Vital Signs and Body Temperature

Vital Signs

• Vital signs are measurements of the body's basic functions, reflecting its physiological status and providing information for evaluating homeostasis.
• Purposes include monitoring patients' condition, establishing baseline data for comparisons, detecting abnormalities in temperature, pulse, respiration, and blood pressure, and evaluating the effect of medications or nursing measures.
• Vital signs include temperature, pulse rate, respiratory rate, blood pressure, and pain.
• Vital signs are assessed on admission, when a client's health status changes, according to medical orders, before and after medication administration, before and after surgery, and according to hospital protocol.

Body Temperature

• Body temperature is the balance between heat production and heat loss from the body.
• Normal body temperature averages 37°C (98.6°F).
• The normal range is 36.4°C - 37.5°C (97.5°F - 99.5°F).
• Two kinds of body temperature exist: core (internal organs and cavities) and surface (skin, subcutaneous tissue, and fat).
• Fever (pyrexia) is a body temperature above the normal range (38°C - 41°C or 100.4°F - 105.8°F).
• Hyperpyrexia is above 41.6°C (106.9°F).
• Hypothermia is below 35°C (95°F).

Factors Affecting Body Temperature

• Age, exercise, stress and hormones, and environmental temperature affect body temperature.

Sites to Measure Temperature

• Measuring temperature can be done orally, rectally, axially, or tympanically (ear).

Types of Thermometers

• Various types of thermometers exist, including oral (long, slender tips), rectal (short, rounded tips), axillary (long, slender tips), and tympanic (digital and electronic).

Equipment for Measuring Temperature

• Necessary equipment includes a thermometer, tissue paper, alcohol swabs, a pen, a vital signs flow sheet, gloves, and plastic thermometer sleeves.

Contraindications for Oral Temperature Measurement

• Oral temperature measurement is contraindicated in infants and children under four to five years old, patients with mouth breathing or seizure disorders, those who've recently undergone surgery on the nose or mouth, are on oxygen therapy, have persistent coughs, or had recent hot or cold fluids.
• Temperature should be measured 15 minutes after such cases.

Contraindications for Rectal Temperature Measurement

• Rectal temperature measurement is contraindicated in patients with recent rectal surgery, diarrhea, or cardiac disease.

Normal Body Temperature

• Oral: average 37°C (98.6°F).
• Rectal: average 37.5°C (99.5°F).
• Axillary: average 36.5°C (97.7°F).
• Normal range: 36.4°C - 37.5°C (97.5°F-99.5°F).

Procedure for Measuring Temperature

• Assess the patient's signs and symptoms.
• Note factors that influence body temperature.
• Establish the appropriate measuring site and device.
• Wash hands and the thermometer.
• Explain the procedure to the patient.
• Hold the thermometer at eye level and read the temperature.
• Dispose of tissues and clean the thermometer.
• Record temperature on a sheet and report any abnormalities.