Assessing Vital Signs

The vital signs 0r cardinal signs are body temperature, pulse, respiration and blood pressure

TPRBP)

Body Temperature, The balance between the heat produced by the body and the heat loss

From the body.:

Types of body temperature

1, Core Temperature- The temperature of the deep tissues of the body. Measyred by taking oral

Rectal temperature.

2. Surface temperature, The temperature of the skin, subcutaneous tissue and fat, Measrured by
taking axillary temperature.

Body heat is primarily produce by metabolism

The heat regulating center is found in hypothalamus.

Factors affecting the body Heat Production are as follows:

1. Basal Metabolic Rate , The younger the person the higher the BMR, The older the
Person the lower the BMR. Therefore , the older persons have lower body temperature,
Than the younger person.

2, Muscle activity ( exercise, swimming, ) Increase cellular metabolic rate, Therefore,

Exercise increases body heat production,

3, Thyroxine output - Increases cellular metabolic rate ( chemical thermogenesis)

Hyperthyroidism is characterized by increased body temperature.

4, Epinephrine, norepinephrine and sympathetic stimulation ,Increase the rate of cellular

metabolism

5, Increased temperature of body cells ( fever), Increases the rate of cellular metabolism”

“Fever further causes fever”

PROCESSES involved in Heat Loss are as follows:

A, Radiation, The transfer of heat from the surface of one object to the surface of another

Without contact between two objects, Ex, it feels warm in a crowded room,

B, Conduction- The transfer of heat one surface to another, It requires temperature

Difference between the two surfaces, ex. Application of moist wash cloth over the skin

c. Convection - The dissipation of heat by air currents ex, exposure of the skin towards
electric fan,

Evaporation , The continuous vaporization of moisture from the skin, oral mucous, , respiratory
tract, ex, TSB,

ALTERATIONS in Body Temperature

1, Pyrexia , Body temperature above normal range also hyperthermia, fever

2, Hyperpyrexia - Very high fever. 41 degrees centigrade

3, Hypothermia , Subnormal core body temperature, this may caused by excessive heat loss

Types of Fever

1. INTERMITTENT FEVER- the temperature; fluctuates between periods of fever and periods
Of normal/ subnormal temperature
2. Remittent Fever- The temperature fluctuates within wide range over the 24 hour period
But remains above normal range,

3, Relapsing Fever – The temperature is elevated for few days, alternated with 1 or 2 days of
normal temperature

4, Constant fever- body temperature is constantly high

Very high temperatures( 41-42) cause irreversible brain cell damages

CLINICAL SIGNS OF FEVER

A, Onset ( cold or chill stage) of fever

a. Increase heart rate

b. Increased respiratory rate and depth
c. Shivering
d. Pale, cold skin
e. Cyanotic nail bed
f. Complaints of feeling cold
g. “ goose flesh” appearance of the skin
h. Cessation of sweating
i. Rise of body temperature

COURSE OF FEVER

a absence of chills

b, skin that feels warm

c, feeling of being neither hot nor cold

d, increased pulse rate

e, increased thirst
 f, mild to moderate dehydration

g, drowsiness, restlessness ,delirium and convulsions

h, herpetic lessions of the mouth fever or blisters

I, loss of appetite

J , malaise, weakness and aching muscles

NURSING INTERVENTIONS IN CLIENTS WITH FEVER

1. Monitor V/S
2. Assess skin color and temperature
3. Monitor WBC, Hct and other pertinent laboratory records
a. Elevated wbc levels indicate presence of infection
b. Elevated Hct indicates dehydration

4, Remove excess blankets when the client feels warm provide extra warmth

When the client feels chilled,

5, Provide edequate foods and fluids, To provide additional calorries and to prevent

Dehydration,

6, Measure intake and output

7. Maintain prescribed IV fluids as ordered by the physician

8, Promote rest , To reduce body heat production

9, Provide good oral hygiene, To prevent herpetic lessions of the mouth

10, Provjde cool circulating air using a fan, To dissipate heat by convection

11, Provide dry clothing and bed linens, to ensure comfort

12 Provide TSB

13 Administer antipyretic as needed

METHODS OF TAKING TEMPERATURE

1, Oral- most accessible and convenient method,

Allow 15 minutes to elapse between client intake of hot and cold food or smoking

And measurement of oral temperature

Place thermometer under the tongue directed towards the side

Wash the thermometer before use, from the bulb to the stem, after use, from the stem

To bulb, This practice assure medical asepsis , TAKE ORAL TEMPERATURE for 2-3 mins,
 This is to ensure adequate for recording temperature .

CONTRAINDICATION TO ORAL TEMPERATURE TAKING

1, Oral lesions or surgery

2, Dyspnea

3, Cough

4, Nausea and vomiting

5, Presence of oral nasal pack

6. seizure prone

7, Very young children

8, Unconscoius

9, Restless, disoriented and confused

RECTAL - most accurate measurement of temperature

Assist client to assume lateral position, To expose anal area,

Lubricate thermometer before insertion

Insert thermometer by 0,5-1,5 inches

Instruct the client to take deep breath during insertion of the thermometer, To relax the
internal sphinter,

Hold the thermometer for 2 minutes

3, AXILLARY- SAFEST and most non- ivasive method of taking temperature

Path dry the axilla,