Vital Signs: Temperature & Pain Assessment

• Vital signs, also known as cardinal signs, serve as indicators of a client's health condition.
• Vital signs include body temperature, pulse, respiration, and blood pressure.
• Monitoring vital signs helps to assess the overall functions of the body.
• Frequency of TPR (temperature, pulse, respiration) and BP (blood pressure) checks depends on the client's condition and institutional policy.
• Explain the procedure to the client before taking their TPR and BP.
• It is important to obtain baseline data for comparison.
• Vital signs, also known as cardinal signs, include body temperature, pulse, respiration, blood pressure, and pain.

Body Temperature

• Balance between heat produced and heat lost by the body.
• Core temperature refers to the temperature of deep tissues.
• Surface body temperature refers to the temperature at the body's surface.
• Pyrexia (hyperthermia) is body temperature above the normal range.
• Hyperpyrexia is very high fever, at or above 41°C (105.8°F).
• Hypothermia is a subnormal temperature.
• Normal oral temperature range for adults is 36.5-37.5 °C.
• Normal axillary temperature range for adults is 35.8-37.0 °C.
• Normal rectal temperature range for adults is 37.0-38.1 °C.
• Normal tympanic temperature range for adults is 36.8-37.9 °C.

Methods of Temperature Taking

• Oral method is accessible and convenient.
• When taking oral temperature, put on gloves, use a washed thermometer and position the tip under the tongue, far back as possible.
• Ensures contact with superficial blood vessels for accurancy.
• With the oral method, wait 15 minutes after hot or old intake and take the oral temp for 2-3 minutes.
• Instruct the patient to close lips but not bite down on the thermometer.
• Rectal method provides the most accurate measurement of temperature.
• For rectal temperature, position patient in lateral position with top leg flexed, drape for privacy, and squeeze lubricant onto tissue.
• Insert thermometer 0.5-1.5 inches, hold in place for 2 minutes, and do not force.
• Axillary method is safest and non-invasive.
• For the axillary method, pat the axilla dry, ask the patient to grasp opposite shoulder and hold in place for 9 minutes,
• Tympanic thermometer requires a clean, shiny lens under the probe.
• When using a tympanic thermometer, straighten the ear canal by gently pulling the ear straight back (kids) or up and back (adults)
• With the typanic method the thermometer has to seal the ear correctly, followed by activating the button.
• Chemical-dot thermometer requires placement for 45 seconds.
• Read the temperature as the last changed color dye.

Contraindications for temperature measurements

• Oral: Young children/infants, unconscious/disoriented patients, mouth breathers, seizure prone, patients with N/V, and patients with oral lesions/surgeries.
• Rectal: Patients with diarrhea, recent rectal/prostatic surgery or injury, recent myocardial infarction, and patients with post head injury

Factors Affecting Body Temperature

• Infants are greatly influenced by environmental temperature.
• Children's temperature is more labile than adults until puberty.
• Elderly are at risk of hypothermia due to factors like lack of central heating, inadequate diet, loss of subcutaneous fat/activity, and reduced thermoregulation.
• Diurnal variations (circadian rhythms) cause body temperature to vary throughout the day, up to 1.0°C between early morning and late afternoon.
• Hard work or strenuous exercise can increase body temperature.
• Women experience more hormone fluctuations than men; progesterone secretion during ovulation raises body temperature.
• Stress stimulates the SNS, increasing epinephrine and norepinephrine production, increasing metabolism and heat production.
• Environmental extremes affect temperature regulatory systems.

Nursing Interventions for Fever

• Monitoring vital signs, assessing skin color/temperature, monitoring WBC/Hct/pertinent lab records, food/fluids, rest, I&O's, TSB, clothing

Heat Production and Loss

• Most body heat is produced by the oxidation of foods (metabolic rate).
• Mechanisms of heat loss include radiation, conduction, convection, and evaporation.
• The pre-optic area of the hypothalamus acts as the temperature regulator/thermostat.
• The hypothalamus receives input from temperature receptors in the skin and mucous membranes (peripheral thermoreceptors) and internal structures (central thermoreceptors).
• With the hyporthalamus, if blood temp increases, neurons of the pre-optic area fire nerve if it decreases.
• Vasoconstriction reduces blood flow to the skin from internal organs, increasing internal body temperature.
• Sympathetic stimulation leads to the adrenal medulla secreting epinephrine/norepinephrine, increasing cellular metabolism and heat production.
• Skeletal muscle stimulation (shivering) increases muscle tone (stretch reflex + muscle contraction) which leads to heat production.
• Thyroxine increases metabolism and body temperature.

Body Temperature Abnormalities

• Fever/hyperthermia/hyperpyrexia is an abnormally high temperature resulting from infection (bacteria, toxins, viruses, stimulates prostaglandin secretion)
• Other causes of hyperthermia include heart attacks, tumors, tissue destruction, or reactions to vaccines.
• Heat cramps and exhaustion are due to fluid and electrolyte loss.
• Other abnormalities include heat stroke and hypothermia.
• Glass clinical thermometers are most commonly used to measure body temperature and have a bulb (mercury) and a stem (Celsius/Fahrenheit).

Pulse

• Pulse is a wave of blood created by contraction of the left ventricle.
• Stroke volume is the amount of blood entering arteries with each contraction (healthy adult)
• Compliance of arteries is their ability to contract and expand.
• Peripheral pulse is located in the periphery (foot, hand, neck).
• Apical pulse is located at the apex of the heart.
• Normal pulse rate for 1 year old: 80-140 beats/min
• Normal pulse rate for 2 year old: 80-130 beats/min
• Normal pulse rate for 6 year old: 75-120 beats/min
• Normal pulse rate for 10 year old: 60-90 beats/min
• Normal pulse rate for adult: 60-100 beats/min
• Tachycardia – pulse rate above 100 beats/min.
• Bradycardia – pulse rate below 60 beats/min.
• Irregularity indicates an uneven time interval between beats.
• Required items for pulse assessment include a watch, stethoscope, and Doppler ultrasound blood flow detector (if needed).
• Place client in sitting/supine position, ensure the client is comfortable and wash your hands
• Gently press index, middle, and ring fingers on the radial artery, inside the patient's wrist.
• Excessive pressure may obstruct blood flow distal to the pulse site.
• Count for a full minute for irregularities.
• Radial pulse can be calculated by washing hands, pt in sitting or supine position.
• Apply transmission gel to ultrasound probe, positioning it directly over artery at lowest volume setting, titling 45 degrees
• After pulse measurement with doppler, clean off antiseptic with soft cloth.
• Age is a factor that affects radial pulse, it decreases with age.
• Gender influences pulse rate. After puberty, male pulse rate is slightly lower than female's.
• Pulse rate usually increases with activity.
• Fever increases pulse rate.
• Hemorrhage typically increases pulse rate.
• Stress increases the rate and force of heartbeat through sympathetic nervous stimulation.
• Pulse rate and blood pressure can vary with positional changes. Blood pools in venous area, reducing blood pressure and heart rate subsequently
• Normal adult pulse rate is between 70-80 beats/min.
• Tachycardia refers to an excessively fast rate (over 100 beats/min) in the adult.
• Bradycardia refers to a heart rate of 60 beats/minute or less in the adult.
• Equal time elapses between beats of a normal pulse. Irregular rhythms are dysrhythmia or arrhythmia
• Pulse volume (amplitude/strength) refers to the force of the blood with each beat and normal pulse volume can be felt with pressure of fingers
• A forceful or full pulse is obliterated with difficulty and weak or feeble pressure from the fingers. The scale is usually 0 to 3.

Pulse Sites

• Temporal - superior/lateral to eye, over temporal bone
• Carotid - side of the neck below the lobe of the ear, between the trachea and the sternocleidomastoid muscle
• Apical - apex of heart
• Brachial - inner aspect of the biceps muscle (infants) or medially in the antecubital space (elbow crease)
• Radial - thumb side of the inner aspect of the wrist
• Femoral - passes alongside the inguinal ligament
• Popliteal - passes behind the knee, palpate if the client flexes the knee
• Posterior tibial - medial surface of the ankle behind the medial malleolus
• Dorsalis pedis - over the bones of the foot, feel the dorsum of foot to space between big second toe.

Respiration

• Respiration is the exchange of oxygen and carbon dioxide between the atmosphere and the body.
• Normal adult respiration rate is 12-20/min.

Respiratory Rate

• Newborn: 30-60/min
• Infant: 30-50/min
• Toddler: 25-40/min
• Preschool: 22-34/min
• School age: 18-30/min
• Best time to assess respiration is after taking a client's pulse.
• Count respiration for 60 seconds.
• Respiratory rates of less than 10 or more than 40 should be reported to the physician.
• Assess and record breath sounds (stridor, wheezing, stertor) as respirations are counted.
• Client factors affect respiration, so a nurse should be aware before the client assessment.
• Healthy adults take 15-20 breaths per minute.

Characteristics of Respiratory Assessment

• Eupnea is a normal respiration rate. Bradypnea is abnormally slow respiration. Tachypnea or polypnea is abnormally fast respiration.
• Depth - normal, deep, or shallow.
• Respiratory rhythm/pattern - regular or irregular.
• Respiratory quality/character - effortless breathing
• The sounds of breathing are normally silent, though abnormal sounds can be obvious to the nurse.

Blood Pressure

• Blood pressure measures the force exerted by the blood against a vessel (arterial).
• Systolic pressure measures the pressure of the blood because of ventricular contraction indicating height of blood flow
• Diastolic pressure measures the pressure of the blood when ventricles are at rest or lower pressure in arteries
• Pulse pressure measures the difference between the diastolic and systolic pressures.
• Blood pressure is measured in millimeters of mercury (mm Hg) and recorded as a fraction.
• Average adult blood pressure is 120/80 mm Hg.
• Hypertension is an abnormally high blood pressure.
• Hypotension is an abnormally low blood pressure (below 100 mm Hg systolic).
• Ensure the client is rested, use correct cuff size, position arm at heart level, and utilize the bell of stethoscope for reading.
• If the client is crying/anxious, measuring the blood pressure should avoided to prevent false-high BP.
• Electronic vital sign monitors track a patient's vital signs without reapplying a blood pressure cuff.

Physiology of Arterial Blood Pressure

• Cardiac output is the volume of blood pumped into the arteries by the heart and increases with exercise and fever.
• Diastolic pressure can be affected by peripheral vacular resistance, especially the blood volume in capillary size.

Factors that Create Blood Pressure resistance in Arterial System

• Arteriole and capillary size determines the decreased peripheral blood resistance that lowers blood pressure.
• Compliance of the arteries contains smooth muscle that permit contrast, affected by arterial walls, elastic/muscular, and affected by arteriosclerosis
• Blood volume - when decreased, blood pressure decreases, when increase, BP increases.
• Blood viscosity increases blood pressure (hematocrit).
• Newborn mean systolic pressure of 78mmHg.
• Exercise increases cardiac output and hence blood pressure.
• Stress stimulates output from the sympathetic nervous system.
• Hypertension risks increase for African American Males in particular group samples.
• Pressure is higher for those overweight.
• Women typically have lower blood pressure post-puberty.

Contributing Factors

• Exercise.
• Stress.
• Race.
• Age.
• Sex.
• Obesity.
• Diurnal.
• Disease.
• Medications
• Pressure is usually lowest early in the morning, when the metabolic rate is lowest, then rises throughout the day and peaks in the late afternoon or early evening.

Assessment Error Contributing Factors

• Bladder cuff too narrow/wide.
• Arm or back unsupported.
• Insufficient rest.
• Repeating too quickly.
• Cuff wrapped incorrectly.
• Deflating improperly.
• Failure to use same arm.
• Failure to consider heart level.
• Recently eating or smoking.
• Failure to identify auscultatory gap pressure

Auscultatory Gap

• Auscultatory gap is a temporary disappearance of sounds normally heard, which can indicate changes to body temperature, pulse, respirations and blood pressure.
• Data provides the baseline to provide care, and it must be abnormal to provide care for an individual.
• Pain, also called Cardinal Signs, is subjective and multi-factorial requiring behavioral assessment.
• Consider patient's verbal description with non-verbal signs (body language and physiological)

Pain Assessment

• Assess pain on a scale (0-10) and ask the client to describe the pain by asking where it located, how long, and what does the pain feel like.
• Observe the patient's behavioral response to pain (body language, moaning, grimacing, withdrawal, crying, restlessness muscle twitching and immobility).
• Assess Manage pain as ordered, provide patient emotional support, use cognitive therapy and provide comfort measures.

Explore the correct techniques for accurate temperature measurement using various methods and special considerations for patient populations. Learn about factors affecting body temperature and pain assessment. Understand the temporal aspects of a patient's pain experience.