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1. Assessing vital signs

2. Objectives: -
The student will be able to: -
Identify steps used to assess a client’s oral,
rectal, and axillary temperature.
Describe the types of factors that normally cause
variation in body temperature, pulse, respiration
and blood pressure.
Identify steps used to assess a client’s pulse,
respiration, and blood pressure.
Identify normal vital signs values for an adult
and infant.
Accurately record and report vital signs
measurements.

3. Introduction
Health care professionals are expected to conduct a
variety of tests and measures to effectively evaluate
a patient's health condition. Assessing a patient’s
vital signs is often the first assessment that a
clinician will perform. Vital signs are measurements
of the body’s most basic functions. Traditionally,
vital signs have been described as body temperature,
pulse, respiratory rate, and blood pressure because
through these basic functions a clinician can
determine signs of human life or death

4. ASSESSING VITAL SIGNS
The word Vital signsincludes four
basic measurements, which reflects
the sensitive changes the physiology
of the body. They are Temperature,
Pulse rate, Respiration rate and
Blood pressure.

5. The term Vital signs is derivative of
the Latin word vita, which means life.
slight alterations can alert the nurse to
the status of a client’s condition.
Because these assessments can indicate
minute-by-minute changes.

6. The nurse must make critical decisions
concerning the method for measuring
the vital signs, the choice of equipment
to use, the frequency for assessing,
modification that need to be
implemented, and the significance of the
data

7. When to Take Vital Signs
On the clients admission to a health care
facility
In a hospital on routine schedule
according to a physician order or hospital
policy
Before and after any surgical procedure.
Whenever a client presents symptoms of
confusion.

8. Conti…
Before and after any invasive
diagnostic procedure.
Before and after the administration of
certain medication that affect
cardiovascular, respiratory and
temperature control function.

9. Conti…
When the client’s general physical
condition changes, as with loss of
consciousness or increased severity of
pain.
Before and after nursing interventions
influencing any one of the vital signs,
such as before a client on bed rest
ambulates.

10. Conti…
Whenever the client reports any
nonspecific symptoms of physical
distress, such as feeling different

11. ASSESSING BODY TEMPERATURE

13. Definition
Body temperaturerepresents the
balance between heat gain and heat
loss.

14. Different Types of
Thermometers
DIGITAL THERMOMETER EARTHERMOMETER

15. RECTAL THERMOMETER
AXILLARY/ORAL AND RECTAL

16. Purpose
•To establish a baseline temperature on
admission.
•Evaluate the client’s recovery from
illness.
•Determine if measures should be
implemented to reduce dangerously
elevated body Temperature.

17. •Determine if measures should be
implemented to conserve body heat when
the body Temperature is dangerously low.
•Detect the response of a client once heat
producing or heat reducing measures has
been initiated.
•To determine if a client has an infection.

18. Factors Affecting Body Temperature
Age: -An infant temperature may
change drastically with changes in the
environment, because his temperature
regulation mechanism is not fully
developed, so extra care is needed,
such as clothes, warm environment to
maintain the infant body temperature.

19. Elderly are sensitive to temperature
changes due to deterioration in
thermoregulation including poor
activities, reduced subcutaneous
tissue, reduced sweat gland activity
and reduced metabolism.

20. •Exercise: -Muscle activity
increases heat production.
•Hormones: -
Hormonal variations during the
menstrual cycle body temperature
fluctuations. Before the menstrual
cycle the body temperature is low
and after ovulation it rises.

21. Circadian(daily) Rhythms
•Body temperature normally changes 0.5
to 1C (0.9to 1.8F) during 24 hours.
The temperature is usually lowest
between 1 -4 am.
•During the day body temperature rises
steadily, peaking between 4 -7 PM And
then descending to early morning
levels.

22. Stress
•Physical and emotional stress
increases body temperature through
hormonal and neural stimulation. For
example a client who is anxious about
entering a hospital may have a higher
than normal temperature. So the nurse
or midwife better wait for some time
before taking temperature.

23. Environment
•Environment influences body
temperature if a client is in a very
warm room, or very cold room, the
nurse/midwife can expect
temperature variations. Smoking,
eating and drinking of warm or
cold fluid can affect body
temperature if taken orally.

24. Patient who is on oxygen
therapy by face will have lower
temperature reading, so it’s
better to take the temperature
Axiallary.

25. Equipment
Rectal or oral glass thermometer.
Electronic Thermometers
(optional).
Lubricant for rectal
thermometer.
Clean gloves(optional).

26. Watch with second hand.
Receptacle for disposable.
Tissues.
Spirit swap.

27. Procedures for Oral
Temperature
ACTION
1. Explain the
procedure to the
client.
2. Ensure privacy
RATIONAL
1. To reduce
apprehension
and promotes
cooperation.

28. 3. Gather your
equipments.
4.Assist patient to a
comfortable position
5. Wash your hands.
Organization
promotes efficient
time
management.
To prevent the
spread of
microorganisms

29. 6. Wipe the
thermometer once
from the bulb toward
the fingers with
tissue.
7. Shake the
thermometer to return
the mercury column
to 35C.
Wiping from area with
few or organisms,
toward an area where
organisms may be
present, to minimize
spread of
microorganisms to
cleaner area.

30. 8.Place the mercury
bulb of the
thermometer well
within the back of the
right or left sublingual
pocket and instruct
him to close his lips
around the
thermometer.
When the bulb rests
deeply in the posterior
sublingual pocket, it
will be in contact with
blood vessels lying
close to the surface and
will accurately
measures body
Temperature.

31. 9.Leave the
thermometer in
place for at least 3
minutes.
Allowing
sufficient time for
the mercury to
expand to be more
accurate.

32. 10. Remove the
thermometer and
wipe it with tissue
Once from the
fingers down to the
mercury bulb,
using a firm
twisting motion.
Organisms to an area
where there are
numerous organisms
reduce spread to
cleaner area. Friction
helps to loosen matter
from the surface.

33. 11. Read the
thermometer by
holding it horizontally
at eye level, and rotate
it between the fingers
until mercury line can
be seen clearly.
Holding it at aye
level facilitate
reading. Rotating
will aid in placing
the mercury line in a
position where it
can be seen.

34. 12. Dispose of the
tissue in
receptacle for
contaminated
items.
Confining
contaminated
articles helps
reduces the spread
of pathogens.

35. 13. Wash the
thermometer in
lukewarm soap water.
Rinse in cool water.
Dry and replace the
thermometer at the
bedside or in the solid
utility room.
Mechanical action of
washing aids in
removal of organic
material and
organisms. All glass
thermometers should
be cleaned or
disinfected before
subsequent reuse.

36. 14. Wash your
hands.
15. Record in flow
sheet or paper,
report any abnormal
findings to
appropriate persons.
To prevent spread of
microorganisms.
Recording provides
accurate
documentation for
future comparisons.

37. Rectal
ACTION
1. Explain the
procedure to the
patient.
2. Ensure patient
privacy.
3. Gather equipment.
RATIONAL
To obtain
cooperation.
Organization
promotes efficient
time management.

38. 4. Wash your
hands.
5.Help patient to
comfortable
position, lying on
his side with
knees bent.
To prevent spread
of
microorganisms.

39. 6. Wipe, shake and
read the rectal
thermometer as in
steps in oral Temp.
7. Don clean
gloves, if desired.
Gloves act as a
barrier from
contact with
organisms in stool
or clients skin.

40. 8.Lubricate the
mercury bulb an
area
approximately 2.5
cm. (1 inch) above
the bulb.
Lubrication reduces
friction and facilitates
insertion and thus
minimizes discomfort
or injury to the
mucous membrane of
the anal canal.

41. 9. Gently insert the thermometer into
the patient anus 2-4 cm and hold the
thermometer in position for 3 minutes.
10. Remove the thermometer and
proceed as for oral Temp.

42. AXILLA
Action
1.Explain the
procedure to the
patient.
2.Ensure patient
privacy.
3.Gather equipment.
Rational
To Obtain
cooperation.
Organization
promotes
efficient time
management.

43. 4.Wash your hands.
5. Prepare the
thermometer as for
the oral Temp steps.
To prevent the
spread of
microorganisms.

44. 6. Place the bulb of
the thermometer
into the center of
the axilla.
The deepest area
of the axilla
provides the most
accurate
measurement of
the Temp.

45. 7.Bring the clients
arm down close
to his body and
place his forearm
over his chest.
To reduce
surrounding air and
ensure reliable
measurement.

46. 8.Remain with client, leaving the
thermometer in place for 10 minutes.
9.Remove the thermometer and
proceeds as for oral Temp.
10. Documentation.

47. Selection of sites for Temperature measurement
Common
sites
AdvantageDisadvantage
MouthMost
accessible
site, more
comfortable
for client.
Not to be used for patient who
can’t hold the thermometer
properly, who might bite the
thermometers, infant or small
children, confused or
unconscious client who had
oral surgery, or trauma of face
and mouth open. Client with
historyofconvulsion or with
shaking chills.

48. RectumItis most
reliable
measurement
used for infant
and young
children.
Should not be used
for clients after
rectal surgery,
rectal tumor,
hemorrhage,
patient with pelvic
traction.

49. AxillarySafest method
because it’s
noninvasive, used
for newborns.
Requires long
time for
measurement
and different to
hold it in
position, less
accurate.

50. Ranges in Normal Body
Temperature
Rate of
Measurement
Centigrade
Scale
Fahrenheit Scale
Oral 370.5C98.60.5F
Rectal 37.5C0.599.50.5F
Axillary 36.5C0.597.70.5 F

51. Converting Temperature
readings
When it’s necessary to convert Temperature
readings the following formulas can be used:
-
To convert Fahrenheit to Centigrade, subtract
32from the Fahrenheit reading and multiply
the result by 5/9. C = (F -32) 5/9
To convert Centigrade to Fahrenheit, multiply
the Centigrade reading by 5/9 and add 32to the
product. F = (9/5 C) + 32

52. Converts intoFahrenheitCentigrade
1. 36 C
2.40 C
3.34 C
Convert into Centigrade
1. 97 F
2.102 F
3.101 F

53. Fever-The simplest definition of a fever is a
body Temperature above 38C (100.4F)
rectally measured under resting conditions.
Hypothermia-
Is a state where body or skin Temperature
drops to 35C (95F) and uncontrolled
shivering begins.

54. Any Questions