Vital sign

• Vital signs


  Measurements that indicate the body's basic functions
• Importance of taking vital signs


  • - It is used to monitor the functions of the body
  • To provide continuous monitoring
  • To assess any changes in the body functions
  • It should be taken in a thoughtful and scientific way
  • They should be evaluated with reference to the patients' present and prior health status
  • The measured values should be compared with the patients' usual range (baseline) and acceptable normal standard
• Time to take vital signs

  On patient admission (Rationale: to obtain baseline data)

  2. Change in health condition (Rationale: to provide data for further nursing care or medical treatment)

  3. Before or after surgery/invasive procedures (Rationale: to monitor patients' condition continuously)

  4. Before/after administering medication that affect cardiovascular or respiratory function (Rationale: to monitor effects/side effects of medication)

  5. Before/after nursing procedures that may affect patients' vital signs (Rationale: to assess the change in patients' condition and to prevent complications)

  
• Different types of vital signs

  • Temperature (T, °C/°F)

  2. Pulse (P, bpm or beats/min)

  3. Respiration (R, bpm or breaths/min)

  4. Blood Pressure (BP, mmHg)

  5. Pain (Pain level, 0-10)

  6. Oxygen Saturation (SpO2, %)
• Guidelines for taking vital signs

  • Appropriate and functional equipment

  2. Knowledge (know the normal range, understand the patient's medical history)

  3. Systematic approach

  4. Teamwork (collaborate with physicians, good communication)

  5. Documentation (communicate significant findings)

  6. Critical thinking (determine indications for medication administration)
• Temperature control


  • It is a homeostatic function regulated by the hypothalamus
  • It reflects the balance between the heat production and the heat lost from the body
• Types of body temperature

  • Core temperature (temperature of the deep tissues, remains relatively constant)

  2. Surface temperature (temperature of the skin, subcutaneous tissues and fat, changes according to the surrounding environment)
• Factors affecting body temperature

  • Age

  2. Diurnal variation (Circadian Rhythm)

  3. Exercise

  4. Hormone

  5. Stress

  6. Environment
• Temperature Scales


  Celsius (Centigrade) vs Fahrenheit

  Conversion formula:

  °C = (°F - 32) x 5/9

  °F = (°C x 9/5) + 32
• Terms used to describe changes in body temperature

  Hyperpyrexia: Body temperature higher than usual range

  Pyrexia: Fever

  Febrile: Patient who has fever

  Afebrile: Patient who has no fever

  Hypothermia: Core body temperature below the normal limit
• Common sites for assessing body temperature

  • Tympanic membrane

  2. Temporal artery

  3. Oral

  4. Rectal

  5. Axillary

  6. Skin
• Assessing body temperature

  Glass thermometer (Not used today, For information only)

  2. Electronic or digital thermometer

  3. Tympanic membrane thermometer

  4. Temporal artery thermometer
• Taking oral temperature

  Contraindications:

  • Children under age of 5
  • Recent oral/nasal surgery
  • Mouth breathers
  • Confused/agitated patients
  • Patients at risk of seizures/with history of seizures
  • Patients have suicidal intention
• Taking axillary temperature

  • Expose the axilla for placement for the thermometer
  • Use probe cover to prevent cross infection
  • Pat axilla dry if moist
  • Place the end of the probe in the centre of the axilla
  • Have the patient bring the arm down and close to the body
  • Hold the probe in place until you hear the beep sound of the electronic thermometer
• Taking rectal temperature

  Contraindications:

  • Patients with colorectal diseases e.g. Haemorrhoids
  • Patients has recent surgery on the perineal area
  • Patients with heavy diarrhoea

  Specific considerations:

  • Place the patient in lateral position
  • Lubricate the thermometer
  • Depth of insertion:
  • Adult: ~1.5 inch (3.8cm)
  • Children: ~1 inch (2.5 cm)
  • Infant: ~0.5 inch (1.3 cm)
  • Hold the patient still while taking rectal temperature, especially for children, to prevent slipping out of the thermometer
• Taking tympanic temperature

  Contraindications:

  • Patients with active ear infections
  • Patients with tympanic membrane drainage tube

  Procedure:

  • Use disposable probe cover
  • Insert the probe slowly into the external ear using gentle but firm pressure
  • For adults (age above 3): pull pinna upward/backward to straighten the ear canal
  • For children (age 3 or under): pull pinna downward/backward
• Taking temporal temperature


  • Expose the forehead by moving the hair aside
  • Place the probe on the centre of the forehead, slightly slide the probe to the hairline
  • Reading affected by sweating
• Nurses' responsibilities

  • - Be aware the factors affecting body temperature
  • Recognize normal temperature variations
  • Understand the significance of body temperature measurement
  • Decide what equipment to use, which site to choose and what method is appropriate
• Purpose of assessing body temperature

  • To establish baseline data
  • To identify whether the body temperature is within normal ranges
  • To determine changes in the core temperature in response to specific therapy, e.g. antipyretic medication
  • To monitor patients at risk for abnormal body temperature, e.g. Patients with infection; patients who have been exposed to extreme temperatures