Vital Signs Assessment

Vital Signs

• Vital signs include temperature, respiration, and oxygen saturation.
• Learning outcomes of the lecture and practical session include describing normal ranges, identifying factors affecting these vitals, and demonstrating the skills to assess and document them. Students also learn to recognize and report abnormal findings.
• Body temperature is a balance of heat produced (metabolism, muscular activity, thyroxine and epinephrine) and heat lost (skin, lungs, body wastes).
• Core temperature refers to deep tissue temperature (e.g., abdominal and pelvic cavity).
• Surface temperature refers to the temperature of skin and subcutaneous tissue.
• Temperature scales include Celsius (°C) and Fahrenheit (°F). Conversion: F = (1.8 x C) + 32.
• Factors affecting body temperature include age, circadian rhythms (physical, mental, behavioural changes over a 24-hour cycle), exercise, hormones (pregnant/ovulation, slight increase), stress (slight increase), and environment.
• Normal body temperature range is 35°C - 37.5°C. A temperature of 38°C or higher often indicates an infection.
• Fever has stages: prodromal (non-specific symptoms like headache, fatigue, malaise, muscle aches), chill (onset of fever with increased heart and respiratory rate, shivering, pale/cold skin), plateau (absence of chills, warm skin, feeling thirsty/dry mouth, mild/severe dehydration, malaise/weakness/muscle aches, loss of appetite), and flush (shivering, flushed skin, diaphoresis (sweating), thirsty/dry mouth, possible dehydration).

Types of Thermometers

• Non-invasive thermometers include mercury-in-glass thermometers, electronic thermometers, infrared (tympanic) thermometers, and temporal artery thermometers.
• Invasive thermometer: Pulmonary artery catheter (gold standard for measuring core body temperature).

Taking Body Temperature

• Common sites for taking body temperature include oral, tympanic, axillary, and rectal.
• Oral temperature is measured in the posterior sublingual pocket with the mouth closed.
• Tympanic temperature is measured in the ear canal. For adults, placing the thermometer tip upward in the ear canal; and downwards in children less than 3 years of age.
• Axillary temperature is taken in the armpit with the arm held tightly across the chest.
• Rectal temperature is taken 1.5-3.5 cm from the anus, varying with age and size.

Assessing Body Temperature

• Steps for assessing body temperature include verifying client identity, selecting the appropriate measurement site, and ensuring client cooperation.
• Consider factors like hot/cold drinks, presence of cerumen/extreme environmental temperatures, moisture, and stool presence.
• Prepare the thermometer, equipment (e.g., gloves, lubricant, pads, tray, rubbish bag), and the environment.
• Position the client appropriately (e.g., reclining, side-lying) based on the selected site.
• Explain the procedure clearly and gain the client's cooperation.

Assessing Respiration

• Respiration involves the exchange of oxygen and carbon dioxide between the atmosphere and the body, controlled by respiratory centers in the medulla oblongata and pons, and chemoreceptors in the medulla, carotid, and aortic bodies. They respond to changes in the concentration of O2, CO2, and H+.
• Factors that can affect respiration include Age, Gender, Exercise, Medications (eg. morphine), Stress, Altitudes, Diseases, and Body Position (sitting or lying down).
• Common assessment aspects involve characteristics such as Rate, Depth, Rhythm, Quality, and Sound.
• Different respiration patterns include but are not limited to Eupnea, Bradypnea, Tachypnea, and Hyperpnea.
• Methods to assess respiration include visual and tactile observation.
• Equipment for measuring respiration includes a watch (with a second hand).
• Necessary steps to assess respiration include minimizing client awareness, counting for one full minute, and observing chest/abdominal movement, depth, rhythm, and quality of breathing.

Pulse Oximetry

• Pulse oximetry is a non-invasive method for measuring arterial blood oxygen saturation (SaO2), it does so by determining the percentage of oxygenated hemoglobin in pulsatile arterial blood flow.
• Pulse oximetry is used for detecting hypoxemia and assessing the patient's tolerance to oxygen therapy.
• Device details include a probe with two light-emitting diodes (red and infrared) and a photodetector.
• Normal SpO2 range is 95-100%, 90-95% may be acceptable in some patients, but less than 85% is certainly abnormal, and less than 70% is life-threatening.
• Factors that can affect pulse oximetry readings include factors like hemoglobin level, presence of carbon monoxide, inadequate blood perfusion or circulation in the area probed, shivering or excessive movements, and proper probe placement.

Documentation

• Documenting vital signs (temperature, respiration, pulse oximetry) is done using a blue/black pen.
• Documentation should be done immediately in a client's progress sheet indicating rate, depth, rhythm, quality of the assessment.
• The documentation of vital signs should be precise, clearly indicate site of measurement (oral (O), tympanic (T), axillary (A), rectal (R)), and be presented graphically (e.g., using temperature charts).

This quiz covers the essential aspects of vital signs, including temperature, respiration, and oxygen saturation. Students will learn to identify normal ranges and factors affecting these vital signs, along with the proper assessment and documentation skills. Explore the concepts of core and surface temperature and their measurement scales.