Transcript Chapter 9 Vital Signs

Chapter 1
Vital Signs
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Objectives
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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.
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Chapter 9
Objectives (cont.)
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Compare the methods and
contraindications of measuring oral,
tympanic, axillary, and rectal
temperatures.
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Chapter 9
Objectives (cont.)
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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.
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Chapter 9
Signs 9-1
Temperature
 Pulse
 Respiration
 Blood Pressure
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Chapter 9
Vital Signs
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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.
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Chapter 9
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.
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Chapter 9
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,
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Chapter 9
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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.
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Chapter 9
Factors affecting body temperature:
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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
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Chapter 9
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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
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Temperature Ranges
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Normal adult temperature is 98.6ºF, or 37ºC.
Normal range can be from 96.8ºF to 100.4ºF, or
36ºC to 38ºC.
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Chapter 9
Alterations in body temperature
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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
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Chapter 9
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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.
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Chapter 9
Nursing Interventions for Client's with
fever:
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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.
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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.
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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
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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)
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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
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Temperature (cont.)
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Temperature Ranges (cont.)
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Temperatures can vary due to:
 Time of day.
 Allergic reaction.
 Illness.
 Stress.
 Exposure to heat or cold.
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Chapter 9
Temperature (cont.)
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Temperature Sites
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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.
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Chapter 9
Temperature (cont.)
 Types of Thermometers
– Electronic Thermometers
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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.
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Chapter 9
Temperature (cont.)
 Types of Thermometers (cont.)
– Glass Thermometers
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Mercury rises in a glass tube until its level matches
the temperature.
Bulb shapes
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Long tip – for oral use.
Security tip – for oral
and rectal use.
Rounded tip – for
rectal.
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Chapter 9
Temperature (cont.)
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Types of Thermometers (cont.)
– Thermometer Handles
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Blue – oral and axillary.
Red – rectal.
Use disposable plastic covers to prevent
contamination.
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Chapter 9
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Advantages and disadvantages of
four sites for body temperature
measurement
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Chapter 9
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
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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
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Rectally; are considered to be very accurate.
Contra indication of rectal temperature
 Diarrhea
 Rectal surgery
 Clotting disorders
 Hemorrhoids "pile"
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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.
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Tympanic membrane; nearby tissue in the ear
canal because the membrane has an abundant
arterial blood supply.
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Temporal artery thermometer are most useful
for infants and children where a more invasive
measurement is not necessary.
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Section 1
Apply Your Knowledge
List the order for taking vital
signs.
Answer:
1. Respiratory rate.
2. Pulse.
3. Temperature.
4. Blood pressure.
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Chapter 9