L2.1: Vital Signs - Body Temperature

• What are vital signs?

  • Signs that indicate the physiologic status of important organs, hence “vital”
  • Temperature, Pulse, Respiration, and Blood Pressure
  • homeostatic-ally regulated and within the normal range
  • Changes in a patients’ vital signs imply physiologic or comfort changes that require medical or nursing care.
  • Taken and compared with accepted normal values and the patient’s usual patterns
• Purposes of Vital Signs

  • Identifying problems.
  • Monitoring patient’s condition.
  • Evaluating the patients’s response to intervention.
  • Basis for clinical problem solving.
  • Part of nursing care in any setting.
• Before and After:

  • A surgical/invasive diagnostic procedure.
  • Nursing interventions that influence vital signs.
  • Range of motion exercises
  • Ambulating a client who has been on bed rest.
• Before, During, and After:

  • A transfusion of blood products.
  • The administration of medications or applications of therapies that affect cardiovascular, respiratory, or temperature-control functions.
• When the patient's general condition changes

  • Loss of consciousness or increased intensity of pain.
• Guidelines for measuring vital signs

  • Based on the patient’s condition, collaborate with the healthcare provider to decide the frequency of vital sign assessment.
  • In the hospital, the physician orders a minimum frequency of vital sign measurement of reach patient. At least every 4 hours when one or more vital sign is abnormal or outside of normal ranges.
  • Every 5-15 minutes when a client is unstable or at risk for rapid physiologic changes such as after surgery.
• Types of Body Temperature

  • Core Temperature
  • Surface Temperature
• Core Temperature

  • Temperature of deep tissues such as abdominal and pelvic activity.
  • Remains relatively constant within the range of 36°C to 37.4°C.
  • Higher than surface temperature.
  • Measured at tympanic or rectal sites.
  • It may also be measures in the esophagus, pulmonary artery, or in the bladder by invasive monitoring devices.
• Surface Temperature

  • Temperature of the skin, subcutaneous tissue, and fat
  • Measure at oral and axillary sites.
  • Rises and falls in response to the environment
• Types of Assessment Sites

  • For the Most Accurate Measurement of Core Temperature
  • Brain
  • Heart
  • Lower third of the esophagus
  • Urinary bladder
  • For the Most Practical and Convenient Temperature Assessment Sites
  • Ear (on the tympanic membrane)
  • Mouth
  • Rectum
  • Axilla
• Types of Assessment Sites

  • For the Most Accurate Measurement of Core Temperature
  • Brain
  • Prohibited because of lack of technology.
  • Heart
  • Temperature of blood circulating through the heart.
  • Lower Third of the Esophagus
  • Through a thermistor catheter (heat-sensing device at the top of the internally placed tube).
  • Urinary Bladder
  • Through a thermistor catheter (heat-sensing device at the top of the internally placed tube).
• Types of Assessment Sites

  • For the Most Practical and Convenient Temperature Assessment Sites
  • Ear (on the tympanic membrane)
  • Mouth
  • Rectum
  • Axilla
  • These areas are anatomically close to superficial areas containing warm blood.
• Types of Temperature Measurements

  • According to Assessment Sites
  • Oral
  • Rectal
  • Axillary
  • Tympanic Membrane
• Types of Temperature Measurements (According to Assessment Sites)

  • Oral
  • Accessible and Convenient.
  • Measures 0.5 to 0.6°C below the core temperature.
  • Area under the tongue is in direct proximity to the sublingual artery.
  • Most practical clinically preferred method.
  • Contraindications:
  • Uncooperative
  • Very Young
  • Unconscious
  • Shivering
  • Prone to Seizures
  • Mouth Breathers
  • Oral Surgery
• Types of Temperature Measurements (According to Assessment Sites)

  • Rectal
  • Most accurate and reliable measurement
  • Differs about 0.1°C from core temperature.
  • Can be embarrassing and emotionally traumatic for AAOx3 clients
  • Difficult for clients who cannot turn to their side.
  • To check for imperforate anus in newborns
  • Contraindication
  • Rectal Surgery
  • Diarrhea
  • Hemorrhoids
  • Other diseases of the rectum
• Types of Temperature Measurements (According to Assessment Sites)

  • Axillary
  • Safe and non-invasive.
  • Preferred site for newborns because it is safe and accessible.
  • Less potential for spreading microorganisms than oral and rectal sites.
  • Some research indicates that this method is inaccurate when assessing for fever.
  • The thermometer must be left in place for longer in order to obtain an accurate measurement
  • Make sure that the area is dry and not wet with perspiration, deodorants, cream, or the like. Do not rub the area dry vigorously as friction will increase the temperature.
• Types of Temperature Measurements (According to Assessment Sites)

  • Tympanic Membrane
  • Readily accessible.
  • Reflects core temperature.
  • Very fast.
  • Can be uncomfortable and involves risk of injuring the membrane if the probe is inserted too far.
  • Presence of cerumen can affect the readings.
  • Repeated measurements may vary.
  • Right and left measurement can differ.
• Normal Range of Body Temperature

  • Oral
  • Fahrenheit: 97.6 to 99.6
  • Celcius: 36.5 to 37.4
• Normal Range of Body Temperature

  • Rectal
  • Fahrenheit: 98.6 to 100.6
  • Celcius: 37.0 to 38.1
• Normal Range of Body Temperature

  • Axilla
  • Fahrenheit: 96.6 to 98.6
  • Celcius: 36.0 to 37.0
• Equipment for measurement

  • Thermometer
  • Most commonly used device to measure body temperature.
• Types of thermometers

  • digital
  • tympanic or infrared
• Types of Thermometers

  • Digital
  • Uses heat sensors.
  • Looks similar to a glass thermometer.
  • Can be used for oral, axillary, and rectal sites.
  • Take one to sixty seconds to measure the body temperature, depending on the site and product used.
  • Cleansed like glass thermometer but wiped rather than soaked with alcohol.
• Types of Thermometers

  • Tympanic or Infrared
  • Uses infrared sensors.
  • Has probe cover and inserted into the ear canal tightly enough to seal the opening.
  • Reading takes one to three seconds, depending on the product.
  • The sensor detects the warmth radiating from the tympanic membrane, and converts the heat into a temperature measurement.
• Temperature Alterations

  • Hyperthermia
  • Hypothermia
• Temperature Alterations

  • Hyperthermia
  • Fever or Pyrexia
  • Body temperature above the usual range
  • Occurs because the heat loss mechanisms of the body are unable to keep pace with the excess heat production.
  • Not harmful if it stays below 39°C in adults, or 40°C in children.
  • The body’s response to bacterial or viral infection, or tissue injury
• Temperature Alterations

  • Hyperthermia
  • Febrile: Clients with Fever
  • Afebrile: Clients without Fever
  • Hyperpyrexia: A Very High Fever (41°C)
• Temperature Alterations

  • Hyporthermia
  • Core body temperature below the lower limit.
  • Below 35°C.
  • Physiologic mechanisms:
  • Excessive heat loss.
  • Inadequate heat production to counteract heat loss.
  • Impaired hypothalamic thermoregulation.
• Types of Fever or Pyrexia

  • Intermittent fever
  • Remittent fever
  • Relapsing fever
  • Constant fever
• Types of Fever or Pyrexia

  • Intermittent Fever
  • Body temperature alternates at regular intervals between periods of fever and of normal/subnormal temperature
  • Ex: Malaria
• Types of Fever or Pyrexia

  • Remittent Fever
  • Wide range of temperature fluctuations (more than 2°C) occurs over the 24-hours period, all of which are above normal.
  • Ex: Cold and Influenza
• Types of Fever or Pyrexia

  • Relapsing Fever
  • Short febrile periods of a few ays are interspersed with periods of 1-or-2 days or normal temperature.
• Types of Fever or Pyrexia

  • Constant Fever
  • Body temperature remains constantly elevated and fluctuates less than 2°C.
  • Ex: Typhoid Fever
• Types of Fever or Pyrexia

  • In some conditions, an elevated temperature is not a true fever, such as in:
  • Heat Exhaustion → Results of excessive heat and dehydration.
  • Heat Stroke → Due to exercising in hot weather.
• Body Temperature Regulation

  • Neural and Vascular Control.
  • Maintaining heat production and heat loss.
  • BMR, Muscle Activity, Thyroxine Output, Sympathetic Response, Fever
  • Behavioral Control
• Body Temperature Regulation

  • Mechanisms of Heat Transfer or Loss
  • Convection
  • Conduction
  • Radiation
  • Evaporation
• Body Temperature Regulation

  • Mechanisms of Heat Transfer or Loss
  • Convection
  • Transfer of heat to the air surrounding the skin.
  • Occurs in liquids or gases.
  • Ex: The use of electric fan to cool off your body.
• Body Temperature Regulation

  • Mechanisms of Heat Transfer or Loss
  • Conduction
  • Transfer of heat by two objects that are in direct contact with one another.
  • Ex: A spoon in a hot cup of tea gets hot due to its direct contact with the hot tea.
  • Warming up your hand on a cold day by wrapping it on a hot mug of coffee.
  • Sitting on a metal chair on a sunny day.
• Body Temperature Regulation

  • Mechanisms of Heat Transfer or Loss
  • Radiation
  • Heat transfers without any medium or direct contact.
  • It is the emission of energy in the form of electromagnetic waves.
  • Ex: On a sunny day, the radiation from the sun warms the skin.
• Body Temperature Regulation

  • Mechanisms of Heat Transfer or Loss
  • Evaporation
  • Transfer of heat by the evaporation of water.
  • Ex: Sweating