Assessment of Vital Signs

Dr. Sahar Adham

2010-2011
Vital Signs : is assessment of function
of the vital organ , it consist of body
temperature , pulse, respiration and
blood pressure ,it’s not automatic ,
routine procedure but it should be
perform according to the client
health status .
Recently, many health agencies
designed pain as the fifth signs
( Cardinal Signs)
Time to Assess Vital Signs
1. On admission to obtain data base
2. Change in client health status
( chest pain)
3. Before and after surgery
4. Before and after administration of
medication which affect respiration and
cardiovascular system
5. Before and after any nursing intervention
as ambulating client who bed redden
 Body Temperature
Reflects the balance between the heat
produced and the heat lost from the body,
measured by unit called degree.

Heat
Heat Loss
Production
There are two kinds of body temperature
1- Core temperature : is the temperature
of deep tissues of body as abdomen al
cavity and pelvic cavity ,it remain constant

2- Surface temperature : is skin

temperature ,subcutaneous tissue and fat
it’s change according to the environment
Factors affecting the body heat
production:
Basal Metabolic Rate (BMR) 
Muscle Activity 
Thyroxine Output 
Epinephrine , nor- epinephrine & 
sympathetic stimulation
Fever 
Heat loss from body through:
Radiation 
Conduction 
Convection 
Vaporization 
Regulation of body temperature

Factors affecting body temperature:

Age
Diurnal Variations
Exercise
Hormones
Stress
Environment
Alterations in Body Temperature
There are two primary alterations in body
temperature:
Pyrexia and Hypothermia

A body temperature a above the usual

range is called pyrexia, hyperthermia,
or fever , client who has a fever is referred
to as febrile not is a febrile .
A very high fever, such 41 C is called
hyperpyrexia
Common types of fevers are :
Intermittent : temperature alternates at
regular intervals between fever and normal
or subnormal temperature.

Remittent fever : a wide range of temperature

(more than 2C ) occurs over the 24 hrs
which are above normal.
.
Relapsing fever: periods of a few days are
interspersed with periods of normal
temperature.

Constant fever: temperature fluctuates

minimally but always remain normal .

Fever Spike: temperature that rises to fever

level rapid following normal temperature
and then returns to normal within few
hours
Nursing intervention for client with fever
1- Monitor vital signs.
2- Assess skin color and temperature.
3- Monitor white blood cell, hematocrit and
ESR for indication of infection
4- Remove excessive blankets , provide
warmth when client feel chill .
5- Provide adequate nutrition and fluids(
2,500-3,000ml per day ) to meet
metabolic rate and prevent dehydration
6- Measure intake and output.
.
Cont.

7- Reduce physical activity to limit heat

production.
8- Administer antipyretic as order
9- Provide oral hygiene to keep the mucous
membrane moist .
10- Provide sponge bath to increase heat
loss by conduction -
11- Keep client cloth and bed linens dry
Clinical signs of hypothermia
1- Decrease body temperature ,respiration and
pulse
2- Severe shivering (initially)
3- Feeling of cold and chills
4- Pale , cool, waxy skin
5- Hypotension
6- Decrease urinary output
7- Lack of muscle coordination
8- Disorientation
9- Drowsiness progressing to coma
Nursing intervention in hypothermia
1- Provide a warm environment.
2- Provide dry clothing.
3- Apply warm blankets.
4- Keep limbs close to body.
5- Cover the client's scalp with a cap or turban.
6- Supply warm oral or intravenous fluids.
7- Apply warming pads.
Temperature Scales
The body temperature is measured in degrees on
Celsius (centigrade) and Fahrenheit. Sometimes a nurse
convert a Celsius reading to Fahrenheit' or vice versa
convert from Fahrenheit to Celsius as:

Example, when the Fahrenheit reading is 100:

C = (100 - 32) x 579 = (68) x 519 = 37 '7

To convert from Celsius to Fahrenheit :

when the Celsius reading is 40:
F = (40x 915) + 32= (72)+ 32= 104