Vital Signs PDF

# Vital Signs ## **Definition:** Measurements of the body’s most basic functions. * Reflect the body’s physiologic status. * Provide information critical to evaluating homeostatic balance. ## **Purposes:** 1. To monitor patient's condition. 2. To obtain baseline data for comparing future measur...

# Vital Signs ## **Definition:** Measurements of the body’s most basic functions. * Reflect the body’s physiologic status. * Provide information critical to evaluating homeostatic balance. ## **Purposes:** 1. To monitor patient's condition. 2. To obtain baseline data for comparing future measurements. * Obtain baseline data for body temperature, pulse, respirations, and blood pressure. 3. To detect abnormalities in body temperature, pulse, respiration, blood pressure. 4. To evaluate effect of medication or nursing measures or response to medication or nursing measures. ## **Vital Signs Include:** * Temperature * Pulse Rate * Respiratory Rate * Blood Pressure >* Pain ## **Times to Assess Vital Signs:** 1. On admission. 2. When a client has a change in health status. 3. According to a nursing or medical order. 4. Before and after the administration of certain medications. 5. Before and after surgery. 6. According to hospital. # **Body Temperature** ## **Definition:** The balance between the heat produced and the heat lost from the body. ## **Normal Body Temperature:** * 37 °C or 98.6 °F (Average) * The range: 36.4-37.5 °C * 97.6-99.6 °F ## **Two Types of Body Temperature:** 1. **Core Temperature** - Temperature of the deep tissues of the body, such as the cranium, thorax, abdominal cavity, and pelvic cavity. * Constant (37) 2. **Surface Temperature** - Temperature of the skin, subcutaneous tissue, and fat ## **Fever (Pyrexia):** A body temperature above the usual range: 38-41°C (100.4-105.8 °F). * **Hyperpyrexia:** Above 41.6 °C * **Hypothermia:** Below 35 °C * 34°C is death ## **Factors Affecting Body Temperature:** 1. Age. 2. Exercise. 3. Stress & Hormones. 4. Environment Temperature (34 to 42) °C. ## **Sites to Measure Temperature:** * **Oral (Mouth):** * **Rectal (Rectum):** * **Axillary (Armpit):** * **Tympanic (Ear):** ## **Types of Thermometers:** 1. **Oral:** Long, slender tips 2. **Rectal:** Short, rounded tips 3. **Axillary:** Long, slender tips 4. **Tympanic:** Digital and electronic types. ## **Equipment:** 1. Appropriate thermometer. 2. Tissue paper. 3. Alcohol swab 4. Pen. Vital signs flow sheet. 5. Gloves. 6. Plastic thermometer sleeves. ## **Contraindication of Oral Body Temperature:** 1. Infants and children (younger than 4 to 5 years). 2. Mouth breathing patients. 3. Patient with seizure disorder. 4. Surgery for nose and mouth. 5. Receiving oxygen therapy. 6. Persistent frequent cough. 7. Immediate post-op under anesthesia 8. After drinking hot fluids or cold fluids. * Can measure after 15 minutes **Oral temperature more reliable (into the sublingual pocket)** ## **Contraindication of Rectal:** 1. Surgery in rectum. 2. Diarrhea. 3. Cardiac disease. ## **Normal Body Temperature** 1. The average normal temperature for adult is 37°C (Oral). 2. **Rectal:** 37.5 °C 3. **Axillary:** 36.5 °C * The normal range of body temperature: 36.4-37.5 °C. # **Procedure** 1. **Assessment signs and symptoms.** 2. **Factors that influence body temperature.** 3. **Previous activities.** 4. **Determine site and measurement device to be used.** 5. **Wash hands then wash the thermometer. Dry thermometer.** 6. **Explain the procedure to the patient.** * Each method is different. * Oral * Rectal * Axillary 7. **Hold the thermometer at eye level, read it.** 8. **Dispose the tissue, wash the thermometer, dry, wash your hands.** 9. **Record temperature on paper or flow sheet and report an abnormal reading to appropriate person.**