MEASURING VITAL SIGNS

OBJECTIVES

• At the end of this lesson, the SPN will be able to:– 1. Explain the correct procedure for recording all

vital signs– 2. Describe the appropriate technique for

measuring all vital signs– 3. Explain factors which may alter vital signs– 4. Demonstrate the procedure for measuring and

recording all vital signs

Five Vital Signs

• Temperature, pulse, respiration, blood pressure, and pain– Vital signs give indications as to the current health status

of the patient and clues to changes in conditions as they occur.

– Knowing age-variable normal values andphysiologic regulators are part of the assessment process.

– Accurate measurements are an absolute requirement.

When Should I Measure a Patient’s Vital Signs?

• The frequency of vital signs depends on the patient’s condition and the events taking place.

• The following are common occasions for assessing vital signs:– 1. On admission to the hospital– 2. At the beginning of a shift, for inpatients– 3. At a visit to a healthcare providers office or

clinic

Taking of Vital Signs Con’t.

– 4. Before, during, and after surgery or certain procedures

– 5. To monitor the effects of certain medications or activities

– 6. Whenever the patient’s condition changes– 7. ***When a client’s VS vary from their baseline,

you should assess and document them more frequently

How Do I Document Vital Signs?

• Most agencies have special flowsheets for documenting vital signs

• ****If VS are not within normal limits, you will also document them in the nurse’s notes , along with any associated symptoms which you will learn in assessment!!!****

• Document any interventions that you did• Document the patient’s response to those

interventions!!!!

Heat Production

Heat is a by-product of metabolism

Basal Metabolic rate (BMR) – heat produced at rest

As metabolism increases, more heat is produced.

Factors Affecting Body Heat Factors Affecting Body Heat ProductionProduction

• Basal metabolic rate (BMR) is affected by the thyroid hormone.

• Increased thyroid hormone causes an increase in metabolic rate and increased temperature.

• Decreased levels of thyroid hormone result in a deceased metabolic rate and a decreased body temperature.

Factors Affecting Body Heat Factors Affecting Body Heat ProductionProduction

Other hormones affecting metabolic rate:– Epinephrine–Norepinephrine–Testosterone

• Men have a higher BMR than women because of testosterone.

• Voluntary muscle movement causes increased heat production.

• Shivering can increase heat production up to five times normal.

OTHER FACTORS THAT AFFECT TEMPERATURE

• Time of day – lower in AM• Environmental temperature• Age of patient – lower in elderly• Physical exercise - temp • INFECTION - When the body is invaded by

pathogens, the body elevates the temperature to elevate the basal metabolic rate in an effort to destroy pathogens.

Hypothalamus acts as the thermostat to control body temperature

Body Temperature Regulation

• Pyrogens may increase the thermostat’s set point higher (resulting in fever)

• An increase in body tempresults in peripheralvasodilation, sweating

(diaphoresis)• A decrease in body temp

results in peripheralvasoconstriction, shivering

OTHER FACTORS THAT AFFECT TEMPERATURE

• Menstrual cycle – varies with cycle

• Emotional state, stress• Smoking - temp • Medication• Eating, drinking, mouth breathing

DRINKING AFFECTS TEMP

• If patient has been drinking, wait at least 15 minutes before taking a temperature

Changes in Vital Signs Occurring with Changes in Vital Signs Occurring with AgingAging

• Temperature: Heat loss may lead to hypothermia in the elderly.

• Lower metabolic rate may also result in hypothermia in the elderly.

Body Temperature RegulationBody Temperature Regulation

Heat loss occurs through the skin’s exposure to the environment through:– Radiation– Conduction– Convection– Evaporation• Heat being lost by evaporation results in 800-

mL loss of water each day.

Body Temperature MeasurementsBody Temperature Measurements

• Temperature measurements vary depending on site used.

• Rectal temperatures are approximately1° F higher than oral temperatures.

• Axillary temperatures are approximately1° F lower than oral temperatures.

• Tympanic membrane measurement approximates core body temperature.

Types of thermometers

• Glass thermometer (mercury –obsolete)–Oral (blue tip) or rectal (red tip)

• Electronic thermometer (oral or rectal)• Tympanic thermometer• Disposable thermometer (skin sensor)• Temporal artery thermometer

Routes used to monitor temperature• Oral

•Placed under tongue•Not accurate immediately after hot

or cold p.o. intake or smoking.• Axillary

•Not as invasive, but less reliable•Normally one degree lower than oral

Routes used to monitor temperature• Rectal

• Lubricated & inserted ½-1 ½ inches into rectum towards umbilicus• Held in place for baby/child• Normally one degree higher than

oral• Contraindicated for pt after rectal

surgery

Correct placement of oral thermometer

Tympanic Thermometer• Tympanic• Adult – grasp top of ear & gently pull up

& back to straighten ear canal• Child < 2 – pull ear lobe down & back to

straighten ear canal• Probe must be sealed in the ear canal• Infection or wax may give false reading• Closest to core temperature

Temporal Artery Thermometer

• Newest route to monitor temperature• Stroke of forehead captures heat emitted

from skin over temporal artery (in front of ear)

• Supposedly most accurate of all temp• Close to rectal temperature, although will

indicate fever or reduced fever much faster than rectal

Normal Body Temperature

Ranges from 97.5 F to 99.5 FAverage of 98.6 F

Or36.4 C to 37.5 C

Average of 37.0 C

FEVER (Pyrexia)•Body temperature above 100.2

•Hypothalmus raises temp. set point.

•Pyrogens such as bacteria cause an increased body temperature.

•Immune system stimulated

PyrexiaPyrexia

• Skin becomes flushed and moist• Metabolism increases• Heart rate and respiratory rate increase

FEVER

• Shaking chills (shivering) occurs when temperature is rising ALWAYS CHECK TEMP IF PT IS SHIVERING!!!

• Sweating (diaphoresis) occurs when fever breaks

3 stages of fever• 1. Onset-Body temp is rising but

has not yet reached the new set point. Patient feels chilly and uncomfortable. May shiver • May be sudden or gradual

depending on the condition causing it

3 Stages of Fever Con’t

• 2. FEVER- the period when the body temperature reaches its maximum and remains fairly constant at the new higher level.

• The person is flushed and feels warm and dry during this phase, which may last from a few days to a few weeks

3 Stages of a Fever Con’t.

• 3. Defervescence-The period when the temperature returns to normal

• The person feels warm and appears flushed in response to vasodilation

• Diaphoresis occurs, which assists with heat loss by evaporation

• This stage is commonly referred to as the fever’s”breaking”

Nursing Interventions to Reduce FeverNursing Interventions to Reduce Fever

• Increase patient’s fluid intake• Lower room temperature• Increase the rate of circulating air• Remove excessive clothing or bed covers• Control or reduce the amount of body activity• Provide sponge bath or cooling blanket• Antipyretics (acetaminophen, ibuprofen)

Complications of prolonged or very high fever

• Dehydration• Delirium• Convulsions

HypothermiaHypothermia

• Body temperature lower than 94° F• People at risk for hypothermia:– Infants– Surgical patients in the operating room– Elderly exposed to cold for prolonged

periods–People exposed to extreme cold weather –People exposed to cold water immersion

Nursing Process

• AssessmentWhich route of temp measurement based on

equipment available, situation, etc.AgeHealth status

Equipment in good working order, correct probe, probe covers, lubricant if needed.

Nursing Process

Nursing Diagnosis:1. Hyperthermia R/T infection or

excessive heat exposure AEB2. Hypothermia R/T prolonged

exposure to cold AEB3. Ineffective thermoregulation R/T

neurological injury AEB

Nursing Process

Planning (Goals)1. Afebrile after 3 days of antibiotics2. Temperature normal within 6 hours3. Temperature maintained <102 F with use of hypothermia blanket

Nursing Process

Implementation:Monitor temp. q4 h with infection or fever, pt feels warm or unwell, on admission, before and after surgery or invasive procedure.

Nursing Process

Implementation: Measures to lower body temp.Anti-pyretic medicationsIncrease fluid intake

Rest Light clothing/bed coverings

Lower environmental temperature Tepid sponge bath

Cooling blanket

Temperature Conversion

• To convert degrees C° to F°, multiply by 1.8 then add 32

• To convert F° to C°, subtract 32 then multiply by 0.5556