Vital Signs

• Vital Signs

  • are the body temperature, blood pressure, pulse rate, respiratory rate, oxygen saturation, and pain scale
• Body Temperature

  • The difference between the amount of heat produced by the body and the amount of heat lost to the environment.
  • Measured in degrees.
  • There are individual variations of these temperatures as well as normal changes during the day, with core body temperatures being lowest in the early morning and highest in the late afternoon.

   
• Kinds of Body Temperature

  • Core temperature
  • Surface temperature
• Factors Affecting Heat Loss/Body's Heat Production

  • basal metabolic rate
  • muscle activity
  • thyroxin output
  • epinephrine and sympathetic stimulation
  • fever
• Radiation

  Transfer of heat from the surface of one object to the surface of another without contact between the two objects, mostly in the form of infrared rays.
• Conduction


  Transfer of heat from one molecule to a molecule of lower temperature.
• Convection

  The dispersion of heat by air currents.
• Evaporation


  Continuous vaporization of moisture from the respiratory tract and the mucosa of the mouth and the skin
• Factors Affecting Body Temperature

  • Age
  • Gender
  • Diurnal variation
  • exercise
  • environment
• Oral


  the body temperature may be measured orally
• Axillary

  • Often the preferred site for measuring. temperature in newborns because it is accessible and safe.
  • Lower than rectal temperatures.
• Rectal

  • Considered to be very accurate.
  • Contraindicated for clients who are undergoing rectal surgery, or have diarrhea or diseases of the rectum.
• Tympanic

  • Nearby tissue in the ear canal.
  • A frequent site for estimating core body temperature.
• Pyrexia

  • a body temperature above the usual range
  • a very high fever, such as 41 degrees is called 'Hyperpyrexia'
• Hypothermia

  • A core body temperature below the lower limit of normal.
  • Clinical Manifestations: Severe shivering (initially) Feelings of cold and chills Pale, cool, waxy skin.
  • 35 degrees or lower resulting form cold weather or exposure of artificial induction
• Febrile


  a client who has a fever
• Afebrile


  A client who has no fever.
• Intermittent Fever

  The body temperature alternates at regular intervals between periods of fever and periods of normal or subnormal temperatures.
• Remittent Fever

  • A wide range of temperature fluctuations occurs over the 24 hours, all of which are above normal.
  • fluctuates throughout the day but never falls all the way back the baseline normal temperature
• Relapsing Fever

  Short febrile periods of a few days are interspersed with periods of 1 or 2 days of normal temperature.
• Constant Fever

  The body temperature fluctuates minimally but always remains elevated.
• Fever Spike

  A temperature that rises to a fever level rapidly following a normal temperature. and then returns to normal within a few hours.
• Onset (Cold or Chill Phase)

  • Increased heart rate
  • Increased respiratory rate and depth
  • Shivering, pallid, cold skin, complaints of feeling cold
  • Cyanotic nail beds
  • Cessation of sweating
• Course (Plateau Phase)

  • Absence of chilis, skin that feels warm
  • Photosensitivity, glassy-eyed appearance
  • Increased pulse and respiratory rates
  • Increased thirst, mild to severe dehydration
  • Drowsiness, restlessness, delirium, or convulsions
  • Malaise, weakness, and aching muscles
• Defervescence (Fever Abatement or Flush Phase)

  • Skin that appears flushed and feels warm
  • Sweating, decreased shivering
  • Possible dehydration
• Heat Exhaustion

  • An Increase in body temperature in response to environmental conditions that, in turn, causes diaphoresis (profuse perspiration).
  • Characteristics: Loss of excessive amounts of water and sodium from perspiring leads to thirst, nausea, vomiting, weakness, and disorientation.
• Heat Stroke

  • A critical increase in body temperature results from exposure to high environmental temperatures.
  • Characteristics: Dry, hot skin
  • The person becomes confused or delirious and experiences thirst, abdominal distress, muscle cramps, and visual disturbances,
• Frostbite

  • Freezing of the body's surface areas (earlobes, fingers, and toes) in extremely low temperatures.
  • Circulatory impairment may be followed by gangrene.
• Normal Adult Temperatures

  • oral - 36.5 - 37. 5 C (3-5 mins.)
  • axillary - 36.5 - 37. 5 C (10 mins.)
  • rectal - 37.0 - 38.1 C (2-3 mins.)
  • tympanic - 36.8 - 37.8 C (<1 min.)
• Electronic Thermometers

  • Can provide a reading in only 2 to 60 seconds, depending on the model.
  • Consists of an electronic base, a probe, and a probe cover, which is usually disposable.
• Chemical Disposable Thermometer

  • Have liquid crystal dots or bars that change color to indicate temperature.
  • Can be used orally, rectally, or in the axilla.
• Temperature-Sensitive Tape

  • It may also be used to obtain a general indication. of body surface temperature.
  • The tape contains liquid crystals that change color according to temperature
• Infrared Thermometers

  • Sense body heat in the form of infrared energy. given off by a heat source.
  • Makes no contact with the tympanic membrane
• Temporal Artery Thermometer

  • using a scanning infrared thermometer that compares the arterial temperature in the temporal artery of the forehead to the temperature in the room.
• Pulse


  is a wave of blood created by contraction of the left ventricle of the heart.
• Pulse Assessment

  The measurement of a pressure pulsation is created when the heart contracts and ejects blood into the aorta.
• Factors Affecting the Pulse

  • Age
  • Sex
  • Exercise
  • Fever
  • Medications
  • Hypovolemia/Dehydration
  • Stress
  • Position
  • Pathology
• Pulse Sites

  • Temporal
  • Carotid
  • Apical
  • Brachial
  • Radial
  • Femoral
  • Popliteal Tibial
  • Dorsalis Pedis
• Characteristics of Pulse

  • Quality
  • Rate
  • Rhythm
  • Volume
• Quality 


  refers to the 'feel' of the pulse, its rhythm, and forcefulness