Reviewer 1

Vital Signs or Cardinal signs

1. Temperature
2. Pulse
3. Blood Pressure
4. Respiratory Rate
5. Pain Scale (subjective data)

>Baseline Data: used as comparison with succeeding vital signs

Temperature
Heat Produced vs. Heat Lost = Body Temperature
> Superficial Temperature : Environmental (skin)
> Core Temperature : Inside the body
> Hypothalamus : Heat regulation center of the body
Factors:
Age: Younger is higher Blood Pressure: Younger is lower
Older is Colder Older is higher
Convertion:
> C = ( F - 32 ) x 5/9
> F = ( C x 9/5)＋32
Most Frequent Routine Measurements
1. Temperature
2. Pulse
3. Respiratory Rate
4. Blood Pressure
5. Oxygen Saturation
> Vital Signs - quick and efficient way of monitoring a patient’s condition
- serves as basis for clinical decision making and problem solving
 Summary of Guidelines:
1. Measuring vital signs is your responsibility
2. Assess equipment
3. Select Equipment based on the patient’s condition
4. Know the patients’ usual range vital signs
5. Know your patients’ medical history
6. Control environmental factor that affects vital signs
7. Use a systematic approach when taking vital signs
8. Use vital signs measurements to determine medication
9. Analyze the results of vital signs
10. Verify and Communicate significant changes in vital signs
11. Instruct the patient or family caregiver in vital signs assessment

Sites of Temperature Measurement

1. Oral
2. Rectal
3. Tympanic Membrane
4. Temporal Artery
5. Esophageal
6. Pulmonary Artery
7. Axillary
8. Urinary Bladder
Reminder :
> Anterior Hypothalamus : control heat loss
> Posterior Hypothalamus : controls heat production
> Mechanisms of Heat Loss
1. Sweating
2. Vasodilation
3. Inhibition of Blood Production
Acceptable Ranges in Adults
Temperature Range
 Average Temperature - 36 to 38
Oral / Tympanic - 37
Rectal - 37.5
Axillary - 36.5
Pulse: 60 - 100 beats per minute
Pulse Oximeter : Higher than 95
Respirations : 12-20 breaths per minutes
Blood Pressure :
Systolic - < 120mmHg
Diastolic - < 80mmHg
Pulse Pressure - 30 - 50 mmHg
Capnography : 35 - 45 mmHg

When to Measure Vital Signs

1. Upon admission
2. During home care visits
3. In a hospital on a routine schedule
4. Before, during, and after transmission of blood
5. Before, during, and after administration of medications
6. When patient’s general condition changes
7. Before, during, and after nursing interventions
8. When a patient reports non specific symptoms of physical distress

Heat Production
> Heat produced by the body is a by- product of metabolism, which is the chemical
reaction in all body cells
> As metabolism increases, additional heat is produced
> Occurs during rest, voluntary movements, involuntary shivering, and non-shivering
thermogenesis
1. Basal Metabolism - accounts for the heat produced by the body at absolute rest.
The average Basal Metabolic Rate (BSR) depends on the body surface area. Thyroid
Hormones also affect the BMR
2. Voluntary Movements - such as muscular activity during exercise require
additional energy. The metabolic rate increases during activity, sometimes causing
heat production to increase
3. Shivering - is an involuntary body response to temperature differences in the
body
4. Non-shivering Thermogenesis - occurs in neonates. Because neonates cannot
shiver, a limited amount of vascular brown tissue, present at birth, is metabolized
for heat production

Heat Loss
> Occurs simultaneously with heat production
> The structure of the skin and exposure to the environment results in constant,
normal heat loss through radiation, conduction, convection and evaporation
1. Radiation
> transfer of heat from the surface of one object to the surface of another
without direct contact between the two
> increases as the temperature difference between the objects increases
> Peripheral Vasodilation - increases blood flow from the internal organs to the
skin to increase radiant heat loss. It is also minimizes radiant heat loss
2. Conduction
> transfer of heat from one object to another with direct contact. Solids, Liquids,
and Gases conducts heat through contact.
3. Convection
> transfer of heat away by air movement
4. Evaporation
> transfer of heat energy when a liquid is changed into a gas. The body
continuously loses heat by evaporation
5. Diaphoresis
> visible perspiration primarily occurring on the forehead and upper thorax

Skin in Temperature Regulation

> the skin regulates temperature through insulation of the body, vasoconstriction
(which affects the amount of blood flow and heat loss to the skin), and temperature
sensation. The skin, subcutaneous tissue and fat keeps heat inside the body.
> the degree of vasoconstriction determines the amount of blood flow and heat loss
to the skin. If the core temperature is too high, the hypothalamus inhibits
vasoconstriction
> if the core temperature becomes too low, the hypothalamus initiates
vasoconstriction, and blood flow to the skin lessens to conserve heat.

Factors Affecting Body Temperature

1. Age
> at birth the newborn leaves a warm, relatively constant environment and enters
one in which temperature fluctuates.
> temperature regulation is unstable until children reach puberty. The visual
temperature range gradually drops as individuals approach older adulthood.
> Older adults are particularly sensitive to temperature extremes because of
deterioration in control mechanisms, particularly poor vasomotor control, reduced
amounts of subcutaneous tissue, reduced sweat gland activity and reduced
metabolism

2. Exercise
> Muscle activity requires an increase blood supply, carbohydrate and fat breakdown.
Any form of exercise increases metabolism and heat production

3. Hormone Level
> Women has higher body temperature fluctuations than men because of the
menstrual cycle
> Low Progesterone Level : body temperature is below baseline level; lower
temperature persists until ovulation
> During Ovulation : Higher progesterone = Higher body temperature
> Menopause : intense body hea and sweating lasting from 30 seconds to 5 minutes
and hot flashes.
 Hot Flashes - caused by the instability of the vasomotor controls for vasodilation
and vasoconstriction

4. Circadian Rhythm
> Body Temperature changes .5 to 1. degrees Celsius during a 24-hour period
> Lowest Temperature : 1:00 - 4:00 AM
> Maximum Value Temperature : 4:00 PM
> Reverse : 1-3 weeks
> does not change with age

5. Environment
> affects infants and older adults more often because their temperature regulating
mechanisms are less efficient.

6. Temperature Alteration
> changes in body temperature outside the usual range related to excessive heat
production, excessive heat loss, minimal heat production, minimal heat loss , or
combination of these

A. Fever
> occurs because heat loss mechanisms are unable to keep pace with exercise heat
production
> results in abnormal rise in body temperature
> important defense mechanism
> mild temperature elevations (39) enhances immune system of the body
> fever fights viral infections by stimulating interferons
> upward shift in the set point
> Not normal if: lower than 39 for adults ; lower than 40 for children
> True Fever : results from an alteration hypothalamic set points
> Pyrogens (bacteria and virus) : elevates body temperature
>acts as antigens, triggering immune system responses
> Hypothalamus - reacts to raise the set points and the body responds by
producing and conserving heat.
 - several hours pas before new set points
- Chills - even when body temp is rising
- Chill Phase - resolves when new set point (higher temperature) is achieved
- Plateau Phase - chills subside and person feels warm and dry
- Third Phase of a Febrile Episode
- if new set point is “overshot” or pyrogens are removed
- hypothalamus set point drops, initiating heat loss response
- skin become warm and flushed because of vasodilation
- diaphoresis - assist in evaporative heat loss
- when fever “breaks” patients become afebrile
- During Febrile Episode
- WBC production
- reduces concentration of iron in blood plasma
- suppressing growth of bacteria
- Fever of Unknown Origin (FUO)
- refers to a fever with an undetermined cause

Reminders:
> Cellular Hypoxia - inadequate oxygen
> Myocardial Infarction - produces Angina or chest pain
> Cerebral Hypoxia - produces confusion

B. Hypothermia
> elevated body temperature related to the inability of the body to promote heat
loss or reduce heat production
>results from an overload of the thermoregulating mechanism of the body
> Malignant Hypothermia
- hereditary condition of uncontrolled heat production when people have
received certain anaesthetic drugs
> Heat Stroke
- prolonged exposure to the sun or high environmental temperature
 - 40 degrees or more
- Patients at risk
1. The very young and old
2. With cardiovascular diseases
3. Hypothyroidism
4. Diabetes or Alcoholism
5. Those who take medications that impairs heat loss
6. Those who exercise strenuously
- Signs and Symptoms
1. Hot and Dry skin
2. Giddiness
3. Confusion
4. Delirium
5. Excess thirst
6. Nausea
7. Muscle Cramps
8. Visual Disturbance
9. Incontinence
- Vital Signs
1. Body temperature as high as 45°C
2. increase HR
3. Lowering of BP

Note: Victims of heartstroke do not sweat because of severe electrolyte loss &
hypothalamic malfunction. If condition progresses, victim become unconscious with
fixed non reactive pupils. Cooling measure should be done.

C. Heat exhaustion
> occurs when pofuse diaphoresis results in excess in water and electrolyte loss.
> Sign and symptoms:
1. Deficient fluid volume
> First Aid:
1. Transporting to a worker area
2. Restoring fluids & electrolyte balance

D. Hypothermia
> heat loss during prolonged exposure to cold
> is classified by core temp. measurement
> Intentional Hypothermia - during surgical or emergency procedures to reduce
metabolic demand & need for oxygen
> Unintentional Hypothermia - falling through a frozen lake
> Accidental Hypothermia - develops gradually goes unnoticed for several hours
-Below 34°C patient suffers
1. Uncontrolled Shivering
2. Loss of memory
3. Depression
4. Poor Judgement

Note: Body temp dercreases : HR,RR & BP Fall

-If Hypotherma progresses:
1. Skin becomes cyanotic
2. Experience cardiac dysrhythmias
3. Loss of consciousness
4. Unresponsiveness to pain
>Severe Hypothermia:

E. Frostbite
> when the body is exposed to subnormal temperatures
> ice crystals form inside the cells and permanent circulatory & tissue damage
occurs.
> Areas Susceptible to Frostbite
1. Earlobes
 2. tip of the nose
3. Fingers
4. Toes
- injured area becomes white , waxy & firm to the touch
- patient loses sensation in the affected area
> Interventions
1. Gradual Warming Measures
2. Analgesia
3. Protection of injured tissue
> Pattern of Fever
1. Sustained - constant body temperature above 38 degrees has little fluctuation
2. Intermittent - fever spikes interspersed with usual temperature level
3. Remittent - fever spikes and falls without a return to acceptable temperature
levels
4. Relapsing - periods of febrile episodes and periods with acceptable temp.
Values
Classification of Hypothermia
Celsius Fahrenheit
Mild 34 - 36 93.2 - 96.8
Moderate 30 - 34 86 - 93.2
Severe <30 <86