Vital Signs: Temperature & Respiration (PDF)

Vital Signs: Temperature, Respiration Jojo Wong Learning Outcomes After this lecture & the practical session, you will be able to: 1. Describe normal ranges of temperature, respiration, and oxygen saturation. 2. Identify factors that affect temperature, respiration, and...

Vital Signs: Temperature, Respiration Jojo Wong Learning Outcomes After this lecture & the practical session, you will be able to: 1. Describe normal ranges of temperature, respiration, and oxygen saturation. 2. Identify factors that affect temperature, respiration, and oxygen saturation. 3. Demonstrate the skills for assessing temperature, respiration, and oxygen saturation. 4. Document the findings of temperature, respiration, and oxygen saturation. 5. Identify & report abnormal findings of temperature, respiration, and oxygen saturation. What is body temperature?  Balance ٪ heat produced & heat lost from the body Heat Produced Heat Lost - Metabolism - Skin - Muscular - Lungs activity - Body wastes - Thyroxine and epinephrine Types of body temperature  Core Temperature - Temperature of the deep tissue of the body (eg. abdominal cavity & pelvic cavity)  Surface temperature - Temperature of the skin, subcutaneous tissue Temperature Scales C = Celsius F = Fahrenheit Conversions: F = (1.8 x C) + 32 C = (F – 32) / 1.8 Body Temperature 103F = ? C Factors affecting body temperature  Age  Circadian rhythms  Exercise Normal range:  Hormones 35ºC - 37.5ºC  Stress  Environment Clinical manifestations of fever Prodromal stage – non-specific symptoms - headache - fatigue - general malaise - muscle aches Chill stage (onset of fever) - heart rate, respiratory rate & depth - shivering & complain of cold - pale & cold skin, “gooseflesh” appearance - cyanotic nail beds - cessation of sweating Clinical manifestations of fever Plateau stage – reaches a new set point - absence of chills - warm skin - respiratory rate & depth - feeling thirsty & dry mouth - mild to severe dehydration - malaise, weakness & muscle aching - loss of appetite Clinical manifestations of fever Flush stage – aims to lower the set point - shivering - flushed skin & feel warm - diaphoresis (obvious sweating) - thirsty & dry mouth - possible dehydration Types of thermometers Non-invasive  Mercury-in-glass thermometer  Electronic thermometer  Infrared (tympanic) thermometer  Temporal artery thermometer Invasive  Pulmonary artery catheter (gold standard for measuring core body temp) Taking body temperature Common sites for taking body temperature  Oral  Tympanic  Axillary  Rectal Oral temperature Site  Right or left posterior sublingual pocket with mouth closed Posterior sublingual pockets - near deep tongue arteries that share same carotid artery blood supply as hypothalamus Oral temperature Not suitable for:  Clients having difficult in breathing  Confusing clients  Infants or young children  Clients prone to seizure  Clients having oral injury or after oral surgery Tympanic temperature  Tympanic membrane is located close to hypothalamus & shared a common blood supply (internal & external carotid arteries) Tympanic temperature Site  Outer portion of ear canal with probe tip seals opening of the canal  Some model require to pull pinna of ear while inserting Adults Up Back Out Children < 3 Down Back Out years old Tympanic temperature Factors influencing accuracy  Presence of ear wax (cerumen)  Cleanliness of probe lens  Smoothness & intact of disposable probe cover Using mobile phone? Tympanic temperature Not suitable for  Clients with ear injury  Clients with ear infection  Clients just have ear canal treatment Axillary temperature  Axillary arteries are branched out from subclavian arteries  For client not suitable for taking temperature at other sites Picture adapted from www.ohbaby.co.nz Axillary temperature Site  In axilla with arm tightly across chest Factors influencing accuracy  Moist skin Rectal temperature  Superior rectal artery is branched out from inferior mesenteric artery Site  1.5 – 3.5 cm from anus, depending on size and age of the client Picture adapted from www.nytimes.com - Infant: 1.5 cm - Child: 2.5 cm - Adult: 3.5 cm Rectal temperature Factor influencing accuracy  Presence of stool Not suitable for  Adult clients cannot turn to side lying  Clients of risk for rectal perforation e.g. neonates  Clients with significant haemorrhoids  Clients after rectal surgery  Clients have diarrhoea Assessing body temperature  Ascertain measurement need & check client’s ID  Select measurement site by assessing client’s ability & condition  Confusing / unconscious clients  Clients prone to seizure  Clients after oral / ear / rectal / upper chest surgery  Clients with injury in mouth / ear / rectum / axilla  Clients difficult in breathing  Neonates, infants or very young children  Clients cannot put into side-lying Assessing body temperature  Assess presence of factors that may influence the findings  Hot / cold drinks  Presenceof cerumen, extreme environmental temperature  Moist armpits  Presence of stool  Immediate after exercise Assessing body temperature  Provide psychological and physical preparation  Wash hand  Prepare & check necessary equipment e.g.  Thermometer & disposable sheath / probe cover  Clean gloves, if necessary  Lubricant on tissue / gauze (for taking rectal temp)  Tissue / wool pad (for taking axillary temp)  Rubbish bag A tray (for putting in all the equipment) Assessing body temperature  Prepare thermometer - Ensure under 35°C - Cover thermometer by disposable sheath/cover - Lubricate thermometer (for rectal temperature)  Explain procedure to gain cooperation  Prepare environment  Prepare client to appropriate position  For rectal temperature  Assist client to slide down trousers (ensure privacy)  Position client on a side facing away you Assessing body temperature Skills (Oral using mercury-in-glass thermometer)  Place bulb of thermometer at client’s mouth under tongue (at right or left posterior sublingual pocket)  Teach client to close mouth, breath through nostrils, hold thermometer by lips and hand, don’t bite on it  Leave thermometer at client’s mouth for 6-7 minutes or according to agency guideline  Assessing body temperature - Skills (Tympanic) Thermometer base Probe Eject butto n Display Scan button The Editors of Nursing 2007 Probe lens cover  Probe lens Remove thermometer from its base & make sure the lens is intact & clean. Set display according to ward practice. Place a disposable probe cover tightly over the lens. The Editors of Nursing 2007  Put your patient at a comfortable position & where you can clearly see her ear canal. Gently insert probe tip into her ear as far as it firmly seals opening & is directed towards tympanic member (some model may require you to pull pinna of ear upward, backward, and slightly away from head). The Editors of Nursing 2007  Press & release Scan button. When you hear a beep sound, read the temperature. Press eject button to discard probe cover. Record reading in patient temperature chart. Snap thermometer back into its base. The Editors of Nursing 2007 Assessing body temperature Skills (Axillary using mercury-in-glass thermometer) Expose & clean axilla with tissue or wool pad Place bulb of thermometer in center of axilla Assist/ instruct client to support thermometer Leave thermometer at client’s axilla for 8-9 minutes or according to agency guideline Assessing body temperature Skills (Rectal using mercury-in-glass thermometer)  Separate buttocks & instruct client to take slow deep breaths  Insert thermometer 1.5 to 3.5 cm through anal sphincters  Leave thermometer at client’s rectum for 3 minutes or according to agency guideline Perry, Potter, Ostendorf & Laplante, 2021 Assessing body temperature Aftercare  Client  Put on clothing, as appropriate  Put into a comfortable position according to client’s preference  Environment  Put furniture (e.g. curtain, side-rail, over-bed table) into order  Arrange necessary items (e.g. call bell, water, tissue) for client, if indicated  Equipment  Thermometer  Discard disposable sheath / probe  Disinfect thermometer e.g. by alcohol swab / disinfectant  Recharge thermometer if appropriate  Discard rubbish  Put away equipment Document body temperature  Document & presented graphically  Document date & time  Document reading immediately  Record temperature in nearest tenth using blue/black pen  Indicate site for temperature taking  Oral (o); Tympanic (T); axillary (A); rectal (R)  Oral ( ); Tympanic ( ); axillary ( ); rectal (О ) 21/9/24 Touch as a screen for Fever? Respiration  Exchange of O2 and CO2 between the atmosphere and the body  Controlled by respiratory centers in the medulla oblongata and pons of the brain, and chemoreceptors in the medulla, carotid and aortic bodies  Respond to changes in concentration of O2, CO2, H+ Factors affecting respirations  Age  Gender  Exercise  Medications (eg. Morphine)  Stress  Altitudes  Diseases  Body position (sitting or lying)  Assessing respiration Respiratory characters can indicate a number of pulmonary and the related conditions Characters Descriptions  Rate Eupnea (14-20); bradypnea, tachypnea  Depth Normal; shallow, deep  Rhythm Regular (I:E = 1:2); irregular  Quality  Sound silent; wheezing, stridor, sighs  Effort effortless; dyspnea, orthopnea Assessing respiration  Tachypnea (Shallow breathing with increased RR)  Bradypnea (Decreased rate but regular breathing)  Hyperpnea (Deep breathing at normal rate) Assessing respiration Methods  Visual observation  Tactile observation Assess presence of factors that may influence the findings e.g.  Has been exercising  Stress or strong emotion  Medications Assessing respiration Necessary Equipment  Watch with a second-hand Skills  Minimize client’s awareness  Count one full minute for chest and/or abdominal movement  Observe depth, rhythm & quality of breathing Documentation  On chart using blue / black pen  On client’s progress sheet  Rate  Depth  Rhythm  Quality Pulse Oximetry  Is a non-invasive, indirect way to measure arterial blood oxygen saturation (SaO2)  Determine the % of oxygenated hemoglobin within pulsatile arterial blood SaO2 vs SpO2 SaO2 (Arterial oxygen saturation)  Measured by CO-oximeter (Arterial blood gases)  The ratio of oxyhemoglobin over all types of hemoglobin SpO2 (Peripheral oxygen saturation)  Measured by Pulse oximeter  The ratio of oxyhemoglobin and deoxyhemoglobin SpO2 - Is a reliable estimation of SaO2 if it is > 70% Pulse Oximetry  For early detection of clinical hypoxemia  Assess client’s tolerance to tapering oxygen therapy File:FingertipPulseOximeter-MD300C1NoLogo.jpg http://www.uk.ask.com/wiki/Pulse_oximetry Pulse Oximetry  Pulse Oximeter:  Probe with 2 light emitting diodes (red & infrared light)  Photodetector - Oxygenated Hb absorb → infrared light - Deoxygenated Hb absorb → red light  Computed the amount of red/ infrared light that reaches the photodector SpO2 normal range Normal range: 95 – 100 %  90% - 95% acceptable range  85% - 89% maybe acceptable for some patients  Less than 85% is certainly abnormal  Less than 70% is life-threatening Factors affecting Oxygen Saturation Readings 100% 80% Hemoglobin  If the hemoglobin is fully saturated with oxygen, the reading will appear normal even if the total hemoglobin level is low. Thus the client could be severely anemic and have inadequate oxygen to supply the tissues but the pulse oximeter would return a normal value. Activity  Shivering or excessive movement of the sensor site may interfere with accurate readings. Factors affecting Oxygen Saturation Readings Carbon Monoxide poisoning  Pulse oximeter cannot discriminate between hemoglobin saturated with carbon monoxide versus oxygen. Circulation  The oximeter will not return an accurate reading if the area under the sensor has impaired circulation.  Assessing pulse oximetry Skills:  Choose site (finger, toe, nose, earlobe or forehead) with adequate blood perfusion  Select appropriate probe (type & size) & disinfect it  Attach probe to the site  Ensure good light transmission  Get client’s cooperation to minimize movement of the site  Nursing care: every 2-4 hrs change location for adhesive sensors Documentation:  SpO2 96% (O2 2L/min)  RA/ air Suggested Article Suggested Reading  Berman, A., Snyder, S. J. & Frandsen, G. (2020). Kozier & Erb’s Fundamentals of nursing: Concepts, process, and practice (11th ed.). Pearson.  Lockwood, C., Conroy-Hiller, T., & Page, T. (2004). Vital signs. JBI reports, 2, 207-230.  Perry, A. G., Potter, P. A., Ostendorf, W. & Laplante, N. (Eds.). (2021). Clinical nursing skills and techniques (10th ed.). Mosby/Elsevier.