2. Chapter 1 Vital Signs Copyright © The McGraw-Hill Companies, Inc.

3. Chapter 9 2 Objectives Recognize normal and abnormal values and characteristics of temperature, pulse, respirations, and blood pressure for infants, children, and adults. Recognize common terminology and abbreviations used in documenting and discussing vital signs.

4. Copyright © The McGraw-Hill Companies, Inc. Chapter 9 3 Objectives (cont.) Compare the methods and contraindications of measuring oral, tympanic, axillary, and rectal temperatures.

5. Copyright © The McGraw-Hill Companies, Inc. Chapter 9 4 Objectives (cont.) Identify the sites for assessing the pulse and blood pressure. List the effects of high and low blood pressure on the body. Successfully complete 9 vital signs procedures.

6. Copyright © The McGraw-Hill Companies, Inc. Chapter 9 5 Signs 9-1 Temperature Pulse Respiration Blood Pressure

7. Copyright © The McGraw-Hill Companies, Inc. Chapter 9 6 Vital Signs Vital Signs (VS)signs of life are the most important measurements you will obtain when you evaluate or assess a client’s condition. this will enable the assessment of the level at which the individual is functioning.

8. Copyright © The McGraw-Hill Companies, Inc. Frequency of vital signs: vital signs are assessed at least every 4 hours in hospitalized patients with elevated temperatures, with low or high blood pressures, with changes in pulse rate or rhythm or with respiratory difficulty as well as in patients who are taking medications that effect cardiovascular or respiratory function or who had a surgery. Chapter 9 7

9. Copyright © The McGraw-Hill Companies, Inc. Chapter 9 8 Temperature Body temperature (T) is one of the first assessments done. Definition of body temperature The balance between the heat produced by the body and the heat loss from the body. Regulation of body temperature: the hypothalamic integrator,

10. Copyright © The McGraw-Hill Companies, Inc. Core temperature is the temperature of the deep tissues of the body such as abdominal cavity and pelvic cavity; it remains relatively constant. The surface temperature is the temperature of the skin, the subcutaneous tissue, and fat. It rises and falls in response to the environment. When the amount of heat produced by the body equals the amount of heat loss, the person is in heat balance. Chapter 9 9

11. Copyright © The McGraw-Hill Companies, Inc. Factors affecting body temperature: Age; the body temperature of infants and children changes more rapidly in response to both heat and cold. Hormones; women tend to have more fluctuations in body temperature than men as a result of hormones changes Chapter 9 10

12. Copyright © The McGraw-Hill Companies, Inc. Stress; the body respond to both emotional and physical stress as a threat increasing the production of epinephrine and nor epinephrine as a result the metabolic rate increases raising the body temperature Environmental temperature; we are responding to a change in environment either by wearing or less clothes. Exercise, hard work or strenuous exercise can increase body temperature. Chapter 9 11

13. Copyright © The McGraw-Hill Companies, Inc. Temperature Ranges – Normal adult temperature is 98.6ºF, or 37ºC. – Normal range can be from 96.8ºF to 100.4ºF, or 36ºC to 38ºC. Chapter 9 12

14. Copyright © The McGraw-Hill Companies, Inc. Alterations in body temperature There are two primary alterations in body temperature: pyrexia and hypothermia Pyrexia A body temperature above the usual range is called pyrexia, hyperthermia, or fever. Hyperpyrexia; is a very high fever usually above 41 °C and survival is rare when the temperature Reaches 44 °C and death due to damaging effects on the respiratory center. The client who has a fever is referred to as febrile; the one who does not is afebrile. Chapter 9 13

15. Copyright © The McGraw-Hill Companies, Inc. The signs and symptoms of fever: loss of appetite, headache, hot, dry skin, flushed face, thirst and general malaise. Young children or other people with high fevers may experience periods of delirium or seizures. Chapter 9 14

16. Copyright © The McGraw-Hill Companies, Inc. Nursing Interventions for Client's with fever: Monitor vital signs Assess skin color and temperature Monitor WBC, HCT, and other laboratory reports for indications of infection or dehydration Remove excess blanket when the client feels warm, but provide extra warmth when the client feels chilled. Measure intake and output Provide adequate nutrition and fluid Reduce physical activity to limit heat production.

17. Copyright © The McGraw-Hill Companies, Inc. Administer antipyretic Provide oral hygiene to keep the mucous membrane moist. Provide a tepid sponge bath to increase heat loss through conduction. Provide dry clothing and bed linens.

18. Copyright © The McGraw-Hill Companies, Inc. Hypothermia; is a core body temperature below the lower limit of normal. The three physiologic mechanisms of hypothermia are: Excessive heat loss Inadequate heat production to counteract heat loss Impaired hypothalamic thermoregulation

19. Copyright © The McGraw-Hill Companies, Inc. The clinical signs of hypothermia: – Decreased body temperature, pulse, and respiration – Severe shivering – Feelings of cold and chills – Pale, cool skin – Hypotension – Decreased urinary output – Lack of muscle coordination – Disorientation – Drowsiness progressing to coma – Frostbite(nose, fingers, toes)

20. Copyright © The McGraw-Hill Companies, Inc. Nursing Interventions for Client's with Hypothermia Provide a warm environment Provide dry clothing Apply warm blanket Keep limbs close to body Cover the client's scalp with a cap Supply warm oral or intravenous fluids Apply warming pads

21. Copyright © The McGraw-Hill Companies, Inc. Chapter 9 20 Temperature (cont.) Temperature Ranges (cont.) – Temperatures can vary due to: Time of day. Allergic reaction. Illness. Stress. Exposure to heat or cold.

22. Copyright © The McGraw-Hill Companies, Inc. Chapter 9 21 Temperature (cont.) Temperature Sites – Oral – within the mouth or under the tongue. – Axillary – in the armpit. – Tympanic – in the ear canal. – Rectal – through the anus, in the rectum. – Other sites include on the skin or in the blood.

23. Copyright © The McGraw-Hill Companies, Inc. Chapter 9 22 Temperature (cont.) Types of Thermometers – Electronic Thermometers Measure temperature through a probe at the end of the device. Hold as close as possible to the area where you wish to measure the temperature.

24. Copyright © The McGraw-Hill Companies, Inc. Chapter 9 23 Temperature (cont.) Types of Thermometers (cont.) – Glass Thermometers Mercury rises in a glass tube until its level matches the temperature. Bulb shapes – Long tip – for oral use. – Security tip – for oral and rectal use. – Rounded tip – for rectal.

25. Copyright © The McGraw-Hill Companies, Inc. Chapter 9 24 Temperature (cont.) Types of Thermometers (cont.) – Thermometer Handles Blue – oral and axillary. Red – rectal. – Use disposable plastic covers to prevent contamination.

26. Copyright © The McGraw-Hill Companies, Inc.

27. Advantages and disadvantages of four sites for body temperature measurement Chapter 9 26

28. Copyright © The McGraw-Hill Companies, Inc. Assessing Body Temperature The four most common sites for measuring body temperature are oral, rectal, axillary, and the tympanic membrane and the skin. Orally: It reflects changing body temperature more quickly than the rectal method. Oral thermometers may have long, short, or rounded tips

29. Copyright © The McGraw-Hill Companies, Inc. Contra indication of oral temperature: Breathing is difficult or rapid Can't close mouth for any reason Breathing through mouth Mouth is inflamed Confused or comatose Infant or young children Oral surgery/ broken jaw Unconscious/agitated people

30. Copyright © The McGraw-Hill Companies, Inc.

31. Rectally; are considered to be very accurate. Contra indication of rectal temperature Diarrhea Rectal surgery Clotting disorders Hemorrhoids "pile"

32. Copyright © The McGraw-Hill Companies, Inc. Axillary; is the preferred site for measuring temperature newborn because it is accessible and offers no possibility rectal perforation. Contraindication of axillary temperature Thin patient Local inflammation Unconsciousness, shocked patients Constricted peripheral blood vessels.

33. Copyright © The McGraw-Hill Companies, Inc. Tympanic membrane; nearby tissue in the ear canal because the membrane has an abundant arterial blood supply.

34. Copyright © The McGraw-Hill Companies, Inc. Temporal artery thermometer are most useful for infants and children where a more invasive measurement is not necessary.

35. Copyright © The McGraw-Hill Companies, Inc. Chapter 9 34 Section 1 Apply Your Knowledge List the order for taking vital signs. Answer: 1.Respiratory rate. 2.Pulse. 3.Temperature. 4.Blood pressure.