Unit V-Vital Signs
Unit V-Vital Signs
Unit V-Vital Signs
MEHTAB
BY
PGCN
OBJECTIVES
• Define Vital Signs.
• Define terms related to Vital sign.
• Describe the physiological concept of temperature,
respiration and blood pressure.
• Describe the principles and mechanisms for normal
thermoregulation in the body.
• Identify ways that affect heat production and heat
loss in the body.
• Define types of body temperature according to its
characteristics.
OBJECTIVES
• Identify the sign and symptoms of fever
• List the factors affecting Temperature, Pulse,
Respiration.
• Describe the characteristics of Pulse and Respiration.
• List factors responsible for maintaining normal blood
pressure.
• Describe various methods and sites used to measure
T.P & B.P.
• Recognize the signs of alert while taking TPR and B.P.
Introduction
• Vital sign are the indicator of the body’s physiologic
status and response to physical environment and
psychological stressor.
• The vital sign or the cardinal sign are temperature,
pulse, respiration, and blood pressure. The findings
are governed by the vital organs.
Definition
• Vital sign are called cardinal signs because of their
importance. These are the indicator of health status,
as these indicate the effectiveness of circulatory,
respiratory, neural, & endocrine body functions.
1. Temperature
2. Pulse
3. Respiration
4. Blood pressure
5. oxygen saturation
6. Pupillary reaction / pain
When to take Vital Signs
• Upon admission.
• On a routine basis.
• Before and after invasive procedure.
• Before and after administration of medication.
• Any deterioration of patient’s general condition.
• Before and after nursing intervention that may
influence vital sign.
• Prior to medical emergency
Temperature
Body Temperature: It is the hotness or coldness of the body.
OR
It is balance between the heat produced by the body and
heat lost from the body.
• Age Infants greatly influenced by the temperature, children more labile than adult and elderly
are extremely sensitive to environmental change due to decreased thermoregulatory control
• Diurnal variation Body temperature normally change throughout the day, varying as
much as 1.0 °C between early morning and late afternoon The point of highest body temperature
is usually reached between 8pm and 12 midnight and the lowest point is reached during sleep
between 4 a.m. and 6 a.m.
• Exercise
• Hormones Women usually experience more hormone fluctuations than men, progesterone
secretion in women raises body temperature.
• Stress Epinephrine and nor epinephrine increases metabolic activity and heat production
• Environment
Factors affecting body temperature:
Alteration in body temperature
Alteration in body temperature
The normal range for adults is considered to be between 36°C
and 37.5°C (96.8°F to 99.5°F).
There are two primary alterations in body temperature:
1. Pyrexia or Hyperthermia
2. Hypothermia.
1. Pyrexia
A body temperature above the usual range is called pyrexia,
hyperthermia, or (in lay terms) fever. A very high fever, such as
41°C (105.8°F), is called hyperpyrexia.
Febrile: The client who has a fever is referred to as febrile.
Afebrile: The one who does not, is called afebrile.
Pyrexia
1. Low Pyrexia: The fever does not rise more than 99
to 100 F
2. Moderate Pyrexia: Body temperature remain between
100-103 degree F
3. High Pyrexia: Body temperature remain between
103- 105 degree F
4. Hyperpyrexia: Temperature above 105 degree F
Pyrexia (Conti…)
4 Common Types Of Fever
1. Intermittent fever: The body temperature alternates at regular
intervals between periods of fever and periods of normal or
subnormal temperature e.g. Malaria
2. Remittent fever: A wide range of temperature fluctuation (more
than 2 0c) occurs over the 24 hr period, all of which are above
normal e.g. a cold or influenza
3. Relapsing fever: Short febrile periods of a few days are
interspersed with periods of 1 or 2 days of normal temperature e.g.
4. Constant fever: The body temperature fluctuates minimally but
always remains above normal e.g. typhoid fever
Pyrexia (Conti…)
Fever Spikes: A temperature that rises to fever level
rapidly following a normal temperature and then
returns to normal within a few hours is called a fever
spike. Bacterial blood infections often cause fever
spikes.
Inverse Fever: The highest range of temperature is
recorded in morning hours and lowest in the evening.
Hectic Or Swinging Fever: When difference between
high and low temperature is very great.
Alteration in body temperature
In some conditions, an elevated temperature is not a true
fever. Two examples are heat exhaustion and heat stroke.
Heat exhaustion: is a result of excessive heat and
dehydration. Signs of heat exhaustion include paleness,
dizziness, nausea, vomiting, fainting, and a moderately
increased temperature (38.3°C to 38.9°C [101°F to 102°F]).
Heat stroke: Persons experiencing heat stroke generally have
been exercising in hot weather, have warm, flushed skin, and
often do not sweat. They usually have a temperature of
41.1°C (106°F) or higher, and may be delirious, unconscious,
or having seizures
Stages / Phases of Fever
• Invasion, onset of Fever, Period of
Onset rising
• Also called Cold or Chilled Phase
• Defervescence, elevated
ABATEMENT temperature declines
• Also called as Flush Phase
Clinical Manifestation of Fever
ONSET (COLD OR CHILL PHASE)
Increased heart rate, Increased respiratory rate and depth, Shivering
Pallid, cold skin ,Complaints of feeling cold , Cyanotic nail beds
“Gooseflesh” appearance of the skin ,Cessation of sweating
COURSE (PLATEAU PHASE)
Absence of chills ,Skin that feels warm , Photosensitivity , Glassy-eyed
appearance , Increased pulse and respiratory rates , Increased thirst
Mild to severe dehydration , Drowsiness, restlessness, delirium, or
convulsions ,Herpetic lesions of the mouth , Loss of appetite (if the
fever is prolonged) ,Malaise, weakness, and aching muscles
DEFERVESCENCE (FEVER ABATEMENT/FLUSH PHASE)
Skin that appears flushed and feels warm , Sweating , Decreased
shivering , Possible dehydration
Hypothermia
Hypothermia is a core body temperature below the lower
limit of normal i.e. 95 F or 35 C. The three physiological
mechanisms of hypothermia are
(a) Excessive heat loss,
(b) Inadequate heat production to counteract heat loss,
(c) Impaired hypothalamic thermoregulation
If skin and underlying tissues are damaged by freezing cold, this
results in frostbite. Frostbite most commonly occurs in hands,
feet, nose, and ears in which ice crystal forms inside the cell and
damage it.
Clinical Manifestation of
Hypothermia
• Decreased body temperature, pulse, and respirations
• Severe shivering (initially)
• Feelings of cold and chills
• Pale, cool, waxy skin
• Frostbite (discolored, blistered nose, fingers, toes)
• Hypotension
• Decreased urinary output
• Lack of muscle coordination, Disorientation, drowsiness
progressing to coma
Types of Hypothermia
1. Induced hypothermia: is the deliberate lowering of
the body temperature to decrease the need for oxygen
by the body tissues such as during certain surgeries.
2. Accidental hypothermia: can occur as a result of
(a) exposure to a cold environment,
(b) immersion in cold water, and
(c) lack of adequate clothing, shelter, or heat.
In older adults, the problem can be compounded by a
decreased metabolic rate and the use of sedative
medications.
Sites to Measure Temperature
Oral
Rectal
Axillary
Tympanic membrane
Temporal artery
Condition of resident determines which is the best site for measuring body
temperature.
Advantages and Disadvantages of Sites for Body
Temperature Measurement
Types Of Thermometer
Thermometer
Thermometer
Two parts of thermometer-bulb and stem
• Blub is fragile part, containing mercury, sensitive to
temperature.
• Stem is hollow tube in which mercury can rise.
There are two scales, Fahrenheit and Celsius
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