LL3a VITAL SIGNS Temperature

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LL3a VITAL SIGNSTemperature Respiration

• Vital signs are indicators of the
• body's physiological status and
• response to Physical,
• Environmental and/or
• Psychological stressors

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• Temperature, Pulse Blood Pressure respiration
  rate can REVEAL the patients ability to
• Maintain body temperature regulation
• Maintain local systemic blood flow
• Maintain oxygenation of the tissues

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• Any difference between a clients
• NORMAL EXPECTED baseline
• measurement and the ACTUAL
• PRESENT vital sign is an indication for
• the nurse to PURSUE APPROPRIATE
• necessary care and INITIATE nursing
• action/therapies.

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• Vital sign changes may reveal sudden changes as
  well as progressive changes
• raised temperature may indicate an infection
• raised pulse - ?bleeding
• lowered blood pressure - ?bleeding

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CONSIDERATIONS OF VITAL SIGN MEASUREMENT

• From a nursing viewpoint
• Measurement provides information used to
  determine a patient / clients baseline data
  response to medical ./ nursing therapy
• Vital sign recording is a quick, efficient way of
  monitoring a condition or identifying problems.
  Can be used as a basis for clinical problem
  solving
• Vital sign measurement is incorporated into
  Practice for assessment determining the need
  for intervention(s), Viewed as routine care
  measures

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TEMPERATURE

• In health, tissues cells function best within a
  relatively narrow range of temperature -
  controlled by the hypothalamus.
• Body Core temperature is maintained within or -
  0.6 of a degree Celsius / centigrade.
• Surface body temperature fluctuates according to
  environmental changes.
• Skin temperature can range between 20o - 40oC
  without causing tissue damage.

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• Temperature range is balanced regulated to
  allow for changes that result from Exercise,
  Activity and Rest.
• Temperature regulatory mechanisms include
  Vasodilation, Vasoconstriction, Sweating
  avoiding environmental extremes hot/cold.
• For body temperature to stay constant HEAT
  PRODUCED must equal HEAT LOST to the environment.
• When internal control mechanisms fail the nurse
  may initiate measures to
• CONTROL the immediate environments
• REMOVE or ADD coverings
• GIVE MEDIATIONS - antipyretics

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Monitoring temperatures

• Types of thermometers
• Glass with a mercury column
• Electronic
• Disposable
• Tympanic Thermometry.

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Factors influencing / affecting temperature

• General -
• age exercise hormones stress environment
• medications daily fluctuation / time / gender
• Specific -
• diagnosed infections burns / open wounds
• Low white cell count lt5,000 High WBC gt 12,000
  
• immunosuppressive drug therapy post operative
  state
• hypothermic therapy hyperthermic therapy
• injury to the hypothalamus infusion of blood
  products
• Nurses asses for Fever or Hypothermia

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RESPIRATIONS

• Human survival depends on the ability for Oxygen
  to reach the body cells and Carbon Dioxide to be
  removed from the cells.
• Factors affecting character of respirations -
• Exercise acute pain anxiety smoking
• anaemia body position medications brain
• stem injury.

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ASSESSMENT OF RESPIRATIONS

• Easiest of all vital signs to measure but most
  often haphazardly recorded.
• NEVER estimate a respiratory rate
• Accurate measurement of the chest wall rising and
  falling is required.
• Any change may be important
• Respiration is tied to the function of numerous
  body systems, therefore the nurse must consider
  all variables when change occurs.

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MEASUREMENT

• RATE - determined by a full inspiration and
  expiration, will vary with age
• DEPTH - assessed by observing the degree of
  movement in the chest wall and is usually
  considered to be deep, normal or shallow.
• RHYTHM - regular occurrence of respiration will
  depict a normal range. During assessment the
  nurse estimates the time interval after each
  respiration cycle. Respiration id then either
  regular or irregular in rhythm

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ALTERATIONS IN BREATHING PATTERN

• Bradypnoea rate regular, but abnormally slow lt
  12 b/min
• Tachypnoea rate regular, but abnormally fast gt
  20 b/min
• Hyperpnoea laboured respirations, increased
  depth, increased rate gt 20 breaths / minute
• Hyperventilation rate depth increased
• Hypoventilation rate depth abnormally low
• Cheyne-Stoke rate depth irregular, alternating
  periods of apnoea and hyperventilation
• Kussmaul resp. abnormally deep, regular but
  increased in rate
• Biots resp. abnormally shallow for 2-3 breaths,
  followed by irregular periods of apnoea

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WHEN TO RECORD VITAL SIGNS

• On clients admission to a health care facility
• In hospital, on routine or schedule according to
  physicians order or hospital policy
• During clients visit to clinic or physicians
  office
• Before after any surgical procedure
• Before after any invasive diagnostic procedure
• Before after administration of medications that
  affect cardiovascular, respiratory temperature
  control function

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• When the clients general physical condition
  changes - e.g. loss of consciousness or
  increased intensity of pain
• Before after nursing interventions influencing
  any one of the vital signs -
  e.g.
  before ambulating client previously on bed rest
  or before client performs range of movement
  exercises
• Whenever client reports to nurse any non-
  specific symptoms of physical distress -
  e.g. "feeling
  funny or different"

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References

• Potter,A. Perry,A. (1997) Fundamentals of
  Nursing, Concepts, Process Practice St Louis
  Mosby Ch 32 p 594
• Taylor,C. Lillis,C. LeMonde,P. (1997)
  Fundamentals of Nursing - The Art Science of
  Nursing Care. Philadelphia Lippincott Ch25 p432