Vital signs (body temperature
Page 2: Learning Outcomes
Explain the physiologic processes involved in the regulation of temperature, pulse, respirations, and blood pressure.
The body requires a constant temperature to function properly.
Compare and contrast factors that increase or decrease body temperature, pulse, respirations, and blood pressure.
Identify sites for assessing temperature, pulse, and blood pressure.
List the characteristics that should be included when assessing pulses.
Demonstrate knowledge of the normal ranges for temperature, pulse, respirations, and blood pressure.
Page 3: Terminology
Metabolism: the set of chemical reactions that occur in living organisms to maintain life.
Page 4: Vital Signs
Vital signs include temperature, pulse, respiration, and blood pressure.
Pain is considered the fifth vital sign.
Page 5: Importance of Vital Signs
Vital signs are an indication of basic body functioning.
Accurate measurements of vital signs are critical.
Vital signs are called vital signs because of their importance.
Page 6: Vital Signs and Problem Solving
Vital signs provide the basis for problem solving.
Assessment of vital signs helps identify nursing diagnosis, implement interventions, and evaluate success.
Page 7: Body Temperature
Body temperature is the difference between the amount of heat produced by the body and the amount of heat lost to the environment.
The body requires a constant temperature to function properly.
Page 8: Core and Surface Body Temperature
Core temperature is the temperature of internal organs such as the heart, liver, and blood.
Skin temperature may vary depending on the environment or physical activity.
Core temperature is higher than surface body temperature.
Page 9: Regulation of Body Temperature
The thermoregulatory center in the hypothalamus is the body's built-in thermostat.
It can sense small changes in body temperature and stimulates the necessary response.
Heat production must equal heat loss.
Page 10: Heat Production
Heat is generated in the core tissues of the body during metabolism.
Other factors that increase heat production include physical activity, exercise, stress, increased production of thyroid hormones, and stimulation of the sympathetic nervous system.
Shivering is a mechanism of heat production.
Page 11: Heat Loss
Skin is the primary site of heat loss.
Heat is transferred to the external environment through radiation, conduction, convection, and evaporation.
Other losses include elimination of urine and feces.
Page 12: Mechanisms of Heat Transfer
Radiation: transfer of heat from one object to another without direct contact.
Conduction: transfer of heat to another object during direct contact.
Convection: loss of heat through the movement of air across the skin.
Evaporation: heat loss by the conversion of a liquid to a vapor.
Page 15: Homeostasis
Homeostasis is the balance that all living things have to maintain.
When this balance is threatened or lost, there is a serious risk to the well-being of the individual.
The nervous and endocrine systems play an important role in maintaining homeostasis.
Page 16: Control Systems in Homeostasis
Control systems detect and respond to changes in the internal environment.
A control system consists of a detector, control center, and effector.
Page 17: Components of Control Systems
Detector or Sensor: detects environmental stimuli and sends information to the control center.
Control Center: receives and processes information from the sensor and signals the effector.
Effector: responds to the commands of the control center and opposes or enhances the stimulus.
Page 18: Negative Feedback Mechanisms
Nearly all control systems are controlled by negative feedback mechanisms.
Negative feedback counteracts the effects that produced the incoming impulses.
Page 20: Temperature Control and Homeostasis
The autonomic nervous system monitors small fluctuations in core body temperature and initiates countermeasures to prevent temperature fluctuations beyond a tightly controlled set point.
Page 22: Normal Temperatures
Body temperature is documented in either Celsius or Fahrenheit degrees.
Average normal temperatures for healthy adults are 35.8°C - 37.5°C (96.4°F - 99.5°F).
Normal temperature varies depending on the route used for measurement.
Normal temperature varies among people.
A person with a normal body temperature is referred to as afebrile (without fever).
Page 25: Factors Affecting Body Temperature
Factors affecting body temperature include age, gender, exercise, hormonal influences, daily variation, stress, environment, ingestion of hot and cold liquids, smoking, and disease conditions.
Page 26: Variations in Temperature
Age, gender, physical activity, exercise, and disease conditions can cause variations in body temperature.
Page 28: Environmental Factors and Temperature
Environmental temperature, exposure to extreme cold or heat, can affect body temperature.
Hypothermia is low body temperature.
Hyperthermia is high body temperature.
Time of the day can also affect body temperature.
Stress can affect body temperature.
Page 29: Increased Body Temperature
Fever or pyrexia is an increase in body temperature above normal.
Fever is an indicator of health status.
Microorganisms, chemicals, cancer, trauma, and surgery can cause fever.
Page 30:
Increased body temperature
Most fevers, unless extremely high (above 40°C/104°F), are not harmful.
Beneficial effects of fever, include destruction of disease causing microorganisms, and enhanced immunity.
When fever is ≥41°C (106°F), it is referred to as hyperpyrexia.
The body must be cooled rapidly to prevent brain damage.
Page 31:
Types of fever
Continuous /sustained: the body temperature remains above normal with minimal variations.
Remittent: the body temperature does not return to normal and fluctuates a few degrees up and down.
Page 32:
Types of fever
Intermittent: the body temperature returns to normal at least once every 24 hours.
Relapsing or Recurrent: the body temperature returns to normal for one or more days with one or more episodes of fever each as long as several days.
Page 33:
Types of fever
Hyperthermia
Happens in situations of extreme heat exposure or excessive heat production (e.g., during strenuous exercise).
Mechanisms that control body temperature are ineffective.
Neurogenic fever
It results from damage to the hypothalamus from conditions like head injury.
Does not respond to antipyretic medications.
Page 34:
Types of fever
Fever of unknown origin (FUO)/pyrexia of unknown origin (PUO)
A fever of 38.3°C (101°F) or higher that lasts for 3 weeks or longer.
Without an identified cause.
Page 35:
Physical Effects of Fever
Loss of appetite
Headache
Hot, dry skin
Thirst
Muscle aches
Fatigue
Increase in respirations and pulse rate
Fluid electrolyte imbalances
Page 36:
Treatment of Fever
Determining the cause of the fever
Treating its underlying cause
Antibiotics - In case of any infection
Antipyretic (fever-reducing) drugs, such as aspirin, ibuprofen, or acetaminophen
Page 37:
Treatment of Fever
Provide comfort and prevent complications.
Modifications of the external environment
Cool sponge baths
Cool packs
Cooling blankets.
Increase Oral fluids to prevent dehydration.
Diet - Simple carbohydrates.
Page 38:
Decreased Body Temperature
Hypothermia is a body temperature below the lower limit of normal.
It occurs when the physiologic responses meant to produce and retain heat are ineffective.
Page 39:
Decreased Body Temperature
Conditions such as unprotected exposure to cold environments, alcoholism, malnutrition and hypothyroidism
Death may occur when body temperature falls below 35°C (95°F)
Page 40:
Physical Effects of Hypothermia
Poor coordination
Slurred speech
Poor judgment
Respirations increase
Pulse becomes weak and irregular
Blood pressure drops.
Page 41:
Treatment of Hypothermia
Rewarming the patient.
Covering with additional clothing and blankets
Use of heating blankets and pads
Warm fluids either orally or through the intravenous route.
Page 43:
Assessing Temperature
Choose the right or appropriate equipment, site, and method.
Equipments
Electronic and digital thermometers,
Tympanic membrane thermometers
Disposable single-use thermometers
Temporal artery thermometers,
Automated monitoring devices.
Follow the manufacturer’s instructions to ensure accurate measurement.
Page 44:
Electronic and Digital Thermometers
Battery-operated devices provide a numerical temperature display.
Page 45:
Tympanic Membrane Thermometers
Use infrared sensors to detect heat given off by the tympanic membrane.
The probe is inserted into the ear canal.
Page 46:
Tympanic Membrane Temperature
Not be used for patients who have drainage from the ear, ear pain, ear infection, or scars on the tympanic membrane.
Readings are approximately equal to oral.
Page 47:
Disposable Single-use Thermometers
Temperature-sensitive patches or tape, commonly applied to the abdomen or forehead, change color at different temperature ranges.
Page 48:
Temporal Artery Thermometers
Measure body temperature by capturing the heat emitted by the skin over the temporal artery.
Battery operated and have a temperature display.
Page 49:
Temporal Artery Temperature
Measurement on the right or left side of the forehead
Look for anything covering the area such as a hat, hair, wigs, or bandages to avoid falsely readings.
It is approximately equal to oral temperature.
Page 50:
Automated Monitoring Devices
Devices are used to measure body temperature, pulse, respirations, and blood pressure simultaneously.
Require less of the nurse’s time, especially when these are monitored frequently.
Page 51:
Choosing the Sites and Methods
Factors affecting site selection
Age
Level of consciousness
Presence and amount of pain
Common sites- Document the site.
Oral (sublingual)
Tympanic
Temporal artery
Rectal
Axillary
Page 52:
Oral Temperature
An electronic probe is placed under the tongue (sublingual area) of a person’s mouth.
Patient must be able to close his or her mouth around the probe.
Page 53:
Oral Temperature
Wait 15 to 30 minutes, if a patient has had either hot or cold food or fluids or has been smoking or chewing gum,
Not used in people with diseases of the oral cavity and in case of surgery of the nose or mouth, receiving oxygen by mask
Page 54:
Manual mercury thermometer
A thermometer consisting of mercury in a glass tube.
Cheap, Accurate, and Simple to use
Display is harder to read and Fragile
Mercury vapor is poisonous.
Page 55:
Axillary Temperature
Place the probe in the center of the axilla
Hold the patient’s arm by the patient’s side until the measurement is complete
Readings are lower than oral.
Page 56:
Rectal Temperature
One of the most accurate routes.
Not be used in newborns, children with diarrhea, and in patients who have heart or rectal diseases, rectal or heart surgery, or blood disorders.
Rectal temperature readings are high