Vitals Signs – Nursing

What are Vital Signs?
•Temperature
•Pulse
•Respirations
•Blood Pressure
•Pain (considered the 5th vital sign)
When to measure vital signs?
•On admission to health care facility
•In a hospital on regular hosp schedule or as MD ordered (q8hours, q4 hours, etc) •Before and after procedures (surgery, invasive diagnostic procedures) •Before, during, and after blood transfusions

•When patient’s general condition changes (nursing judgment) GUIDELINES FOR ASSESSMENT
•Taken by nurse giving care
•Equipment should be in good condition
•Know baseline VS and normal range for pt and age group
•Know pt’s medical history
•Minimize environmental factors

GUIDELINES CONTINUED
•Be organized in approach
•Increase frequency of VS as condition worsens
•Compare VS readings with the whole picture
•Record accurately
•Describe any abnormal VS
VS MUST BE ACCURATE
•Both measuring and recording
•VS vary according to pt’s illness/condition
•Compare results with pt’s normal
•Results are used to determine treatments, medications, diagnostic work, etc REPORTING ABNORMAL VS
•WHEN—grossly abnormal, return to normal, noted change for that pt •WHY—indicates change in metabolism or physiological function within the body •WHO—student reports to instructor, then TL, RN, Dr (follow chain of command) •HOW—orally to appropriate person, then document on chart Body Temperature

•Difference between heat produced by body processes and the heat lost to the external environment •Range 96.8 – 100.4 F (36 – 38 degree C)
•Average for healthy young adults 98.6F or 37degrees C
•No single temp is normal for all people
HEAT IS PRODUCED BY:
•Metabolism
•Increased muscle activity
•Vasoconstriction
•External sources
HEAT IS LOST BY:
•Vasodilation
•Convection
•Radiation
•Conduction
•Evaporization

TEMP or FEVER?
•TEMPERATURE—the measurement of heat in the body
•FEVER—the measurement of heat in the body that is above normal for the individual TYPES OF THERMOMETERS
READING A THERMOMETER
Normal Range Throughout Life Cycle
•Adults- 96.8- 100.4 degree F
•Adult Avg 98.6 F Oral
•Adult Avg 99.5 F Rectal
•Adult Avg 97.7 F Ax
•Newborn range – 95.9- 99.5F
•Infants and children – same as adults
•Elderly – Avg 96.8F

Frequently used terms:
•Pyrexia or fever
•Febrile
•Hyperthermia
•Hypothermia
•Afebrile

FEVER—A DEFENSE MECHANISM
•Indicator of disease in body
•Pathogens release toxins
•Toxins affect hypothalamus
•Temperature is increased
•Rest decreases metabolism and heat production by the body PATTERNS OF FEVER
•SUSTAINED- remains above normal with little change
•RELAPSING – periods of febrile episodes interspersed with acceptable temp values •INTERMITTENT—varies from normal to above normal to below normal (may have a fairly predictable pattern) •REMITTENT—fever spikes and falls w/o a return to normal temp values Factors Affecting Body Temp

•Age ( newborn- temp control mechanism immature, elderly- sensitive to temp changes) •Exercise
•Hormonal level
•Circadian rhythm (temp normally changes 0.9 to 1.8 degree F /24hr Lowest 1-4AM Max-6PM )

•Stress
•Environment
ORAL TEMPERATURE
•Accessible
•Dependable
•Accurate
•Convenient

RECTAL TEMPERATURE
•Most reliable
•MUST hold thermometer in place
AXILLARY TEMPERATURE
•Safe
•Non-invasive
•Least accurate
TYMPANIC TEMPERATURE
•Non-invasive
•Safe
•Accurate
•Disadvantages
–Excessive cerumen
–Improper technique

AXILLARY TEMPERATURE
IMPORTANT POINTS
•AXILLA MUST HAVE ADEQUATE TISSUE & BE FREE OF PERSPIRATION •Not good method for persons with elevated temp
•Used when cannot get oral or tympanic
•Leave in place 10 minutes
ORAL TEMPERATURES
•Wait 15-30 minutes after eating, drinking, chewing gum or smoking •If mouth breather-do not take orally
•Leave in place 2 – 4 minutes with glass thermometer

TYMPANIC TEMPERATURES
•Oral & tympanic readings will be same/ similar
•Must direct probe toward TM (eardrum)
•Follow instructions
•Keep plugged in and on charger when not in use
•Usually preferred method
•Adults –pull pinna of ear up & back
•Children under 3y/o-pull pinna of ear down & back

RECTAL TEMPERATURES
•MOST accurate
•MUST hold thermometer in place
•Very high temp
•Unconscious
•Do not take rectal temp on clients with heart conditions
•Leave in place 2-3 min with glass thermometer
•Lubricate thermometer
•DO Not take hand from thermometer while rectal in progress