Vitals Signs - Nursing

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  • Topic: Fever, Temperature, Hyperthermia
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  • Published : March 2, 2013
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VITAL SIGNS
NUR 102

What are Vital Signs?
Temperature
Pulse
Respirations
Blood Pressure
Pain (considered the 5th vital sign)
When to measure vital signs?
On admission to health care facility
In a hospital on regular hosp schedule or as MD ordered (q8hours, q4 hours, etc) •Before and after procedures (surgery, invasive diagnostic procedures) •Before, during, and after blood transfusions

When patient’s general condition changes (nursing judgment) GUIDELINES FOR ASSESSMENT
Taken by nurse giving care
Equipment should be in good condition
Know baseline VS and normal range for pt and age group
Know pt’s medical history
Minimize environmental factors

GUIDELINES CONTINUED
Be organized in approach
Increase frequency of VS as condition worsens
Compare VS readings with the whole picture
Record accurately
Describe any abnormal VS
VS MUST BE ACCURATE
Both measuring and recording
VS vary according to pt’s illness/condition
Compare results with pt’s normal
Results are used to determine treatments, medications, diagnostic work, etc REPORTING ABNORMAL VS
WHEN—grossly abnormal, return to normal, noted change for that pt •WHY—indicates change in metabolism or physiological function within the body •WHO—student reports to instructor, then TL, RN, Dr (follow chain of command) •HOW—orally to appropriate person, then document on chart Body Temperature

Difference between heat produced by body processes and the heat lost to the external environment •Range 96.8 – 100.4 F (36 – 38 degree C)
Average for healthy young adults 98.6F or 37degrees C
No single temp is normal for all people
HEAT IS PRODUCED BY:
Metabolism
Increased muscle activity
Vasoconstriction
External sources
HEAT IS LOST BY:
Vasodilation
Convection
Radiation
Conduction
Evaporization
TEMP or FEVER?
TEMPERATURE—the measurement of heat in the body
FEVER—the measurement of heat in the body that is above normal for the individual TYPES OF THERMOMETERS
READING A THERMOMETER
Normal Range Throughout Life Cycle
Adults- 96.8- 100.4 degree F
Adult Avg 98.6 F Oral
Adult Avg 99.5 F Rectal
Adult Avg 97.7 F Ax
Newborn range – 95.9- 99.5F
Infants and children – same as adults
Elderly – Avg 96.8F
Frequently used terms:
Pyrexia or fever
Febrile
Hyperthermia
Hypothermia
Afebrile

FEVER—A DEFENSE MECHANISM
Indicator of disease in body
Pathogens release toxins
Toxins affect hypothalamus
Temperature is increased
Rest decreases metabolism and heat production by the body PATTERNS OF FEVER
SUSTAINED- remains above normal with little change
RELAPSING – periods of febrile episodes interspersed with acceptable temp values •INTERMITTENT—varies from normal to above normal to below normal (may have a fairly predictable pattern) •REMITTENT—fever spikes and falls w/o a return to normal temp values Factors Affecting Body Temp

Age ( newborn- temp control mechanism immature, elderly- sensitive to temp changes) •Exercise
Hormonal level
Circadian rhythm (temp normally changes 0.9 to 1.8 degree F /24hr Lowest 1-4AM Max-6PM )

Stress
Environment
ORAL TEMPERATURE
Accessible
Dependable
Accurate
Convenient

RECTAL TEMPERATURE
Most reliable
MUST hold thermometer in place
AXILLARY TEMPERATURE
Safe
Non-invasive
Least accurate
TYMPANIC TEMPERATURE
Non-invasive
Safe
Accurate
Disadvantages
Excessive cerumen
Improper technique

AXILLARY TEMPERATURE
IMPORTANT POINTS
AXILLA MUST HAVE ADEQUATE TISSUE & BE FREE OF PERSPIRATION •Not good method for persons with elevated temp
Used when cannot get oral or tympanic
Leave in place 10 minutes
ORAL TEMPERATURES
Wait 15-30 minutes after eating, drinking, chewing gum or smoking •If mouth breather-do not take orally
Leave in place 2 – 4 minutes with glass thermometer
TYMPANIC TEMPERATURES
Oral & tympanic...
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