VITAL SIGNS

INTRODUCTION
vital sign
sign of life; usually an indicator of a
person's general physical condition.

 The most frequent measurements obtained by

health workers are those of

Temperature
Pulse
Respiration
Blood pressure

TEMPERATURE
The balance between the heat produced

and the heat lost from the body.

PULSE
Number of times the heart beats in 1 minute.
RESPIRATION
Number of times a patient breaths in 1 minute.
BLOOD PRESSURE
Blood pressure is the force exerted by the blood
against the walls of the blood vessel as it flows
through them.

T. P .R and B.P

Referred as vital signs.

These findings are governed by vital organs.
These measures indicate the effectiveness of
Circulatory
Respiratory
Neural
Endocrine body functions

WHY TO ASSESS VITAL SIGNS?

To determine clients usual state of

health.
Change signals
Change in physiological function.
The need for medical or nursing
intervention.
Evaluate
clients
response
to
intervention.

Acceptable ranges
Temperature:
oral /tympanic-(37C) ( 98.6F)
Rectal -37.5C ( 99.5F )
Axillary -36.5C (97.7F)
Pulse :60-100 beats/minute
Respiration:12-20 breaths/minute
Blood pressure:120/80mmHg

Body temperature

BODY TEMPERATURE
MEANING
It is the difference between the amount of
heat produced by body processes and the
amount of heat lost to the external
environment.
Heat produced heat lost=body temperature.
and is measured in heat units called degrees

Types
Core temperature
Surface temperature

Physiology
1. Core temperature
Temperature of the deep tissues(cranial ,
thoracic , abdominal cavity).it remains
relatively constant.
2. Surface temperature
It is the temperature of the skin,
subcutaneous tissue ,and fat . It by
contrast ,rises and falls in response to the
environment.

 Surface temperature varies depending

on blood flow to the skin and the amount

of heat lost to the external environment.

1.neural and vascular control

HYPOTHALAMUS
Controls the temperature.

located between cerebral hemispheres.

Anterior hypothalamus controls heat loss
Posterior

hypothalamus controls heat

production .

 Diseases or trauma to the hypothalamus or spinal cord

Serious alteration in temperature control

Heat Produced and Lost

Heat Produced
Metabolism of food
Muscle and gland activity
Heat Lost
Perspiration
Respiration
Excretion of feces and urine

BASAL METABOLIC RATE

(BMR): Is the rate of energy utilization in
the body required to maintain essential
activities or heat produced by the body at
absolutely rest.

Heat loss
Radiation

Conduction
Convection
Vaporization

(evaporation.)

Radiation;

The transfer of heat from

the surface of one object to

the surface of another
without contact between the
two objects, mostly in the
form of infrared rays.

Conduction; .
it is the transfer of heat from one molecule

to a molecule of lower temperature .

conductive transfer cannot take place
without contact between the molecules .
Applying an ice pack or bathing a patient with
a cool cloth.

Convection
it is the dispersion of heat by air

currents.
E . g. fan

Evaporation

It is a continuous evaporation of moisture from the

respiratory tract and from the mucosa of the mouth and
from the skin.

FACTORS AFFECTING
TEMPERATURE..
Age

Exercise
Hormones
Diurnal variations(circadian rhythms)
Stress
Environment

Assessment of body
temperature
Sites
Equipments
Technique
Special consideration

INTRODUCTION
As body temperature is indicator of normal body

functioning .nurse checks the body temperature of

client as baseline data as well as to detect any
abnormality.

Nurses role
.

Selection
of site

Frequency of
monitoring .

Documenting
and reporting

Ensure
accuracy .

SITES:
1.

2.
3.
4.
5.

Oral
Rectal
Axillary
Tympanic membrane
Forehead

THERMOMETERS

THERMOMETERS
TYPES
Electronic
Chemical disposable thermometers.
Mercury- in glass thermometer
Temperature sensitive tape
Infrared thermometers
Temporal artery thermometers

Electronic thermometer;
it consists of a rechargeable battery
powered display unit ,a thin wire cord
,and a temperature processing
probe covered by a disposable probe
cover .
2. Can provide a reading in only 2 to 60
seconds
1.

 Mercury- in glass thermometer;

it is a glass tube sealed at one end ,with a

mercury filled bulb at the another .exposure of

the bulb to heat causes the mercury to expand
and rise in the enclosed tube.

TEMPERATURE SENSITIVE TAPE

The tape contains liquid crystals that change color
according to the temperature .When applied to the skin
,usually of the forehead or abdomen ,the temperature
digits on the tape respond by changing color.

Infrared thermometers
Sense body heat in the form of infrared

energy given off by heat source , which in

the ear canal is primarily the tympanic
membrane..
The infrared thermometer makes no
contact with the tympanic membrane.

Temporal artery thermometers

Determine

temperature using a scanning

infrared thermometer that measures arterial
temperature in the temporal artery of the
forehead

 The probe is placed in the middle of the

forehead and then drawn laterally to the

hairline .

Temperature scales..
Body temperature is measured in degree

on two scales:
Celsius or Fahrenheit

1.

Convert Fahrenheit to Celsius

C =(F-32)*5/9
Ex.40C =104f-32*5/9

2. Convert Celsius to Fahrenheit

F = (C *9/5)+32
Ex.104f=40*9/5+32

POINTS TO REMEMBER
1.Absence of inflammation .inflammed area is
already more warm than the other body parts.

2.How much accurate reading is required ?.E.g

.surgery.
3.Conscious level of the client.
5.Age of the client (client below 6 years cant
keep thermometer orally .he may break it.)

 4.Factors such as eating ,smoking ,drinking.

oral

forehead

rectal

SITES
Tympanic
membrane

axillary

 ASSESSING BODY TEMPERATURE

PROCEDURE

Oral temperature
Placing the thermometer bulb under the

tongue in posterior sublingual pocket.

ADVANTAGES:

Easily accessible
change .

requires

no

position

More accurate.

Can be held easily under the Tongue.

There is good supply of blood under tongue

.so correct temperature is recorded .

No privacy is needed.

Reflects rapid change in core temperature.

DISADVANTAGES :
Children, insensible persons may bite the

thermometer.(chance to break )

Possibility of cross infection.

Risk for body fluid exposure.

CONTRAINDICATIONS:
1.Clients who are extreme ,nervous, delirious,
unconscious and mentally confused and can
not follow the instructions.

2.The clients having convulsions .

3. Mouth breathers.
4.Who have injury , operation and inflammation
of the mouth and nasal surgery.

5. Client with frequent cough.

6.Children below six years of age.
7. Client on mask oxygen inhalation.

8.Drinking,smoking.

AXILLARY
Thermometer placed under the arm pit in

between the skin folds.

ADVANTAGES :
causes less discomfort.
safe and inexpensive.

does not affect by hot and cold drinks.

Used with newborns and unconscious clients.
No chance of cross infection .
Taking hot and cold drinks will not affect the

temperature.

DISADVANTAGES:
Presence of moisture gives false reading.
If thermometer not placed properly may give

false reading.

Long measurement time.

Requires continuous positioning by nurse.

RECTAL TEMPERATURE
Insert lubricated thermometer 1 inch in

adult rectum inch in infant rectum.

Advantage :
most reliable

Disadvantage
Needs privacy.
Danger of damaging the rectal mucosa.
If rectum packed with feacal matter gives

false reading.
Needs lubrication of bulb.

 Requires positioning and is often source of client

embarrassment and anxiety.

Risk of body fluid exposure.

Contraindicated in :
Rectal surgery
Diarrhea and rectal disease
Immunosuppressed
Significant hemorrhoids
Inflammed rectum

TYMPANIC MEMBRANE
TEMPERATURE
The
body
temperature
as
measured
electronically at the tympanic membrane

Advantage :
Reflects core temperature
Ear is readily accessible.
Permits rapid reading.(2-5sec)
Result is not affected by other factors

.Ex.food or fluid intake

 Obtained without disturbing.

Used in newborns to reduce infant handling and

heat loss

DISADVANTAGES
Requires removal of hearing aids before

measurement.

Inflammation of the ear (otitis media)and

cerumen (wax)impaction distorts readings.

 Oral-2 minutes.
Axilla-3-5 minutes.
Rectal-1 minute.

 Low pyrexia: temperature between 99 -100

degree F.
Moderate pyrexia: temperature between 100 103 degree F.
High pyrexia : temperature between 103- 105
degree F.
Hyper pyrexia: temperature above 105 Degree F
Rigor : a sudden severe attack of shivering in
which the body temperature rises to a stage of
hyperpyrexia

 Hypothermia: temperature falls below 95 F

Hyperthermia: hyperthermia is when body

temperature becomes elevated, as methods for

thermoregulation are not as effective. Therefore,
the body is absorbing more heat than it is
dissipating also known as overheating of the
body