[HA SL] VITALS

OUTLINE

  1. Vital Signs
    1. When to assess
  2. Body Temperature
    1. Factors Affecting Body Temperature
    2. Sites for Body Temperature
    3. NormaL Ranges
    4. Conversion Table
    5. Types of Fever
    6. Purposes for Assessing Body Temperature
    7. Steps in Assessing Body Temperature

VITAL SIGNS

  • Measurement of the body’s most basic functions
  • Reflect the function of our body processes that are essential for life
  • Regulation of the following:
  1. Temperature
  2. Pulse/heart rate
  3. Respiratory rate
  4. Blood pressure
  • Useful in detecting/monitoring medical problems
  • Can be measure in a medical setting, home or site of emergency

TIMES TO ASSESS THE VITAL SIGNS

  1. On admission to health agency
  • As baseline data
  1. When there is a change in health status or report abnormal symptoms
  2. Before and after a surgery or invasive procedure
  • Could affect the respiratory or cardiovascular system
  1. Before or after any nursing intervention that could affect the vital signs

BODY TEMPERATURE

  • Reflect the balance between heat produced and heat loss from the body
  • Measured in degrees

FACTORS AFFECTING BODY TEMPERATURE

  • AGE
  • Infants and elderly are both greatly influenced by extreme environmental temperature
  • Decrease in thermoregulatory controls
  • DIURNAL OR CIRCADIAN RHYTHM VARIATION
  • Refers to the sleep-wake rhythm
  • Body temperature vary throughout the day
  • EXERCISE
  • Increases body temperature
  • HORMONES
  • Ovulation due to progesterone secretion
  • Raises body temperature
  • STRESS
  • Stimulation of sympathetic nervous system
  • Stimulation of produces epinephrine
  • Increases metabolic activity
  • Increased metabolic activity also increases body temperature
  • ENVIRONMENT
  • Externally affect the body’s thermoregulatory system

SITES FOR BODY TEMPERATURE

  • ORAL
  • Reflects changing body temperature more quickly than rectal method
  • The thermometer is placed under the tongue (sublingual)
  • Could injure mouth following oral surgery
  • ADVANTAGES
  • Accessible and convenient
  • DISADVANTAGES
  • Glass thermometer can break if bitten
  • Inaccurate if client has just ingested hot or cold food OR fluid, smoke
  • RECTAL
  • Readings are considered more accurate
  • Readings are taken per rectal area
  • ADVANTAGES
  • More reliable
  • DISADVANTAGES
  • Inconvenient and unpleasant
  • Patients who cannot turn to the sides
  • Could injure following rectal surgery
  • Presence of stool or feces may interfere with thermometer placement
  • If stool is soft, thermometer might be embedded in stool rather than the rectum
  • AXILLARY
  • Preferred for infants or new-borns
  • Accessible and offers no possibility of rectal perforation
  • ADVANTAGES
  • Safe and non-invasive
  • DISADVANTAGES
  • Thermometer must be left in place for a longer period
  • Obtain accurate measurement
  • TYMPANIC MEMBRANE
  • The nearby tissue in the ear canal is another core body temperature
  • Repeated measurements may vary
  • Right and left measurements may differ
  • Presence of cerumen (ear wax) can affect the reading of the temperature
  • ADVANTAGES
  • Readily accessible
  • Reflects the core temperature more faster
  • DISADVANTAGES
  • Can be uncomfortable .
  • Involves risk for injuring the membrane if probe inserted too far
  • FOREHEAD
  • Using a chemical thermometer or temporal artery thermometer
  • More useful in infants and children

NORMAL RANGE OF TEMPERATURES FOR ADULTS

LOCATION

FAHRENHEIT

CELSIUS

ORAL

97.6 - 99.6

36.5 - 37.5

RECTAL

98.6 - 100.6

37.0 - 37.5

AXILLARY

96.6 - 98.6

36.0 - 37.5

TYMPANIC

99.5 - 98.6

36.0 - 37.5

FOREHEAD

94.0

34.4 - 37.0

FAHRENHEIT TO CELSIUS

CELSIUS TO FAHRENHEIT

+32

TYPES OF FEVER

  • INTERMITTENT FEVER
  • Body temperature alternates at irregular intervals between periods of fever and period of normal and subnormal temperatures
  • REMITTENT FEVER
  • A wide range of temperature fluctuations
  • More than 2 degrees celsius or 3.6 degrees fahrenheit over 24 hour period
  • All are above normal
  • RELAPSING FEVER
  • Short febrile periods of a few days interspersed with periods of 1 to 2 days of normal temperature
  • CONSTANT FEVER
  • Body temperature fluctuates minimally but remains above normal
  • FEVER SPIKE
  • Temperature that rises to fever level rapidly following a normal temperature then returns to normal within a few hours

PURPOSES FOR ASSESSING BODY TEMPERATURE

  1. Establish baseline data for subsequent evaluation
  2. Identify whether core temperature is within normal range
  3. Determine changes in the core temperature in response to specific therapies
  4. Monitor clients at risk for imbalance temperature
  • Clients at risk for infection, exposed to extreme temperatures

ASSESSING BODY TEMPERATURE

  • ASSESSING
  • Clinical signs of fever
  • Clinical signs of hypothermia
  • Site most appropriate for measurement
  • Factors that might affect core body temperature
  • ASSEMBLE EQUIPMENT
  • Thermometer
  • Thermometer sheath or cover
  • Water soluble lubricant for rectal temperature
  • Disposable gloves
  • Towel for axillary temperature
  • towel/wipes
  • PROCEDURE
  1. Introduce yourself and verify client’s identity
  • Explain what you are going to do, why is it necessary and how they can cooperate
  1. Perform hand hygiene and observe other appropriate infection control
  2. Provide client privacy
  3. Place client in appropriate position
  4. Place thermometer
  • Apply protective sheath or probe cover
  • Lubricate if rectal thermometer is used
  1. Wait the appropriate amount of time
  • Electronic and tympanic thermometers will indicate that the reading is complete via light or tone
  • Check the instructions for the length or time one should wait prior reading the temperature