ATI Vital Signs PDF

CHAPTER 27 UNIT 2 Temperature HEALTH PROMOTION SECTION: HEALTH ASSESSMENT/DATA COLLECTION CHAPTER 27 Vital Signs PHYSIOLOGIC RESPONSES ● Vital signs are measurements of the body’s most basic functions and include temperature, pulse, respiration, and blood pressure. Many facilities also conside...

CHAPTER 27 UNIT 2 Temperature HEALTH PROMOTION SECTION: HEALTH ASSESSMENT/DATA COLLECTION CHAPTER 27 Vital Signs PHYSIOLOGIC RESPONSES ● Vital signs are measurements of the body’s most basic functions and include temperature, pulse, respiration, and blood pressure. Many facilities also consider pain level and oxygen saturation vital signs. (SEE CHAPTER 41: PAIN MANAGEMENT, CHAPTER 53: AIRWAY MANAGEMENT, MATERNAL NEWBORN CHAPTER 23: NEWBORN ASSESSMENT, AND NURSING CARE OF CHILDREN CHAPTER 2: PHYSICAL ASSESSMENT FINDINGS.) Temperature reflects the balance between heat the body produces and heat lost from the body to the environment. Pulse is the measurement of heart rate and rhythm. Pulse corresponds to the bounding of blood flowing through various points in the circulatory system. It provides information about circulatory status. Respiration is the body’s mechanism for exchanging oxygen and carbon dioxide between the atmosphere and the blood and cells of the body, which is accomplished through breathing and recorded as the number of breaths per minute. Blood pressure (BP) reflects the force the blood exerts against the walls of the arteries during cardiac muscle contraction (systole) and relaxation (diastole). Systolic blood pressure (SBP) occurs during ventricular systole, when the ventricles force blood into the aorta and pulmonary artery, and it represents the maximum amount of pressure exerted on the arteries when ejection occurs. Diastolic blood pressure (DBP) occurs during ventricular diastole, when the ventricles relax and exert minimal pressure against arterial walls, and represents the minimum amount of pressure exerted on the arteries. FUNDAMENTALS FOR NURSING ● ● The neurologic and cardiovascular systems work together to regulate body temperature. Disease or trauma of the hypothalamus or spinal cord will alter temperature control. The rectum, tympanic membrane, temporal artery, pulmonary artery, esophagus, and urinary bladder are core temperature measurement sites. The skin, mouth, and axillae are surface temperature measurement sites. HEAT PRODUCTION AND LOSS Heat productionresults from increases in basal metabolic rate, muscle activity, thyroxine output, testosterone, and sympathetic stimulation, which increases heat production. Heat lossfrom the body occurs through: ● Conduction:Transfer of heat from the body directly to another surface (when the body is immersed in cold water). ● Convection:Dispersion of heat by air currents (wind blowing across exposed skin). ● Evaporation:Dispersion of heat through water vapor (perspiration). ● Radiation:Transfer of heat from one object to another object without contact between them (heat lost from the body to a cold room). ● Diaphoresis:Visible perspiration on the skin. ASSESSMENT/DATA COLLECTION EXPECTED TEMPERATURE RANGES ● ● ● ● ● An oral temperature range of 36° to 38° C (96.8° to 100.4° F) is acceptable. The average is 37° C (98.6° F). Rectal temperatures are usually 0.5° C (0.9° F) higher than oral and tympanic temperatures. Axillary temperatures are usually 0.5° C (0.9° F) lower than oral and tympanic temperatures. Temporal temperatures are close to rectal, but they are nearly 0.5° C (1° F) higher than oral, and 1° C (2° F) higher than axillary temperatures. A client’s usual temperature serves as a baseline for comparison. CHAPTER 27 Vital Signs 135 CONSIDERATIONS PROCEDURES FOR TAKING TEMPERATURE Age ● Newborns have a large surface‑to‑mass ratio, so they lose heat rapidly to the environment. A newborn’s temperature should be between 36.5° and 37.5° C (97.7° and 99.5° F). By age 5, children should be able to maintain an average temperature of 37° C (98.6° F). ● Older adult clientsexperience a loss of subcutaneous fat that results in lower body temperatures and feeling cold. Their average body temperature is 35° to 36.1° C (95.9° to 99.5° F). Older adult clients are more likely to develop adverse effects from extremes in environmental temperatures (heat stroke, hypothermia). It also takes longer for body temperature to register on a thermometer due to changes in temperature regulation. Perform hand hygiene, provide privacy, and apply clean gloves. Hormonal changescan influence temperature. In general, temperature rises slightly with ovulation and menses. At ovulation, body temperature can increase by 0.3° to 0.6° C (0.5° to 1.0° F) above the client’s baseline. During menopause when the client is experiencing a hot flash, skin temperature can increase up to 4° C (7.2° F). Rectal Exercise, activity, and dehydrationcan contribute to the development of hyperthermia. Illness and injurycan cause elevations in temperature. Fever is the body’s response to infectious and inflammatory processes. Fever causes an increase in the body’s immune response by: ● Increasing WBC production. ● Decreasing plasma iron concentration to reduce bacteria growth. ● Stimulating interferon to suppress virus production. Recent food or fluid intake and smokingcan interfere with accurate oral measurement of body temperature, so it is best to wait 20 to 30 min before measuring oral temperature. Circadian rhythm, stress, and environmental conditions can also affect body temperature. Oral ● ● Gently place the oral probe (with cover) of the thermometer under the tongue in the posterior sublingual pocket lateral to the center of the lower jaw. Leave it in place until the reading is complete. AGE‑SPECIFIC: Use this site for clients who are 4 years of age and older. Note: Do not obtain oral temperature readings for clients who breathe through their mouth or have experienced trauma to the face or mouth. ● ● ● ● ● Rectal measurement of temperature is more accurate than axillary. Assist the client to Sims’ position with the upper leg flexed. Wearing gloves, expose the anal area while keeping other body areas covered. Spread the buttocks to expose the anal opening. Ask the client to breathe slowly and relax. Insert the rectal probe (with cover and lubrication) of the thermometer into the anus in the direction of the umbilicus 2.5 to 3.5 cm (1 to 1.5 in) for an adult. If you encounter resistance, remove it immediately. Once inserted, hold the thermometer in place until the reading is complete. Clean the anal area to remove feces or lubricant. Use the rectal site to verify the temperature for any reading obtained through another site that is greater than 37.2º C (99º F). SAFETY MEASURE: Do not obtain rectal temperatures for clients who have diarrhea, are on bleeding precautions (those who have a low platelet count), or have rectal disorders. AGE‑SPECIFIC: The American Academy of Pediatrics NURSING INTERVENTIONS recommends not measuring rectal temperatures on infants younger than 3 months. Note: Stool in the rectum can cause inaccurate readings. EQUIPMENT Electronic thermometersuse a probe to measure oral, rectal, tympanic, temporal artery, or axillary temperature. Electronic thermometers require the use of a probe cover or probe cleaning with each use (per the manufacturer) and can be set to play a signal when the reading is complete. Tympanic or temporal arterial temperatures require a device specifically for measuring temperature at that site. Axillary ● ● Place the oral probe of the thermometer (with cover) in the center of the client’s clean, dry axilla. Lower the arm over the probe. Hold the arm down, keeping the thermometer in position until the reading is complete. Disposable, single‑use thermometersare for oral, axillary, and rectal temperature measurement. They reduce the risk of cross‑infection. These can include single-use thermometer strips or patches that have an adhesive side, and can be applied to the forehead or abdomen. 136 CHAPTER 27 Vital Signs CONTENT MASTERY SERIES