higher pulse rate than older ones - Sex / Gender: Females have higher PR after puberty - Exercise - Medications: digitalis, beta-blockers dec. PR, epinephrine & atropine inc. PR

 Factors

affecting Pulse Rate: Hemorrhage Stress Position changes

Temporal: over temporal bone of head; superior & lateral to eye Carotid: at lateral aspect of neck, below ear lobe Apical: at left MCL 5th ICS w/ the aid of stethoscope Brachial: at inner aspect of upper arm / medially at antecubital space Radial: on thumb side of inner aspect of wrist Femoral: alongside of inguinal ligament Posterior Tibial: medial aspect of ankle behind medial malleolus Popliteal: back of knee Pedal (Dorsalis Pedis): at dorsum of foot

Left ventricle contracts causing a wave of bld to surge through arteries called a pulse. Felt by palpating artery lightly against underlying bone or muscle. Carotid, brachial, radial, femoral, popliteal, posterior tibial, dorsalis pedis Assess: rate, rhythm, strength can assess by using palpation & auscultation. Pulse deficit the difference between the radial pulse and the apical pulse indicates a decrease in peripheral perfusion from some heart conditions ie. Atrial fibrillation.

Peripheral place 2nd, 3rd & 4th fingers lightly on skin where an artery passes over an underlying bone. Do not use your thumb (feel pulsations of your own radial artery). Count 30 seconds X 2, if irregular count radial for 1 min. and then apically for full minute. Apical beat of the heart at its apex or PMI (point of maximum impulse) 5th intercostal 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

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 of an 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

Age Infants Toddlers Preschoolers School agers Adolescent Adult

Heart Rate (Beats/min) 120-160 90-140 80-110 75-100 60-90 60-100

Tension or elasticity, the compressibility of the arterial wall, is pulse obliterated by slight 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)

The normal pulse for healthy adults ranges from 60 to 100 beats per minute.

The pulse rate may fluctuate and increase with exercise, illness, injury, and emotions. Girls ages 12 and older and women, in general, tend to have faster heart rates than do boys and men.

Athletes, such as runners, may have heart rates in the 40's and experience no problems.

You feel the beats by firmly pressing on the arteries, which are located close to the surface of the skin at certain points of the body.

The pulse can be found on the side of the lower neck, on the inside of the elbow, or at the wrist.

Place the tips of your index and middle fingers just proximal to the patients wrist on the thumb side, orienting them so that they are both over the length of the vessel.

Push lightly at first, adding pressure if there is a lot of subcutaneous fat or you are unable to detect a pulse. If you push too hard, you might occlude the vessel and mistake your own pulse for that of the patient.

Measure the rate of the pulse (recorded in beats per minute). Count for 30 seconds and multiply by 2 (or 15 seconds x 4).

If the rate is particularly slow or fast, it is probably best to measure for a full 60 seconds in order to minimize the error.

Is the time between beats constant?. Irregular rhythms, are quite common.

Does the pulse volume feel normal? This reflects changes in stroke volume. In hypovolemia, the pulse volume is relatively low