Vital Signs

Define Various determinations that provide information about the patients basic body condition Often the first sign that there is a problem

VITAL SIGNS
Temperature Pulse Respirations Blood Pressure

Other Vital Signs

Pain assessment Skin color Pupil size and reaction Level of consciousness Response to stimuli

Temperature
Measurement of the balance between heat loss and heat produce
Types
Oral - mouth Rectal - rectum Axillary - armpit Aural (tympanic) ear

Heat Produced and Lost

Heat Produced
Metabolism of food Muscle and gland activity

Heat Lost
Perspiration Respiration Excretion of feces and urine

Normal Body Temperature

Normal range 97 100 degrees F

Variations in Normal Body Temperature

Lower in morning Higher in evening Eating or drinking anything hot or cold, smoking a cigarette or exercising in the last 15 minutes

Measured in degrees Celsius or degrees Fahrenheit

Oral Temperature
Taken in the mouth Thermometer left in for 3-5 minutes Most common, convenient, comfortable way to take temperature Check for eating/drinking anything hot/cold exercising or smoking a cigarette 15 minutes prior

Rectal Temperature
Taken in the rectum Thermometer left in for 3-5 minutes Most accurate Insert 1-1 inches, hold in place and screen patient for privacy

Axillary/Groin Temperature
Taken under the armpit or in the groin fold Thermometer left in for 8-10 minutes Least Accurate Dry armpit/groin, place in center and hold in place

Aural/Tympanic Temperature
- taken in the ear - measures the thermal infrared energy radiating from the blood vessels in the eardrum - position and ear wax can affect readings -left in until it beeps -temperature is calculated into an equivalent by mode

Temperature By Body Site

Oral
Normal temp 98.6 Normal Range 97.6-99.6

Rectal
Normal temp 99.6 Normal Range 98.6-100.6

Axillary/groin
Normal temp 97.6 Normal Range 96.6-98.6

Tympanic
Normal temp 98.6

Factors that Increase Temperature

Illness Infection Exercise Excitement High temps in the environment

Factors that Decrease Temperature

Starvation/fasting Sleep Decreased muscle activity Mouth breathing Exposure to cold temperatures Certain diseases

Temperature Conditions
Hyperthermia
Increased body temp Body temp >104F >106 F will cause convulsions and death

Fever
- temp over 101 F R - Due to illness or injury

Temperature Conditions
Hypothermia
Body temp below 96 F - due to exposure to cold temperatures - Depends on core temperature, age and length of exposure

Types of Clinical Thermometers

Clinical thermometers
Slender glass tube containing mercury or colored fluid Types
Oral blue tip, long slender bulb, marked oral Security plain tip Rectal red tip, short stubby bulb, marked rectal

Mercury Thermometers
Not used now Colored column of red alcohol Toxic to the body and environment Can be absorbed through the skin and inhaled as a vapor through the lungs Heavy metal that accumulates in the brain and causes mental retardation

Clean up Broken Mercury Thermometer

Use appropriate PPEs Do not touch mercury Seal in a glass container Dispose according to regulations

Types of Thermometers
Electronic
Can be used for oral, rectal, or axillary Blue probe for oral Red probe for rectal Disposable probe covers prevent crosscontamination

 Tympanic
- used to record temperature in the ear - Records temperature in 1-3 seconds

Positioning the Patients Ear for Tympanic temperature

Infants under 1 year
Pull ear pinna straight back

Infants over 1 year and adults

Pull ear pinna straight back and down

Positioning the pinna correctly straightens the auditory canal so the probe will point directly at the tympanic membrane
Pull ear pinna straight back and down

Reading Thermometers
Digital thermometers -until you hear the beep
Tympanic thermometers - hold in place for 2-3 seconds, remove and read

Reading a Glass Thermometer

Hold thermometer at eye level Find the column of mercury/red liquid Each long hash mark represents one degree Each short hash mark represents 2/10th of a degree Exception: long line at 986 F represent normal body temperature

Charting a Temperature
Use a superscript to record 10ths 102.2 should be written as 102.2 This avoids errors Use a TPR Chart Mark temp under correct date and time Indicate method of taking temperature - R - rectal - Ax axillary - T - tympanic No abbreviation indicates an oral temp

Clean A Clinical Thermometer

Use warm water to clean and rinse Soak in a disinfecting solution such as alcohol for 20 minutes