Prepared by

MARY ANN A. CUBON,RN,RM,MAN

Vital Signs
Also known as cardinal signs are
a persons temperature, pulse,
respiration and blood
pressure, abbreviated as T, P,
R and BP.
Are indicators of vital body
functions and reflects a persons
present health status as
compared to accepted normal

Times to Assess Vital Signs

On admission to a health care agency to obtain baseline data

Based on agency/institutional policy and procedures

Anytime there is a change in patients condition or reports symptoms
such as chest pain or feeling hot or faint.
Before and after any surgical or invasive procedure
Before and after the administration of a medication that
could affect the respiratory or cardiovascular systems
(Ex: before giving a digitalis preparation)
Before and after any nursing intervention that could affect the vital
signs
(Ex: ambulating a client who has been on bed rest, after enema, BT)

Body Temperature
The balance between the heat
produced and the heat lost
from the body, and is measured
in heat units called degrees.
Normal Range (oral temperature) of
an adult: 36.7 C - 37 C (98 -98.6
F)

Two types of body

temperature
1. Core temperature is the
temperature of the deep tissues of
the body, such as the abdominal
cavity and pelvic cavity. It remains
relatively constant, 37C.
2. Surface temperature
temperature of the skin,
subcutaneous tissue and fat and it
rises and falls in response to the

Factors Affecting Heat

Production/Loss
Heat production
Basal metabolism/BMR
Muscular activity
(shivering)
Thyroxine & Epinephrine
(stimulating effects on
metabolic rate)
Temperature effect on
cells (fever)

Heat loss
Radiation
Conduction
Convection

Evaporization

1.
Basal Metabolic Rate/BMR - rate of energy use in
the body needed to maintain essential activities such
as breathing. Metabolic rates decrease with age. In
general, the younger the person, the higher the BMR.
2.
Muscle activity including shivering, increases the
metabolic rate thereby increases heat production.
3.
Thyroxine output. Increased thyroxine output
increases the rate of cellular metabolism throughout
the body thus increasing the bodys temperature.

4. Epinephrine, norepinephrine, and

sympathetic stimulation/stress
response. These hormones immediately
increase the rate of cellular metabolism in
many body tissues. Epinephrine and
norepinephrine directly affect liver and
muscle cells, thereby increasing cellular
metabolism.
5. Fever increases the cellular metabolic
rate and thus increases the body's
temperature further.

Mechanisms of Heat Loss

1. Conduction

transfer of body heat to a cooler object in

direct contact with the body.
the amount of heat transferred depends on the
temperature difference and the amount and
duration of the contact.

Ex: Bathing a client in cool or tepid water will lower the

clients temperature.
The body transfers heat to an ice pack placed on the
forehead.
A newborn placed on a cold counter/table after delivery

Mechanisms of Heat Loss

2. Convection
Is the flow of heat from the body
surface to cooler surrounding air.
Dispersion/dissemination of heat by
air currents or motion.
Ex: The use of fans blows current of
cool air across the surface of a warm
body enhances heat loss by air.

Mechanisms of Heat Loss

3. Radiation
Transfer of body heat to a cooler object
not in contact with the body.
transfer is in the form of infrared rays
or by electromagnetic waves.
Ex:
Body heat is transferred to a hanging
curtain/draft, cabinets and other
furniture.

Mechanisms of Heat Loss

4. Evaporation
The loss of heat through conversion of
a
liquid to a vapor/gas.
Ex: Body fluid in the form of perspiration and
moisture from the respiratory tract/lungs
evaporates.

Insensible water loss is the continuous,

and unnoticed water loss Insensible
heat loss

Factors Affecting Body Temperature

Age- infants and elderly are greatly influenced by the temperature of
the environment due to inadequate diet, loss of subcutaneous fat, lack of
activity, and reduced thermoregulatory control.

Diurnal variations/circadian rhythms body temperature

normally change throughout the day, varying as much as 1.0C between
the early morning and the late afternoons. This is due to environmental
and physiologic processes/ events that occur at 24-hour intervals.
Body temp during early morning is usually lower (about 1.0C)
than in the late afternoon and early evening .
Point of highest body temp is usually reached between 4:00- 6:00
PM.
Lowest point is reached during sleep between 4:00 - 6:00 AM.

Exercise- hard work or strenuous exercise can increase body

temperature to as high as 38.3C to 40C (101F to 104F) measured
rectally.

Range of oral temperatures during

24 hours for a healthy young adult

 Hormones Progesterone secretion at the time of

ovulation raises body temperature by about 0.3C to
0.6C (0.5F to 1.0F) above basal temperature.
Stress- highly stressed or anxious client have an
elevated temperature due to the stimulation of the
sympathetic nervous system causing an increase
production of epinephrine and norepinephrine, thereby
increasing metabolic activity and heat production.
Environment - extremes in environmental temperatures
can affect a person's temperature regulatory systems.
In a warm room --- body temp will be elevated; if client
has been outside in cold weather --- body temp will be
low.

Terms and Definitions for Types of

Fever
2 Alterations in body temperature:
Pyrexia/Hyperthermia/Fever - a body
temperature above the usual range (36.7 C 37C).

Hypothermia- a body temperature below the

lower limit of normal.
Hyperpyrexia a very high fever, such as 41 C
(105.8F)
Febrile - a client who has a fever.
Afebrile a client who has no fever

Types of Fever
Intermittent: The body temperature alternates regularly
between periods of fever and periods of normal or subnormal
temperature.
Remittent: The body temperature fluctuates several degrees
(> 2C) above normal, but does not reach normal between
fluctuations.
Constant: The body temperature remains consistently
elevated and fluctuates less than 2C (3.6).
Crisis: The fever returns to normal suddenly.
Lysis: The fever returns to normal gradually.

 Fever spike: A temperature that rises to

fever level rapidly following a normal
temperature and then returns to normal
within a few hours.

Relapsing: A short febrile periods of a

few days interspersed with periods of 1 or 2
days of normal temperature. The body
temperature returns to normal for at least a
day, but then the fever recurs.

Nursing Interventions for Clients with

Fever
Monitor vital signs.
Assess skin color and temperature: flushed skin, warm to touch
Monitor pertinent laboratory reports for indications of infection or
dehydration.
Remove excess blankets when the client feels warm, but provide extra
warmth when the client feels chilled.
Provide adequate nutrition and fluids (e.g., 2,500-3,000 ml per day) to
meet the increased metabolic demands and prevent dehydration.
Measure intake and output.
Reduce physical activity to limit heat production
Administer antipyretics (drugs that reduce the level of fever) as
ordered.
Provide oral hygiene to keep the mucous membranes moist.
Provide a tepid sponge bath/TSB to increase heat loss through
conduction.
Provide dry clothing and bed linens.

Nursing Care for Clients with

Hypothermia

Provide warm environment

Provide dry clothing
Apply warm blankets
Keep limbs close to body
Cover the clients scalp: newborns
Supply warm oral or intravenous
fluids
Apply warming pads

Assessing Body
Temperature
The most common sites for measuring
body temperature are:
Oral
Rectal
Axillary
Tympanic membrane
Skin/temporal artery.

Each of the sites has advantages and

disadvantages.

Advantages and Disadvantages

SITE

MOUTH

ADVANTAGES

DISADVANTAGES

Easy access and

convenient

Glass thermometer can

break if bitten.
Painful if mouth is
inflamed or injured.
Not recommended for
confused, comatose,
uncooperative patients,
and small children.

Commonly used
because of rich
blood supply.
Comfortable for
most people.

Inaccurate if client has

just ingested hot/cold food
or fluid or smoked.
Could injure the mouth
following oral surgery.

SITE
RECTUM

ADVANTAGES
Common site when oral
not available.
Believed most reliable
or accurate because it
reflects core
temperature.

DISADVANTAGES
Inconvenient and more
unpleasant for clients;
difficult for client who
cannot turn to the side.
Requires lubricant.
Frightening to infants
and small children.
Could injure the rectum
following rectal surgery.
Must be held in place for
safety.
Presence of stool may
interfere with
thermometer placement.
If the stool is soft, the
thermometer may be
embedded in stool
rather than against the
wall of the rectum.

SITE

ADVANTAGES

AXILLA

Safe and
noninvasive
Easy to use on
newborns and
confused
patients.
Least invasive

TYMPANIC
MEMBRANE

DISADVANTAGES
The thermometer must be
left in place a long time to
obtain an accurate
measurement.
Least desirable for adult like
to be affected by
environmental
temperatures because the
axilla is more

Easy to use,
readily
accessible and
safe for all ages.
Does not require
position change.

Can be uncomfortable and

involves risk of injuring the
membrane if the probe is
inserted too far.

Reflects the core

temperature

Repeated measurements
may vary; right and left
membranes can differ

Very fast;
reading obtained

Presence of cerumen/ear
wax can affect the reading.

SITE

SKIN/TEMPORAL
ARTERY

ADVANTAGES

Safe
Noninvasive
Very fast

DISADVANTAGES

Requires electronic
equipment that
may be expensive
or unavailable
Presence of
perspiration in the
head requires
variation in
technique
Expensive

Types of thermometer
Glass thermometers can
1. Mercury/Glass
thermometer

be hazardous due to its

mercury content which is
toxic to humans.
Mercury is a toxic metal
for humans. Low doses of
mercury compounds can
have serious neuro
developmental effects
and can damage the
cardiovascular, immune
and reproductive
systems whereas high
doses could be fatal.

2. Electronic
thermometers

o Electronic thermometers
are available for oral
and rectal use.
o It can provide a reading
in only 2 to 60 seconds.
o The equipment consists
of
a battery-operated
portable
electronic unit, a probe
that
the nurse attaches to
the
unit, and a probe
cover,
which is usually

3. Temperature-sensitive
tape

The tape contains liquid

crystals that change color
according to temperature.
When applied to the skin,
(forehead, abdomen), the
temperature digits on the
tape respond by changing
color after the length of
time specified by the
manufacturer (15
seconds).
It does not indicate the
core temperature.

 Uses infrared technology to

An infrared (tympanic) thermometer

measure the tympanic

membrane temperature.
The infrared thermometer
makes no contact with the
tympanic membrane, only at
the external opening of the
ear canal, where it senses
body heat in the form of
infrared energy given off by a
heat source, which in the ear
canal is the tympanic
membrane.
The reading is complete
through a light ,tone or beep.

Placement of a tympanic thermometer

Pull the pinna of the
ear up and back for
placement of a
tympanic
thermometer in a
child over 3 years of
age; down and back
for children under
age 3.

Temporal artery thermometers

determine temperature using
a scanning infrared
thermometer that compares
arterial temperature in the
temporal artery of the
forehead to the temperature
in the room and calculates the
heat balance to approximate
the core temperature of the
blood in the pulmonary artery.

The probe is placed in the

middle of the forehead and
then drawn laterally to the
hairline. If the client has
perspiration on the forehead,
the probe is also touched
behind the earlobe so the
thermometer can compensate

Temperature Scales
The body temperature is measured in degrees on two scales:
Celsius (centigrade) and Fahrenheit.
To convert from Fahrenheit to Celsius: deduct 32 from the
Fahrenheit reading and then multiply by the fraction 5/9; that is:
C = (Fahrenheit temperature - 32) x 5/9
For example, when the Fahrenheit reading is 100:
C = (100 - 32) x 5/9 = (68) x 5/9 = 37.8C

To convert from Celsius to Fahrenheit: multiply the Celsius reading

by the fraction 9/5 and then add 32; that is:
F = (Celsius temperature x 9/5) + 32
For example, when the Celsius reading is 40:
F = (40 X 9/5) + 32 = (72 + 32) = 104F

QUIZ 1

1 Normal pulse range for the adult at rest.

2-5 Four factors that may significantly change body temperature.
6 When is the point of highest body temperature usually reached?
7 A term that describes a fast heart rate.
8 It is considered the thermoregulatory center of the body.
9-12 Give at least 4 common sites for counting the pulse rate.
13 What do you call the sounds you usually hear when taking the blood pressure?
14 It is referred to as the respiratory center of the body.
15 A term that describes an abnormally slow respiration.
16 The bell head of the stethoscope should be placed over which artery to measure
blood pressure in the arm?
17 It is a quick, inexpensive, noninvasive method of assessing
oxygenation or arterial blood oxygen saturation.
18 Which route in taking the body temperature is not indicated for a patient who just
took in a cup of hot coffee?
19-20 Convert: 100.6F C

1) 60 100 beats normal pulse rate adults

2) Basal Metabolic Rate/BMR factors body temp
3) Muscle activity
4) Thyroxine output
5) Fever
6) 4 AM 6PM Highest body temp reached
7) tachycardia name fast heart rate
8) hypothamalus thermoregulatory center of the body
9)
10)
11)
12)
13) Medulla respiratory center of the body
14) Bradypnea abnormally slow respiration
15)
16)
17)
18)
19)
20)