P R E PA R E D B Y:

M.BILAL
BSN, RN. MSN UHS

N U R S I N G I N S T R U C T O R I U H FA I S A L
ABAD
 VITAL SIGNS

 Homeostasis: a state of equilibrium within the body

maintained through the adaptation of body systems to
changes in either the internal and external environment.

 When injury/illness occurs the body’s ability to

maintain homeostasis is impaired – which will show in
a person’s Vital Signs.
 Vital Sign definition

 Clinical measurements, particularly pulse rate,

temperature, respiration rate, and blood pressure, that
signify the state of a patient's fundamental body
functions.
 Essential body functions, comprising pulse rate, body
temperature, BP and respiration, used as a
measure of health or physical condition.

 When and How to assess vital sign

 Its nursing judgment

 Depends upon the client Health status.

 Some agencies have plocies to take vital sign

 Some time nurse delegate vital signs to UAPs but it

should be if it is routine vital sign or pt is stable or in

chronic condition. But real assessment interpretation of
the measurment rests with RNs.
 Times to Assess Vital signs

 On admission

 Chang in health status

 Before and after surgery

 Before and after administration of Risk medicine.

 Before and after nursing interventions which could

affect vital sign.
 As routine in admitted patient as per policy
 FOUR MAIN VITAL SIGNS

 Body Temperature  Thermometer

 Pulse  Stethoscope or
 Blood Pressure Palpation
 Respirations  Sphygmomanometer
 Watch or Clock
 Fifth vital Sign

 Traditional vital signs are Temperature, Pulse,

Respiration and BP.
 Many agencies such as veterans administration,
American pain society and Joint Commission
considered pain as fifth vital sign

 Oxygen saturation is also measured at the same time as

the other traditional vital signs.
 Temperature

 The degree of hotness or coldness of the body.

 Two kind of body temperature.
 Core temperature : Temperature of the deep tissue of
the body. Such as abdominal and Pelvic cavity
It remains relatively constant.
Surface temperature:
Temperature of the skin subcutaneous
tissue and fat. It rises or falls in response to environment
 Factor Affecting Body Temperature

 Age

 Diurnal Variation

 Exercise

 Hormones

 Stress

 Environment
 Factors contributing production and loss of heat

Heat production
.
Heat loss

• Basal metabolism • Radiation

• Muscular activity • Conduction/
(shivering) convection
• Thyroxine and • Evaporation
epinephrine
(stimulating effects
on metabolic rate)
• Temperature effect
on cells

Figure 24.25
 Mechanisms of Heat Loss

 Four mechanisms
1. Radiation: is the loss of heat in the form of
infrared rays
2. Conduction: is the transfer of heat by direct
contact
3. Convection: is the transfer of heat to the
surrounding air
4. Evaporation: is the heat loss due to the evaporation
of water from body surfaces
 Heat-Loss Mechanisms

 Dilation of cutaneous blood vessels

 Enhanced sweating

Voluntary measures include

 Reducing activity and seeking a cooler environment

 Wearing light-colored and loose-fitting clothing

 Mechanisms of Heat Exchange

 Insensible heat loss accompanies insensible water loss

from lungs, oral mucosa, and skin

 Evaporative heat loss becomes sensible (active) when

body temperature rises and sweating increases water

vaporization
 Heat-Promoting Mechanisms

 Constriction of cutaneous blood vessels

 Shivering

 Increased metabolic rate via epinephrine and

norepinephrine

 Enhanced thyroxin release

 Heat-Promoting Mechanisms

Voluntary measures include

 Putting on more clothing

 Drinking hot fluids

 Changing posture or increasing physical activity

 Regulation of Body Temperature

 Body temperature reflects the balance between heat

production and heat loss

 At rest, the liver, heart, brain, kidneys, and endocrine

organs generate most heat

 During exercise, heat production from skeletal muscles

increases dramatically
 Regulation of Body Temperature

 Normal body temperature = 37C(98.6F)

 Optimal enzyme activity occurs at this temperature

 Increased temperature denatures proteins and depresses

neurons
 Regulation of body temprature

Inputs Outputs

Central Neural
thermosensors sweating
warm cool shivering
vasoconstriction
Hypothalamus vasodilation

Peripheral
thermosensors Hormonal
adrenaline
warm cool TRH
 Role of the Hypothalamus

 Preoptic region of the hypothalamus contains the two

thermoregulatory centers

 Heat-loss center

 Heat-promoting center
 Role of the Hypothalamus

 The hypothalamus receives afferent input from

 Peripheral thermoreceptors in the skin

 Central thermoreceptors (some in the

hypothalamus)

 Initiates appropriate heat-loss or heat-promoting

activities
 Skin blood vessels dilate:
capillaries become flushed
with warm blood; heat radiates
from skin surface

Activates heat-
loss center in
hypothalamus Sweat glands activated:
secrete perspiration, Body temperature
Stimulus
which is vaporized by decreases: blood
Increased body body heat, helping to temperature declines
temperature; cool the body and hypothalamus
blood warmer heat-loss center
than hypothalamic “shuts off”
set point

Figure 24.27, step 1

 Stimulus
Decreased
body tempera-
ture; blood
cooler than
Skin blood vessels constrict: hypothalamic
blood is diverted from skin set point
capillaries and withdrawn to
Body temperature deeper tissues; minimizes
increases: blood overall heat loss from skin
temperature rises surface
and hypothalamus Activates heat-
heat-promoting promoting center
center “shuts off” in hypothalamus
Skeletal muscles
activated when more
heat must be generated;
shivering begins

Figure 24.27, step 2

 Homeostatic Imbalance

 Hypothermia

 Is a core body temperature below the lower limit of

normal.

 Shivering stops at core temperature of 30 - 32C

 Can progress to coma a death by cardiac arrest at ~

21C
 Physiological mechanism of hypothermia

3 main mechanism

 Excessive heat loss

 Inadequate heat production to counteract the heat loss

 Impaired hypothalamic thermoregulation

 Cont..

 Hypothermia can be induced or accidental

 Induced: deliberate decrease in body temperature to
decrease the oxygen need of tissue such as some
surgeries
 accidental: can occur due to
a) Exposure to cold environment
b) Immersion in cold water
c) Lack of adequate clothing, shelter or heat.
 Clinical Manifestation of hypothermia

 Decreased body temperature, Pulse and respiration

 Severe shivering (initially)
 Feeling of cold and chills
 Pale ,cool and waxy skin
 Frostbite
 Hypotension
 Decrease urine output
 Disorientation ,drowsiness leading to coma
 Lack of muscle coordination
 Nursing Intervention of Hypothermia

 Provide warm environment

 Provide dry clothing

 Apply warm blankets

 Keep limbs close to the body

 Cover the clients scalp

 Give warm oral or IV fluids

 Apply warming pads

 Hyperthermia

 A body temperature above usual range is called

hyperthermia . Fever and Pyrexia also used
alternatively.
 Hyperpyrexia : Very high body temperature 41.2C or
(105.8 F)
Febrile :client who have fever
Afebrile: client who does not have fever
 Hyperthermia

 Elevated body temperature depresses the

hypothalamus

 Positive-feedback mechanism (heat stroke) begins at

core temperature of 41C

 Can be fatal if not corrected

 Hyperthermia

 Controlled hyperthermia

 Due to infection (also cancer, allergies, or CNS injuries)

 Macrophages release interleukins (“pyrogens”) that

cause the release of prostaglandins from the

hypothalamus
 Fever

 Prostaglandins reset the hypothalamic thermostat

higher

 Natural body defenses or antibiotics reverse the

disease process; cryogens (e.g., vasopressin) reset

the thermostat to a lower (normal) level
 Types fever

 Intermittent

 Remittent

 Constant

 Relapsing
 Homeostatic Imbalance

 Heat exhaustion: is result of excessive heat and

dehydration

 Heat-associated collapse after vigorous exercise

 Due to dehydration and low blood pressure

 Heat-loss mechanisms are still functional

 May progress to heat stroke

 Sign of heat exhaustion

 Paleness

 Dizziness

 Nausea

 Vomiting

 Fainting

 Increased body temperature

 Heat stroke

 Person experiencing heat stroke usually have been

exercising in hot weather, have warm flushed skin
and often do not sweat
 Having body temperature 41c or 106F
 Delirious
 Unconscious or having seizure.
 Phases of fever

 Chill phase (onset)

 Plateau phase (Course)

 Abatement phase (defervescence)

 Fever spike

 A temperature that rises to fever level rapidly following

a normal temperature and then return to normal

temperature within few hour.

 Its occurs in bacterial infections

 Clinical manifestation

 Clinical manifestation of fever vary with the phases of

fever.
 In fever set point of hypothalamus set higher than
normal(39.5 c 103.1F).
 Reaches new set point after several hours .this interval
cause heat production response.(onset cold) chill phase
 When new set point reaches no, longer experience of
chills (plateau phase)
 When high temperature cause removed set point
reduced and heat loss response (Abatement/flush phase)
 S/S of cold or chill phase

 Tachycardia
 Tachypnea
 Shivering
 Cold skin
 Cyanotic nail beds
 Feeling of cold
 “Gooseflesh” appearance of skin (arrectores pilorum
muscles contraction )
 Cessation of sweating
 S/S of plateau phase

 Absence of chills
 Warmness of skin
 Photosensitivity
 glass eye appearance
 Tachycardia and tachypnea
 Polydypsia
 Dehydration and loss of appetite
 Drowsiness
 Herpetic lesion of mouth
 Malaise, weakness and aching muscle
 S/S of flush phas /fever abatement

 Warmed and flushed skin

 Sweating
 Decreased shiviring
 Possible dehydration
 Nursing intervention of fever

 Monitor vital sign

 Assess skin color and temperature

 Monitor WBCs , hematocrit value and other reports for

sign of infection and dehydration

 Remove excessive blanket when client feels warm

 Conti..

 Provide extra warmth when client feels chilled

 Provide adequate nutrition to meet metabolic needs

 Give fluids to avoid dehydration

 Monitor IOP
 Conti ..

 Reduce physical activity during flush phase to limit

heat production

 Administered antipyretics as advised

 Provide oral care to keep oral mucosa moist

 Provid a tepid sponge bath to inc heat loss

 Provide dry clothes and bed linen

 Sites of temperature

 Oral

 Rectal

 Axillary

 Tympanic membrane

 Temporal artery
 Sites for taking theTemperature

 Oral temperature

Advantages Disadvantages

 Easily accessible  Bitten of thermometer

 Convenient
 Inaccurate if ingested

hot ,cold food or fluid.

 Could injured mouth

following oral surgery

 Rectal temperature

Advantages Disadvantages

 Reliable measurement  Inconvenient

 Used when accurate  Unpleasant
temperature is required  Difficult for pt who can
not turn to the side.
 Could injured the rectum
 Presence of stool
interfere with placement
of thermometer
 Axillary temperature

Advantages Disadvantages
 Sites for taking the Temperature
SITE ADVANTAGES DISADVANTAGES

 Thermometers can be broken

ORAL Accessible and convenient Inaccurate if client has just ingested hot or cold fluid, or
smoked

Inconvenient and more unpleasant; difficult for client

who cannot turn to side
RECTAL Reliable measurement Could injure the rectum following surgery
Presence of stool may interfere with thermometer
placement

AXILLARY Safe and noninvasive Thermometer must be left in place for a long time

Readily accessible; reflects Can be uncomfortable and involves risk of injuring the
TYMPANIC
the core temperature, very membrane if inserted too far
MEMBRANES
fast Presence of cerumen can affect the reading

TEMPORAL Requires electronic equipment (expensive / unavailable)

ARTERY Safe and non invasive , ;
very fast Variation in technique if the client has perspiration on
the forehead
 Fahrenheit and Celsius Conversion
Formulas

Fahrenheit to Celsius: Celsius to Fahrenheit:

 Example

 How many degrees Celsius are 68 degrees Fahrenheit?

Replace Fahrenheit with 68 and solve for Celsius:

 C = (68 - 32) * 5/9,

C = 36 * 5/9,
C = 20
20 °C = 68 °F