1. MEASURING VITAL SIGNS

2. 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

3. 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 and physiologic regulators are part of the assessment process.
Accurate measurements are an absolute requirement.

4. 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

5. 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

6. 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!!!!

7. Heat Production Heat is a by-product of metabolism
Basal Metabolic rate (BMR) – heat produced at rest
As metabolism increases, more heat is produced.

8. Factors Affecting Body Heat Production
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.

9. Factors Affecting Body Heat Production
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.

10. 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.

11. Hypothalamus acts as the thermostat to control body temperature

12. Body Temperature Regulation
Pyrogens may increase the thermostat’s set point higher (resulting in fever)
An increase in body temp results in peripheral vasodilation, sweating
(diaphoresis)
A decrease in body temp results in peripheral vasoconstriction, shivering

13. OTHER FACTORS THAT AFFECT TEMPERATURE
Menstrual cycle – varies with cycle
Emotional state, stress
Smoking -  temp
Medication
Eating, drinking, mouth breathing

14. DRINKING AFFECTS TEMP
If patient has been drinking, wait at least 15 minutes before taking a temperature

15. Changes in Vital Signs Occurring with Aging
Temperature: Heat loss may lead to hypothermia in the elderly.
Lower metabolic rate may also result in hypothermia in the elderly.

16. Body 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.

17. Body Temperature Measurements
Temperature measurements vary depending on site used.
Rectal temperatures are approximately 1° F higher than oral temperatures.
Axillary temperatures are approximately 1° F lower than oral temperatures.
Tympanic membrane measurement approximates core body temperature.

18. 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

19. 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

20. 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

21. Correct placement of oral thermometer

22. 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

23. 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

24. Normal Body Temperature
Ranges from 97.5 F to 99.5 F
Average of 98.6 F Or
36.4 C to 37.5 C
Average of 37.0 C

27. FEVER (Pyrexia) Body temperature above 100.2
Hypothalmus raises temp. set point.
Pyrogens such as bacteria cause an increased body temperature.
Immune system stimulated

28. Pyrexia Skin becomes flushed and moist Metabolism increases
Heart rate and respiratory rate increase

29. FEVER
Shaking chills (shivering) occurs when temperature is rising ALWAYS CHECK TEMP IF PT IS SHIVERING!!!
Sweating (diaphoresis) occurs when fever breaks

30. 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

31. 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

32. 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”

33. Nursing 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)

34. Complications of prolonged or very high fever
Dehydration
Delirium
Convulsions

35. Hypothermia 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

36. Nursing Process Assessment
Which route of temp measurement based on equipment available, situation, etc.
Age
Health status
Equipment in good working order, correct probe, probe covers, lubricant if needed.

37. Nursing Process
Nursing Diagnosis: 1. Hyperthermia R/T infection or excessive heat exposure AEB 2. Hypothermia R/T prolonged exposure to cold AEB 3. Ineffective thermoregulation R/T neurological injury AEB

38. Nursing Process Planning (Goals)
1. Afebrile after 3 days of antibiotics
2. Temperature normal within 6 hours
3. Temperature maintained <102 F with use of hypothermia blanket

39. 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.

40. Nursing Process Implementation: Measures to lower body temp.
Anti-pyretic medications
Increase fluid intake
Rest
Light clothing/bed coverings
Lower environmental temperature
Tepid sponge bath
Cooling blanket

41. 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