VITAL SIGNS

➢ Also termed as cardinal signs.

➢ Reflects the body’s physiological status and provides information critical to evaluating homeostatic balance.

➢ What are the five critical assessment areas?

○ Temperature

○ Pulse

○ Respiration

○ Blood pressure

○ and Pain

HOW FREQUENT SHOULD VITAL SIGNS BE TAKEN?

- Frequency of vital sign measurements is determined by:

1. Client’s health status

2. Physician’s orders

3. the established standards of care for the particular setting

- Note: Whenever change is suspected in the client’s status, the nurse SHOULD CHECK the signs, regardless of setting.

BODY TEMPERATURE

➢ measure of heat inside the body

➢ reflects the balance between the heat produced and the heat lost from the body

➢ Measured in heat units called degrees.

➢ Measured in either the centigrade scale or the fahrenheit scale

➢ Temperatures are measured in degrees Celsius (°C) or degrees Fahrenheit (°F). The table below shows equivalent Celsius and Fahrenheit temperatures.

37°C 98.6°F 38.9C 102°F

37.2°C 99°F 39.5°C 103°F

37.5°C 99.5°F 40°C 104°F

37.8°C 100°F 40.6°C 105°F

38°C 100.4°F 41.1°C 106°F

38.3°C 101°F 41.7°C 107°F

KINDS OF BODY TEMPERATURE

1. Core temperature

- temperature of the deep tissues of the body

- remains relatively constant

2. Surface temperature

- temperature of the skin, subcutaneous tissue and fat.

- rises and falls in response to the environment

FACTORS AFFECTING BODY TEMPERATURE

A. Age

B. Exercise

C. Hormones

D. Stress

E. Environment

F. Diurnal variations

COMMON SITES FOR MEASURING BODY TEMPERATURE

1. Oral

- accessible & convenient

- can break if bitten

- inaccurate if client ingested hot or cold food or drinks or smoked

2. Axillary

- safe and noninvasive

- thermo must be left in place a long time to obtain an accurate measurement

3. Rectal

- reliable measurement

- inconvenient & unpleasant for clients

- presence of stool may interfere with result

4. Tympanic

- readily accessible; fast

- reflects core temperature

- uncomfortable and risky

- R and L measurements can differ

INSTRUMENT USED IN TEMPERATURE TAKING

➢ “Thermo” - warm

➢ “Meter” - to measure

Common Types of Thermometer:

1. Electronic thermometer – equipment that consists of a battery-operated portable electronic unit designed with a probe for either oral or rectal.

2. Temperature sensitive tape – tape that contains liquid crystals that change color according to the temperature. Applied to the skin, usually the forehead or abdomen.

3. Chemical disposable thermometer – has liquid crystal dots or bars that change color to indicate temperature.

4. Temporal artery thermometer – a scanning infrared thermometer that compares arterial temperature to room temperature. calculates the heat balance to approximate the core temperature.

RATIONALE

1. To determine if core temperature is within normal range

2. To provide baseline data for further evaluation

3. To determine alteration in disease condition

4. To determine changes in response to specific therapies.

THERMOMETER TRAY INCLUDES

● Thermometer

● Thermometer probe and cover

● Container with thermometer wipes

● Waste receptacle

TAKING THE ORAL TEMPERATURE

SPECIAL CONSIDERATIONS

1. Patient must be conscious & can hold the thermometer securely under his tongue & can breathe through his nose.

2. Allow 15 minutes to lapse before taking the temperature by mouth if client has taken hot or cold drink or has been smoking.

3. Take note of the contraindications for taking oral temperature.

TAKING THE AXILLARY TEMPERATURE

SPECIAL CONSIDERATIONS

1. This method should be used only when there is no other way of obtaining the body temperature. This is considered the least reliable method.

2. Use this procedure when no individual clean oral thermometer is available.

TAKING THE RECTAL TEMPERATURE

SPECIAL CONSIDERATIONS

➢ Indications:

○ critically ill, disoriented, senile & unconscious

○ dyspneic, unable to keep the mouth closed for any reason.

➢ Contraindications:

○ coronary precaution

○ rectal or perineal surgery

○ inflamed rectum

○ eye surgery

TAKING THE TYMPANIC TEMPERATURE

SPECIAL CONSIDERATIONS

➢ Apply disposable cover onto the tympanic thermometer

➢ Turn device “on” by pressing button on front

➢ Place thermometer in ear and depress top button to make reading

➢ After reading, flop the blue tab to release the disposable probe cover without contact

➢ Turn the client's head to one side. For an adult, pull pinna upward and back; for a child, pull down and back

➢ Gently insert probe with firm pressure into ear canal.

➢ Gentle insertion prevents trauma to external canal. Firm pressure is needed to ensure probe will record an accurate temperature.

PALPATING THE PULSE

FACTORS AFFECTING PULSE RATE

1. Age

2. Sex

3. Exercise

4. Fever

5. Medications

6. Hemorrhage

7. Stress

8. Position changes

PULSE SITES

➢ Commonly used site – radial artery because it is readily accessible

COUNTING RESPIRATION

➢ What is respiration?

- Is the act of breathing. It includes intake of oxygen (inhalation) and output of carbon dioxide (exhalation).

ASSESSMENT

➢ Rate – how many breaths per minute

➢ Depth – breathing may be normal, deep or shallow

➢ Quality – breathing different from normal, effortless breathing

➢ Rhythm – regularity of expiration & inspiration

➢ Effectiveness – measured in part by the uptake of O2 from the air into the blood & the release of carbon dioxide from the blood into expired air

SPECIAL CONSIDERATIONS

➢ For what purpose do we check or count the client’s respiration?

○ Quiet down an infant or child before respirations are counted.

○ Observe the rise and fall of the abdomen if the client is a young child.

○ Ask the older adult to remain quiet or count respirations after taking the pulse.

ASSESSING THE BLOOD PRESSURE

➢ Sphygmomanometer – instrument used in measuring the blood pressure in the arteries.

➢ Aneroid sphygmomanometer – has calibrated dial with a needle that points to the calibrations

➢ Digital (electronic) sphygmomanometer

SPECIAL CONSIDERATIONS

1. Ensure that the equipment is intact and functioning properly.

2. Make sure that the client has not smoked or ingested caffeine within 30 minutes prior to measurement.

3. Do not measure BP in any limb in the ff. situations:

● when there is injury or disease

● when there is a cast or bulky bandages

● When client has had mastectomy or removal of axillary lymph nodes

● When client has an IV or blood transfusion in the limb.

1) Why should we put the client’s feet flat on the floor when taking the blood pressure? – Crossing the knee results in elevated systolic and diastolic pressures.

2) Why do we position the arm at heart level? – BP increases when arm is below the level of the & decreases when above the

3) Why must the cuff be wrapped evenly around the upper arm? – To allow the bladder of the cuff to compress the artery.

4) How far should the lower border of the cuff be positioned on the arm? – approximately 2.5 cm above the antecubital space

5) When does the nurse stop pumping up the cuff when taking the blood pressure? – Pump up until 30 mmHg above the point where the brachial pulse disappeared.

6) How long must one wait if the BP has to checked the second time? – wait 2 minutes before taking a second reading