16. Vitals- Temperature

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VITAL SIGNS

INTRODUCTION

vit l sign

sign of life; usually an indicator of a

person's general physical condition.

• The most frequent measurements obtained byhealth workers are those of

Temperature • Pulse

• Respiration

Blood pressure

TEMPERATURE

• The balance between the heat produced

and the heat lost from the body.

PULSE• Number of times the heart beats in 1 minute.

RESPIRATION • Number of times a patient breaths in 1 minute.

BLOOD PRESSURE • Blood pressure is the force exerted by the bloodagainst the walls of the blood vessel as it flows

through them.

T P R and B P

Referred as vital signs….

• These findings are governed by vital organs.• These measures indicate the effectiveness of

• Circulatory

• Respiratory

• Neural

• Endocrine body functions

WHY TO ASSESS VITAL SIGNS?

• To determine client’s usual state ofhealth.

Change signals–

Change in physiological function.

The need for medical or nursing

intervention.• Evaluate clients response tointervention.

Acceptable ranges

Temperature:oral /tympanic-(37°C) ( 98.6°F)

Rectal -37.5°C ( 99.5°F )

Axillary -36.5°C (97.7°F)

Pulse :60-100 beats/minute

Respiration:12-20 breaths/minuteBlood pressure:120/80mmHg

Body temperature

BODY TEMPERATURE

MEANING

• It is the difference between the amount ofheat produced by body processes and the

amount of heat lost to the externalenvironment.

Heat produced –heat lost=body temperature.

and is measured in heat units called degrees

•Core temperature

•Surface temperature

Physiology

1 Core temperature

• Temperature of the deep tissues(cranial ,

thoracic , abdominal cavity).it remains

relatively constant.

2 Surface temperature

It is the temperature of the skin,subcutaneous tissue ,and fat . It by

contrast ,rises and falls in response to the

environment.

• Surface temperature varies dependingon blood flow to the skin and the amountof heat lost to the external environment.

1.neural and vascular control

HYPOTHALAMUS

Controls the temperature.• located between cerebral hemispheres.

• Anterior hypothalamus controls heat loss

• Posterior hypothalamus controls heatproduction .

• Diseases or trauma to the hypothalamus or spinal cord

• Serious alteration in temperature control

Heat Produced and Lost

Heat Produced

• Metabolism of food

• Muscle and gland activity

Heat Lost• Perspiration

• Respiration

• Excretion of feces and urine

BASAL METABOLIC RATE

(BMR): Is the rate of energy utilization in

the body required to maintain essentialactivities or heat produced by the body atabsolutely rest.

Heat loss

• Radiation

• Conduction

• Convection

Vaporization(evaporation.)

• Radiation ;

• The transfer of heat from

the surface of one object tothe surface of anotherwithout contact between thetwo objects, mostly in the

form of infrared rays.

onduction; .

• it is the transfer of heat from one molecule

to a molecule of lower temperature .conductive transfer cannot take placewithout contact between the molecules .

• Applying an ice pack or bathing a patient with

a cool cloth.

• onvection

• it is the dispersion of heat by aircurrents.

• E . g. fan

Evaporation

• It is a continuous evaporation of moisture from the

respiratory tract and from the mucosa of the mouth andfrom the skin.

FACTORS AFFECTING

TEMPERATURE..

• Age

• Exercise

• Hormones

Diurnal variations(circadian rhythms)• Stress

• Environment

Assessment of body

temperature

• Sites

• Equipments

• Technique

• Special consideration

INTRODUCTION

• As body temperature is indicator of normal bodyfunctioning .nurse checks the body temperature ofclient as baseline data as well as to detect anyabnormality.

Nurses role

• .Selectionof site

Documentingand reporting

Frequency ofmonitoring .

Ensureaccuracy .

SITES:

1. Oral

2. Rectal

3. Axillary

4. Tympanic membrane5. Forehead

T RMOM T RS

THERMOMETERS

TYPES• Electronic

• Chemical disposable thermometers.

• Mercury- in –glass thermometer• Temperature sensitive tape

• Infrared thermometers

Temporal artery thermometers

Electronic thermometer;

1. it consists of a rechargeable battery

powered display unit ,a thin wire cord

,and a temperature –processing

probe covered by a disposable probe

cover .

2. Can provide a reading in only 2 to 60

seconds

• Mercury in glass thermometer;

• it is a glass tube sealed at one end ,with a

mercury filled bulb at the another .exposure ofthe bulb to heat causes the mercury to expand

and rise in the enclosed tube.

TEMPERATURE SENSITIVE TAPE

The tape contains liquid crystals that change color

according to the temperature .When applied to the skin,usually of the forehead or abdomen ,the temperature

digits on the tape respond by changing color.

Infrared thermometers

• Sense body heat in the form of infraredenergy given off by heat source , which inthe ear canal is primarily the tympanic

membrane..• The infrared thermometer makes nocontact with the tympanic membrane.

Temporal artery thermometers

• Determine temperature using a scanninginfrared thermometer that measures arterialtemperature in the temporal artery of the

forehead

• The probe is placed in the middle of theforehead and then drawn laterally to the

hairline .

Temperature scales…..

• Body temperature is measured in degreeon two scales:

Celsius or Fahrenheit…

1. Convert Fahrenheit to Celsius

C =(F-32)*5/9

Ex.40°C =104°f-32*5/9

2. Convert Celsius to Fahrenheit

F = (C *9/5)+32

Ex.104°f=40*9/5+32

POINTS TO REMEMBER

1.Absence of inflammation .inflammed area isalready more warm than the other body parts.

2.How much accurate reading is required ?.E.g.surgery.

3.Conscious level of the client.5.Age of the client (client below 6 years cantkeep thermometer orally .he may break it.)

• 4.Factors such as eating ,smoking ,drinking.

rectal

axillaryTympanicmembrane

forehead

• ASSESSING BODY TEMPERATURE

PRO EDURE

Oral temperature

• Placing the thermometer bulb under thetongue in posterior sublingual pocket.

Easily accessible –requires no positionchange .

• More accurate.

• Can be held easily under the Tongue.

• There is good supply of blood under tongue.so correct temperature is recorded .

• No privacy is needed.

• Reflects rapid change in core temperature.

ADVANTAGES:

DISADVANTAGES :

• Children, insensible persons may bite thethermometer.(chance to break )

• Possibility of cross infection.

• Risk for body fluid exposure.

CONTRAINDICATIONS:

1.Clients who are extreme ,nervous, delirious,unconscious and mentally confused and cannot follow the instructions.

2.The clients having convulsions .

3. Mouth breathers.

4.Who have injury , operation and inflammation

of the mouth and nasal surgery.

5. Client with frequent cough.

6.Children below six years of age.

7. Client on mask oxygen inhalation.

8.Drinking,smoking.

AXILLARY

• Thermometer placed under the arm pit inbetween the skin folds.

ADVANTAGES : • causes less discomfort.

• safe and inexpensive.

• does not affect by hot and cold drinks.

• Used with newborns and unconscious clients.

• No chance of cross –infection .

• Taking hot and cold drinks will not affect the

temperature.

DISADVANTAGES:

• Presence of moisture gives false reading.

• If thermometer not placed properly may givefalse reading.

• Long measurement time.• Requires continuous positioning by nurse.

RECTAL TEMPERATURE

• Insert lubricated thermometer 1 ½ inch inadult rectum ½ inch in infant rectum.

Advantage :

• most reliable

Disadvantage• Needs privacy.

• Danger of damaging the rectal mucosa.

If rectum packed with feacal matter givesfalse reading.

• Needs lubrication of bulb.

• Requires positioning and is often source of clientembarrassment and anxiety.

• Risk of body fluid exposure.

Contraindicated in :

Rectal surgery

Diarrhea and rectal disease

Immunosuppressed

Significant hemorrhoids

Inflammed rectum

TYMPANIC MEMBRANE

TEMPERATURE

The body temperature as measuredelectronically at the tympanic membrane

Advantage :

• Reflects core temperature

• Ear is readily accessible.

• Permits rapid reading.(2-5sec)

• Result is not affected by other factors

.Ex.food or fluid intake

• Obtained without disturbing.

• Used in newborns to reduce infant handling andheat loss

DISADVANTAGES

• Requires removal of hearing aids beforemeasurement.

• Inflammation of the ear (otitis media)andcerumen (wax)impaction distorts readings.

• Oral-2 minutes.

• Axilla-3-5 minutes.

Rectal-1 minute.

• Low pyrexia: temperature between 99 -100degree F.

• Moderate pyrexia: temperature between 100 -

103 degree F.• High pyrexia : temperature between 103- 105degree F.

• Hyper pyrexia: temperature above 105 Degree F

• Rigor : a sudden severe attack of shivering inwhich the body temperature rises to a stage ofhyperpyrexia

• Hypothermia: temperature falls below 95 F

• Hyperthermia: hyperthermia is when body

temperature becomes elevated, as methods for

thermoregulation are not as effective. Therefore,the body is absorbing more heat than it is

dissipating also known as overheating of the

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