VITAL SIGNS

TEMPERATURE Oral Axillary Rectal

Oral Method Most convenient Most accessible Nursing Alert! Applicability is for children aged six (6) years and above Not applicable for children below six (6) years old Contraindicated in patients with: Oral surgery Mouth breathers History of convulsive seizures Unconscious Incoherent Irrational Mentally disrupted Insane Procedure Nothing Per Orem for about thirty (30) minutes before taking temperature No food intake No drinks No smoking No chewing gum No whistling No gargling Rationale: Any of the above would alter the result Placement: Under the tongue, beside the frenulum (right or left) Total Time: Two (2) to three (3) minutes

Axillary Method Least realiable Safest method Nursing Alert! During application, be sure that axilla is dry Dry using a patting motion Nursing Alert! Do NOT RUB!!! Rationale: This increases heat due to friction Rubbing increases blood supply to the area Therefore, there will be increase in temperature reading Rubbing provides a false-positive elevation of temperature reading Duration: In adults nine (9) minutes In children five (5) minutes

Rectal Method Most reliable (except for tympanic thermometer) Most accurate (except for tympanic thermometer) Concept! If tympanic method is used using a tympanic thermometer, the rectal method is only second most reliable and second most accurate Disadvantage: Placement on a different site yields a different reading Therefore, ensure that the bulb of the rectal thermometer rests on the mucous membrane Contraindications: Hemorrhoids Rectal Surgery Certain Cardiac ailments due to stimulation of the vagus nerve; valsalva maneuver leads to arrhythmias Position of Patient when taking the reading: Sims left position Sims right position For Newborn, lift up ankles to keep buttocks up In Toddlers, set on prone position on adults lap Duration: Two (2) minutes

Conversion of Centigrade to Fahrenheit Centigrade = (5/9)F 32 Centigrade = (F/1.8) 32

Conversion of Fahrenheit to Centigrade Fahrenheit = (9/5)C + 32 Fahrenheit = (1.8)C + 32

Concepts!!! Peak body temperature occurs at 12NN to 3PM or 4PM Lowest body temperature occurs in the early morning hours of the day

FEVER Normally, the hypothalamus is able to adjust body temperatures between 37C to 40C But due to the presence of pyrogenic materials like the following: Pathogenic microorganisms Toxins Foreign substances Any substance capable of increasing body temperature Creates a deficiency of -3C, making a person enter the FIRST STAGE OF FEVER

First Stage of Fever Typical signs and symptoms indicate the bodys compliance mechanism to increase and conserve heat: Chills Shivering Gooseflesh Contraction of arectores pilorum or pilo arecti muscles Vasoconstriction Decreases blood supply to the skin Pallid Skin Cyanotic nail beds Key Concept!!! Patient complains of feeling cold Sweating will stop because body will minimizes heat loss Also called: Onset Stage Chill Stage Cold Stage This stage is characterized by low febrile temperatures Nursing Management Key Concept Aim is to minimize heat loss Key Concept Do NOT apply TEPID SPONGE BATH because this would make patient progress to SHOCK Provide additional clothing as necessary Provide additional blankets as necessary Provide something warm to drink These measures would result to a gradual increase in body temperature Question: When will you start application of TSB? Answer: If there is a 1C to 2C increase in body temperature

Second Stage of Fever Also called: Coarse Stage of Fever Peak Stage of Fever Key Concept! Patient does not feel hot or cold Skin is warm to touch Skin is flushed Fever blisters are present Herpetic lesions Absence of shivering Possible dehydration Important Concept!!! For every increase of temperature, there is a corresponding increase in pulse rate Rationale: Increase in temperature results in an increase in pulse rate due to increased metabolic rate Increased metabolic rate increases oxygen demand Due to increased oxygen demand of susceptible brain cells, CONVULSIVE SEIZURES may occur. These may also be due to irritation of nerve cells FEBRILE CONVULSIONS Increased oxygen demand also leads to an increase in respiratory rate Patient complains of: Loss of appetite Myalgia or muscle pains due to increased catabolism Nursing Management Tepid Sponge Bath Cooling Bed Bath

Tepid Sponge Bath Temperature of water is 32C This temperature is maintained throughout the procedure How to apply: Done by patting Rationale: To avoid friction, which increases temperature Important Concept! Do NOT use ALCOHOL when applying TSB Rationale: Alcohol dries the skin and leads to irritation Key Concept! TSB should not be done hurriedly Rationale: When done hurriedly, TSB will stimulate shivering Shivering would lead to increased muscle activity Increased muscle activity would lead to increased temperature

Cooling Bed Bath Water temperature will start at 32C Procedure will go on with gradual decrease in water temperature until it is maintained at 18C Therefore, to achieve this drop in temperature, utilize ice Same procedure of application as in Tepid Sponge BathTypes of Fever1. Intermittent Fever A fever that is alternated at regular intervals by periods of normal and subnormal temperature

2. Remittent Fever Fever alternated by wide range of fluctuations in temperature, all of them are ABOVE NORMAL. Duration is within a 24-hour period

3. Relapsing Fever Short periods of febrile episodes alternated by one (1) to two (2) days of normal temperature

4. Constant Fever Minimal fluctuations of temperature, all of which are ABOVE NORMAL

5. Staircase or Spiking Fever Common in patients with TYPHOID FEVER

PULSE ASSESSMENT

Concepts! If pulse is regular, count or monitor pulse for thirty (30) seconds and multiply by two (2). This is legal!

If pulse is irregular, count or monitor the pulse for one (1) FULL minute

Assessment of the Pulse Deficit This is the most accurate method Involves two nurses using one watch Starts at the same time Ends at the same time Comparison of results ensues Count is done for one (1) full minute

Scale in Pulse Assessment 0 - Absent or cannot be felt 1+ - Weak or thready 2+ - Normal 3+ - Grounding

BLOOD PRESURE

Systolic Produced by ventricular contraction Pressure on blood vessels during depolarization or ventricular contraction

Diastolic Pressure that remains in the walls of the blood vessels during relaxation or repolarization or resting

Broadly two (2) types: Direct By insertion of a catheter Indirect Method Auscultatory method Palpatory method Flush Method

Auscultatory Method Uses Korotkoff sound A popping sound NOT the heart beat It is a phenomenon an unknown phenomenon!

Determining Amount of Inflation Using auscultatory method Ask patient what is his last BP reading and then add 30 40 mmHg from last systolic reading. Deflate gradually rate is approximately 2 3 mmHg per second Alternative auscultatory method Auscultate for the last sound as you go up. Then add 30 40 mmHg Then deflate

Tripartite Blood Pressure Done if patient is an adult. Example: 140 mmHg systolic first loudest sound 100 mmHg 1st diastolic muffling 70 mmHg 2nd diastolic last sound Therefore, the tripartite blood pressure is 140 / 100 / 70 If there is no muffling, an example would be: 160 / no muffling / 110

Concepts!!! Take systolic on loudest sound if patient is an adult If patient is pediatric or up to ten (10) years old, take the first sound, whether it is faint or loud If, for example, first sound is at 190 mmHg and there is silence up to 140 mmHg and then there is a sound at 130 mmHg down to 80 mmHg then Use the PALPATORY METHOD in combination with the AUSCULTATORY METHOD because there is an auscultatory gap

Repeat using: Auscultatory method Palpatory method

How to do the Palpatory Method Inflate Determine up to what point to inflate Palpate pulse If pulse is absent, add 30 40 mmHg Deflate First palpable pulse is true systolic pressure For diastolic pressure, proceed using the auscultatory method

Flush Method Represents the mean blood pressure Represents the average of the systolic and diastolic pressures When done: When you have a BP apparatus without a stethoscope Used for pediatric patients How done: Inflate up to the point where extremity becomes pale Deflate slowly and look for a REBOUND FLUSH when extremity becomes red again This is the true reading!! Note that there is only ONE reading!!!

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