Chapter 8

Vital Signs

T-temperature
P--pulse

Vital
Signs

R--respiration
Bp--blood
pressure

vital signs

reflect the bodys physiological status

present condition

provide information to evaluate homeostatic

balance in status

be a quick and efficient way

to monitor a patients condition

to identify problems

to evaluate the patients response to intervention

vital signs

Vital signs and other physiological

measurements are the basis for clinical
problem solving.
An alteration in vital signs may signal the
need for medical or nursing intervention.
--Vital signs should be taken at regular intervals.
--As nurses we should
know the relevant knowledge about vital signs
be able to measure vital signs accurately
interpret their significance
make decisions about interventions

Section
Guidelines for Taking Vital Signs

1. select equipment :

be functional and appropriate

based on the patients condition and characteristics

2. know the patients normal range of vital signs

---serve as a baseline for comparison with findings
taken later

3. know the patients medical history, therapies,

and prescribed medications

Some illnesses or treatments cause predictable vital

sign changes.
Most medications affect at least one of the vital signs.

Section
Guidelines for Taking Vital Signs

4. control or minimize environmental factors

may affect vital signs
5. use an organized, systematic approach
when taking vital signs
---each procedure requires following a step-by-step
approach to ensure accuracy

6. the frequency of vital signs assessment

--based on the physician and the patients condition

Section
Guidelines for Taking Vital Signs
7. use vital sign assessment to determine
indications for medication administration
----cardiac drugs

8. analyze the results of vital sign

measurement--not interpret them in isolation
9. verify and communicate significant changes
in vital signs
7

Section Body Temperature

Physiology of Body Temperature

Factors Affecting Body Temperature

Alterations in Body Temperature

Nursing Process and

Thermoregulation

Physiology of Body Temperature

Definition of body temperature

Heat production and heat loss

Regulation of body temperature

Average temperature and normal r

ange of adult
9

Definition of body temperature

Body temperature is the heat of the
body.-- reflects the balance between
the amount of heat produced by body processes
the amount of heat lost to the external
environment

10

Definition of body temperature

core temperature : temperature of deep

tissues (cranium, thorax, abdominal and
pelvic cavity ), relatively constant

Surface temperature :the temperature of the

skin, the subcutaneous and the fat tissue ,
fluctuates from 36 to 38

11

Heat Production

Heat is produced in the body through

metabolism.

The main heat production organs of the

body are liver and skeletal muscles.

Heat production occurs during rest, voluntary

movements, involuntary shivering, and nonshivering
thermogenesis(brown adipose).

12

Heat Loss
Heat is lost through physical mode. The main
heat loss part of the body is skin. (70%)
(R29%,elimination1%)

Radiation

Conduction

Convection

Evaporation
13

Radiation

Radiation is the transfer of heat between

two objects without direct contact by
electromagnetic waves.
Heat radiates from the skin to any
surrounding cooler object.

increase T difference between two objects

Increase radiating surface area

heat loss

Increase the extent of vasodilation

14

Conduction

Conduction is the transfer of heat from one

object to another with direct contact.
When the warm skin touches a cooler
object(solid; gas; liquid), heat is lost.

Heat loss velocity depends on

Heat conducting capability

T difference between the two objects

Contacting area

15

Convection

Convection is the transfer of heat away by

air or liquid movement.

Heat is first transferred to air or liquid

molecules directly in contact with the skin.
Air or liquid currents carry away the
warmed air or liquid.

Heat loss velocity depends on

current velocity

T difference between the object and air or liquid

16

Evaporation

Evaporation is the transfer of heat energy

when a liquid is changed to a gas.

The body continuously loses heat by

evaporation. --R;skin 300-400ml/d

By regulating sweating, the body promotes

additional evaporative heat loss. --febricide

Evaporation is the main heat loss mode when

environment temperature is higher than
body temperature.
17

Regulation of Body Temperature

Neural and Vascular Control

Behavioral Control

18

Neural and Vascular Control

T regulation center :the hypothalamus ,

controls body temperature the same way a
thermostat works in the home (reflex arc)

the anterior hypothalamus controls heat

loss Via sweating, vasodilation, inhibition of heat
production

the posterior hypothalamus controls heat

production via muscle shivering , heat
conservation by vasoconstriction of surface blood
vessels

19

Normal Blood Temperature

(37 )

(to or
toward)
Decreased blood
temperature

Factors which
increase metabolic rate
or
Environmental
temperature
Increased blood temperature
above level at which thermostat
in hypothalamus is set (37 )

Stimulated thermal receptors

Of heat-dissipating center
in hypothalamus, initiating
impulses that lead to

Increased heat
Loss by evaporation
Increased sweat
secretion

Increased heat
Loss by radiation

Dilation of skin
blood vessels

Heat loss mechanisms to maintain normal body

temperature

20

Behavioral Control

environmental temperature fall:

add clothing
move to a warmer place
raise the thermostat setting
increase muscular activity by running
sit with arms and legs tightly wrapped together

21

Behavioral Control

The ability of a person to control body

temperature depends on

the degree of temperature extreme

the persons ability to sense feeling
comfortable or uncomfortable--infants, older
adults

thought processes or emotions--depression

the persons ability to remove or add clothes

infants, children
22

Average Temperature
and Normal Range of Adult
site

average temperature

normal range

oral

37

36.3-37.2

rectal

37.5

36.5-37.7

axillary

36.5

36.0-37.0

23

Factors Affecting Body Temperature

Measurement site
Circadian rhythms :
drops between 2 and 6 AM
peaks between 1 and 6PM

Age: With age,T tends to fall .

infancy: temperature regulation is labile
aging: control mechanisms deteriorate

24

Factors Affecting Body Temperature

Hormonal influences :
progesterone: raise the body temperature

Exercise :increase body temperature

Medications:
anaesthetic: depress T regulation center
promote vasodilation

febrifuge: T

25

Factors Affecting Body Temperature

Stress: Stimulate sympathetic nervous system

-- epinephrine and norepinephrine production ,
-- metabolic activity

heat production --T

Environment: the extent of exposure,

air temperature and humidity
the presence of convection currents

Ingestion of hot/cold liquids

Smoking: increase body temperature

26

Alterations in Body Temperature

Fever or Hyperthermia

Hypothermia

27

Fever or Hyperthermia

A body temperature above the usual range

is called fever.

A true fever results from an alteration in

the hypothalamic set point.

Pyrogens such as bacteria and virus cause

a rise in body temperature.

Fever is an important defense mechanism.

28

Fever process and manifestation

Fever-chill phase: heat production>heat loss;

experience tiredness, paleness, dryness, chills,
shivers, and feels cold

(2 patterns)

plateau phase : heat production=heat loss;

warm , dry, R , P , headache, faint, inappetence

fever break phase: heat production<heat loss;

skin -- warm, flushed, diaphoresis

(2 patterns)

29

Hyperthermia (clinical)

An elevated body temperature related to the

bodys inability to promote heat loss or
reduce heat production is hyperthermia.

Any disease or trauma to the hypothalamus

can impair heat loss mechanisms.

30

Classification of Fever (Oral)

Mild

37.5-37.9

99.5-100.2

Moderate

38.0-38.9

100.4-102.0

Severe

39.0-39.9

102.2-105.6

Profound

>41

>105.8

31

Patterns of Fever

is the modality of a temperature curve.

differ depending on the causative pyrogen.

The increase or decrease in the amount of

pyrogens results in fever spikes and declines
at different times of the day.

The duration and degree of fever depends on

the pyrogens strength and the ability of the
individual to responds.
----serve a diagnostic purpose.

32

Patterns of Fever

Constant Fever

Remittent Fever

Intermittent fever

Irregular Fever

33

Constant Fever

sustains between 39~40

demonstrates little
fluctuation of less than 1
within 24 hours.
( pneumonia , typhoid)

34

Remittent Fever

has great fluctuation

above the normal with
more than 1 in 24 hours
and cannot return to
normal temperature level.
(septicemia , rheumatic
fever)
35

Intermittent fever

fluctuates greatly in 24 hours,

may suddenly rise above the
normal then suddenly fall to or
below the normal

alternates regularly between a

period of fever and a period of
normal temperature levels
(malaria, tuberculosis)

36

Irregular Fever

irregularity alternates
between a period of fever
and a period of normal
temperature values.
( influenza , cancer)

37

Hypothermia

A body temperature below the lower limit of

normal 35 is called hypothermia
Heat loss during prolonged exposure to cold
overwhelms the bodys ability to produce
heat causing hypothermia
Hypothermia may be intentionally induced
during surgical procedures to reduce
metabolic demand and the bodys need for
oxygen
38

Classification of Hypothermia

Mild

33.1-36

91.5-96.8

Moderate

30.0-33

86.1-91.4

Severe

27-30

80.6-86.0

<27

<80.6

Profound

39

Manifestation of Hypothermia

34.4-35: uncontrolled shivering loss

of memory depression, poor judgment

falls below 34.4

heart and respiratory rates
blood pressure fall

skin ---- cyanotic

progress--- cardiac dysrhythmias

loss of consciousness
unresponsive to painful stimuli

40

Nursing Process
and Thermoregulation

Assessment

Nursing Diagnosis

Planning

Implementation

Intervention
41

Assessment

Sites: mouth rectum, axillary

tympanic membrane

Thermometers
Glass Thermometer
Electronic Thermometer
Disposable Thermometer

42

Glass Thermometer

VCD
43

Electronic Thermometer

44

Disposable Thermometer

45

Nursing Diagnosis
Nursing diagnosis
Hyperthermia

Diagnostic foundation

Increase body temperature above usual range

Flushed skin, skin warm to touch
Increased pulse and respiratory rate
Herpetic lesions of the mouth

Hypothermia

Decreased body temperature

Pale, cool skin
Decreased pulse and respiratory rate
Feelings of cold and chill

Ineffective

Older adults or infants, weak inability to adapt

thermoregulation

to environmental temperature

46

Planning

require an individualized care plan -maintaining normothermia and reducing risk

factors

education is important

Objects: restoring normothermia

minimizing complications
promoting comfort

care plan should support goals

47

Examples for goals and outcomes

Goal
Restore and maintain normothermia.

Outcome
Temperature maintained within normal
range during environment changes.

48

Examples for goals and outcomes

Goal

Outcomes

Minimize complications of altered body

temperature.
patients blood pressure, pulse, and respirations
are within normal limits
patients skin integrity maintained
patients nutritional intake meets body needs
patients mucous membranes are moist
patient is able to participate in ADL activities
patients skin is warm and pink
patient reports sense of rest and comfort
49

Examples for goals and outcomes

Goal
Reduce risk of altered body temperature.

Outcomes
patient identifies risk factors for altered
body temperature
patient practices measures to prevent
body
temperature alteration

50

Implementation

Nursing measures for patient with

a fever

Nursing Interventions for patient

With Hypothermia

51

Nursing measures
for patient with a fever

Assessment

Obtain body temperature during each phase of febrile

episode
Assess
for
contributing
factors
such
as
dehydration

infection

or
environmental
temperature
Identify physiological response to temperature.
Obtain a11 vital signs
Observe skin color
Assess skin temperature
Observe for shivering and diaphoresis
Assess patient comfort and well-being
Determine phase of fever--chill plateau fever break

52

Nursing measures
for patient with a fever
Intervention

1.Promote heat loss and lower the

temperature.
Limit physical activity--heat production
reduce external covering--heat loss
physical therapies:ice packs ; bathing with alcoholwater solutions
medication

Take temperature after lowering the temperature

physically for 30 minutes, record the readings.

53

2.Intensify observation of the patients

conditions.

take temperature
1 time/4h--severe fever,
4 time/day T<38.5
1-2 times/day for three days after body temperature
returns normal.
Observe patients face color, pulse, respiration,
diaphoresis and other signs when taking patients
temperature.
Assess
for
contributing
dehydration

infection
temperature

factors
such
as

or
environmental

Observe therapeutic effect.

Observe the intake of liquids and the output of urine.
Contact physicians
conditions.

promptly

when

find

abnormal

54

3. Provide nutrients to meet increased

energy needs

Provide measures to stimulate appetite and offer

well-balanced meals
Provide fluids at least 3000ml per day for patient with
normal cardiac and renal functional to compensate
fluids lost through insensible water loss and sweating

55

4.Promote comfort and prevent

complications.

Allow rest periods.

Control temperature of the environment without
inducing shivering
Provide oral hygiene and keep oral moist to prevent
oral infection.
Keep clothing and bed sheet dry to increase comfort
and heat loss through conduction and convection

56

5.Provide psychological care.

Meet patients reasonable requirements.
Provide health education about fever.

6.Obtain blood cultures when ordered.

7.Provide supplemental oxygen therapy as

ordered to improve oxygen delivery to body
cells when ordered

57

Nursing Interventions
for patient With Hypothermia
Control environment temperature at 22~24 .
Elevate body temperature.
patients are monitored closely for cardiac
irregularities and electrolyte imbalances.
Observe the vital signs, take temperature
once at least per hour until the temperature
returned normal and stability.
Eliminate pathogeny.
Health education.
58

Evaluation

all nursing goals have been met

use other evaluative measures such as

palpation of the skin and assessment of
pulse and respirations

If therapies are effective body

temperature will return to a normal
range other vital signs will stabilize and
the patient will report a sense of
comfort
59

Section

Pulse

Physiology and Regulation

Character of The Pulse and

Observation of Abnormal Pulse

Nursing process and Pulse

Determination

60

Physiology and Regulation

The pulse is the rhythmical throbbing of

arteries produced by the regular
contraction of the heart.

The number of pulsing sensations

occurring in 1 minute is the pulse rate

Healthy adult pulse rate can range

between 60-100 beats per minute in
quiet state.
61

Forming of Pulse

Electrical impulses from the sinoatrial node travel

through heart muscle to stimulate cardiac
contraction

Approximately 60 to 70 ml (stroke volume) of blood

enters the aorta with each ventricular contraction

The arterial walls expand to compensate for the

increase in pressure. As the ventricle of the heart is
in diastole, arterial walls return to original status by
its own elasticity and peripheral resistance.

62

Forming of Pulse

The expansion and retraction of the aorta

sends a wave through the walls of the
arterial system that can be felt as a light tap
on palpation. The pulse is the palpable
bounding of the blood flow

63

Factors Influencing Pulse Rate

Age Normally Pulse Rates at Varies Ages

Age

normal range of pulse rate (beats/min)

Infants

120-160

Toddlers

90-140

Preschoolers

80-110

School ages

75-100

Adolescent

60-90

Adult

60-100

64

Sex : After puberty, the average male pulse rate is

slightly lower than the female. 5 times/min

Exercise

Temperature: Fever ;

Emotions: Acute pain ,anxiety -- pulse rate

Hypothermia

Unrelieved severe pain-- pulse rate

Drugs : atropine

digitalis

Postural changes: Standing or sitting , Lying

down

Hemorrhage:

Pulmonary conditions: poor oxygenation

65

Character of The Pulse and

Observation of Abnormal Pulse

Pulse Rate

Pulse Rhythm

Strength

Equality

66

Abnormal Pulse Rate

Tachycardia

is an abnormally elevated heart

rate above 100 beats per minute in adults

(fever, anemia, hemorrhage, hyperthyroidism)

Bradycardia

is a slow rate, below 60 beats per

minute in adults (atrioventricular block,

increased intracranial pressure, hypothyroidism )

67

Pulse Rhythm

Normally a regular interval of time occurs

between each pulse or heart beat An
interval interrupted by an early or late beat
or a missed beat indicates an abnormal
rhythm or dysrhythmia

68

Abnormal Pulse Rhythm

Intermittent Pulse

Pulse Deficit

69

Intermittent Pulse

one pulse missing during regular or

irregular pulse patterns

one pulse absents every one pulse-bigeminy

one pulse absents two normal pulses be

called -- trigeminy

occur in cardiomyopathy, myocardial

infarction, digitalis intoxication, and
transient symptoms caused by excited
emotion or fear
70

Intermittent Pulse

threatens the heart ability to provide

adequate cardiac output

An electrocardiogram (ECG) is necessary to

define the pulse dysrhythmia.

Children often have a sinus dysrhythmia,

which is an irregular heartbeat that speeds
up with inspiration and slows down with
expiration.
71

Pulse Deficit

Refers to pulse rate is less than heart rate

An inefficient contraction of the heart

--fails to transmit a pulse wave to the
peripheral pulse site --creates a pulse
deficit

To assess a pulse deficit

simultaneously

--one nurse assess radial rates

--a colleague assess apical rates

It can be seen in patients with atria

fibrillation.
72

Strength

reflects the volume of blood ejected against

the arterial wall with each heart contraction
and the condition of the arterial vascular
system leading to the pulse site

normally remains the same with each

heartbeat

may be graded or described as

strong weak thready or bounding
73

Abnormal Strength

Bounding Pulse

Thready Pulse

Alternating pulse

Water Hammer Pulse

Paradoxical Pulse

74

Bounding Pulse

an increased stroke volume, which can be

palpated by fingertips slightly

often be seen with fever, hyperthyroidism,

and aortic valve incompetence.

75

Thready Pulse

weak and diminished, which is barely by

fingertips

often occurs with massive hemorrhage,

shock, and aortic stenosis

76

Alternating pulse

alternates between increased and

diminished patterns along with strong and
weak contraction of the ventricles

common causes are hypertensive heart

disease, myocardial infarction

77

Water Hammer Pulse

The abrupt distension and quick collapse of

the pulse is palpated following the
increased cardiac output with resultant
pulse pressure surges.

It often occurs with hyperthyroidism,

aortic valve incompetence.

78

Paradoxical Pulse

The pulse is obviously weak or not

palpable on inspiration. It results from
the declined strokes by the left ventricle
on inspiration.

Common causes are pericardial effusion

and constrictive pericarditis.

79

Equality

The nurse should assess both radial pulses

to compare the characteristics of each. A
pulse in one extremity may be unequal in
strength or absent in many diseases, such
as thrombosis, aberrant blood vessels, or
aortic dissection.

The carotid pulse should not be measured

simultaneously because excessive pressure
may stop blood supply to the brain.
80

Nursing process and

Pulse Determination

Assessment

Nursing Diagnosis

Nursing Plan

Implementation

Evaluation

81

Assessment
the nurse should collect the following data:

the patients general condition, such as age

, sex, status of an illness and treatment;

the pulse rate, rhythm, strength, equality

and factors influencing pulse

arterial wall elasticity

82

Nursing Diagnosis

Tachycardia; bradycardia;
dysrhythmias ; activity intolerance;
anxiety; fear; fluid volume deficit;
gas exchange impaired;
Hyperthermia; and hypothermia
83

Nursing Plan

interventions based on the nursing diagnosis

identified and the related factors;

the expected outcomes generally:

patients can tell the normal range and physiological

changes of the pulse;

patients can cooperate with the treatment and care.

84

Implementation

Instruct the patients to rest to decrease

heart energy consuming.

Oxygen

administration

is

provided,

according to the patients condition.

Observe the patients condition closely.

85

Implementation

Instruct the patients to take medicine on

time and observe the effect and side effect
of the medicine.

Tell the patients to keep first-aid medicine

along with them.

Provide mental support, let the patients to

keep steady mood.
86

Implementation

Health education:

stop smoking and drinking

take light and digestible diet, keep bowels

smooth;
teach the patients to monitor the pulse prior
to taking medicines that affect the heart rate.
Tell the patients to report any notable
changes of heart rate or rhythm to health care
provider.
Teach the patients and family members the
basic first-aid skills.
87

Evaluation

evaluate the therapeutic effect by assessing

the pulse rate, rhythm, strength, and
equality;

evaluate the patients mental status,

cooperation with treatment and nursing;

evaluate the patients knowledge about

health

88