Understanding Vital Signs: Temperature Basics

• Vital signs include temperature, pulse, respiration, blood pressure, and pain assessment
• Monitoring vital signs is essential for assessing a patient's condition
• Frequency of vital sign measurement depends on the patient's condition and hospital policy
• Baseline vital signs are the initial measurements used to compare with subsequent readings
• Significant changes in vital signs should be promptly reported to the healthcare provider

Temperature

• Temperature reflects the balance between heat production and heat loss
• Core temperature remains relatively constant
• Body temperature is influenced by age, exercise, hormone levels, circadian rhythm, stress, and environment
• Normal oral temperature range is 36°C to 38°C (96.8°F to 100.4°F)
• Rectal temperatures are typically 0.5°C (0.9°F) higher than oral temperatures
• Axillary temperatures are typically 0.5°C (0.9°F) lower than oral temperatures
• Tympanic membrane temperature measurement is quick and non-invasive, suitable for pediatric patients
• Temporal artery temperature measurement is also quick and non-invasive
• Fever (pyrexia) is an elevated body temperature, usually above 38°C (100.4°F)
• Hyperthermia is a condition where the body temperature is dangerously high
• Hypothermia is a condition where the body temperature is dangerously low, typically below 35°C (95°F)
• Heatstroke occurs when prolonged exposure to high temperatures overwhelms the body's heat-regulating mechanisms
• Heat exhaustion occurs when the body loses excessive amounts of fluid and electrolytes through perspiration

Pulse

• Pulse is the palpable bounding of blood flow noted at various points on the body
• Pulse rate reflects the number of heartbeats per minute
• Normal adult pulse rate is 60 to 100 beats per minute
• Tachycardia is an abnormally fast heart rate, usually above 100 bpm
• Bradycardia is an abnormally slow heart rate, usually below 60 bpm
• Factors affecting pulse rate include age, exercise, temperature, emotions, medications, and hemorrhage
• Common pulse sites include radial, brachial, carotid, femoral, and dorsalis pedis arteries
• When assessing pulse, consider rate, rhythm, strength, and equality
• Pulse rhythm can be regular or irregular
• Pulse strength is described as bounding, strong, weak, or thready
• Apical pulse is auscultated at the apex of the heart using a stethoscope
• Pulse deficit is the difference between the apical pulse rate and the radial pulse rate

Respiration

• Respiration involves ventilation, diffusion, and perfusion
• Ventilation is the mechanical movement of air into and out of the lungs
• Diffusion is the movement of oxygen and carbon dioxide between the alveoli and red blood cells
• Perfusion is the distribution of red blood cells to and from the pulmonary capillaries
• Normal adult respiratory rate is 12 to 20 breaths per minute
• Bradypnea is an abnormally slow respiratory rate, usually below 12 breaths per minute
• Tachypnea is an abnormally fast respiratory rate, usually above 20 breaths per minute
• Apnea is the absence of breathing
• Dyspnea is difficult or labored breathing
• Orthopnea is difficulty breathing when lying down
• When assessing respiration, consider rate, depth, rhythm, and effort
• Respiratory depth can be shallow, normal, or deep
• Respiratory rhythm can be regular or irregular
• Adventitious breath sounds include crackles (rales), wheezes, and rhonchi
• Factors affecting respiration include exercise, anxiety, body position, and neurological injury

Blood Pressure

• Blood pressure is the force exerted by the blood against the walls of the arteries
• Systolic pressure is the peak pressure exerted during ventricular contraction
• Diastolic pressure is the minimum pressure exerted when the ventricles are at rest
• Normal adult blood pressure is typically less than 120/80 mm Hg
• Hypertension is abnormally high blood pressure, typically 130/80 mm Hg or higher
• Hypotension is abnormally low blood pressure, typically less than 90/60 mm Hg
• Pulse pressure is the difference between systolic and diastolic pressure
• Factors affecting blood pressure include age, gender, ethnicity, time of day, exercise, weight, and emotions
• Blood pressure is measured using a sphygmomanometer and stethoscope
• Orthostatic hypotension is a drop in blood pressure that occurs when changing from a lying or sitting position to a standing position

Pain Assessment

• Pain is a subjective experience and is defined as whatever the patient says it is
• Pain assessment is a critical component of nursing care
• Use pain scales (e.g., numeric rating scale, visual analog scale) to quantify pain intensity
• Assess pain location, characteristics, onset, duration, and aggravating/alleviating factors
• Nonverbal cues of pain may include facial expressions, body movements, and vital sign changes
• Pain management strategies include pharmacological and non-pharmacological interventions
• Regularly reassess pain and the effectiveness of pain relief measures