Learning Objectives
1. Identify the measurements that constitute vital signs. State why they are known as vital signs. Describe the relationships among the vital signs.
2. Give examples of reasons for changes in body temperature. Describe the related physiology.
3. State normal adult body temperature as measured in four different body areas.
4. Differentiate among the terms febrile, afebrile, intermittent and remittent fevers, crisis, and lysis.
5. In the skills laboratory, demonstrate the ability to measure body temperature by various methods and with various equipment available.
6. Describe radial, apical, and apical-radial pulse. In the skills laboratory, demonstrate the ability to measure each of these. Identify other points on the body where pulses can be obtained.
7. In the skills laboratory, demonstrate the ability to count and to describe respirations.
8. In the skills laboratory, demonstrate the ability to measure blood pressure and orthostatic blood pressure accurately using the arm cuff and thigh cuff and using the aneroid manometer and the electronic monitor.
9. State the normal adult pulse rate, respiration rate, and blood pressure ranges.
10. Describe what is meant by pulse oximetry. In the skills laboratory, demonstrate the ability to perform this procedure.
11. Describe the concept of pain as the fifth vital sign.
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IMPORTANT TERMINOLOGY |
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apical pulse |
eupnea |
pedal pulse |
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apical-radial pulse |
Fahrenheit |
popliteal pulse |
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apnea |
febrile |
pulse |
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auscultation |
femoral pulse |
pulse pressure |
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axillary |
fever |
radial pulse |
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bradycardia |
hand sanitization |
rectal |
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bradypnea |
hypertension |
sphygmomanometer |
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carotid pulse |
hypotension |
stertorous breathing |
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Celsius |
Korotkoff’s sounds |
stethoscope |
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Cheyne-Stokes |
Kussmaul’s respirations |
systole |
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respirations |
lysis |
tachycardia |
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crisis |
oral |
tachypnea |
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cyanosis |
orthopnea |
temporal |
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diastole |
oximetry |
tympanic |
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dyspnea |
palpation |
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Acronyms |
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AP |
MAP |
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A-R |
O |
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Ax |
PMI |
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BP |
PO |
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BPM |
R |
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C |
SBP |
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DBP |
TA |
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F |
TM |
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HR |
TPR |
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I&O |
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Body temperature, pulse, respiration (TPR), and blood pressure (BP) are basic client assessments. Taken and documented over time, these data demonstrate the course of a client’s condition. TPR and BP are called vital signs (VS) or cardinal symptoms because these measurements are indicators of functions necessary to sustain life.
Key Concept The temperature, pulse, respiration, and blood pressure are called vital signs because they must all be within normal limits to sustain life. In addition, pain is considered to be the fifth vital sign. Pain is to be assessed each time the other vital signs are measured.
Temperature, pulse, and respiration are usually observed together. Many healthcare facilities routinely require observation of these signs at least every morning and evening for all clients. For some illnesses, more frequent observation of vital signs is necessary, to detect variations indicating a change in the client’s condition. Often, variations occur in more than one vital sign. The healthcare provider will order more frequent assessments of the client with an unstable condition. The nurse may also use judgment to determine if a client requires more frequent assessment or rechecking of vital signs.
THE GRAPHIC RECORD
The graphic record is a flow sheet used to easily document large amounts of information for all members of the healthcare team to read. Usually the graphic record documents measurements of vital signs, fluid intake and output (I&O), weight, and bowel movements, assessed at regular intervals. In some facilities, a paper graphic record is kept in the client’s chart. In most acute-care facilities, this information is entered into the electronic record. Follow the procedure used in your facility. When complete, whether on paper or an electronic record, the graphic record provides a picture of the variations that occur throughout the client’s illness. The electronic record allows each component to be represented in graphic form, for easy assessment of changes.
Recording Vital Signs
Vital signs must be recorded accurately and promptly to provide continuous and current documentation. A record of a client’s vital signs helps providers diagnose and respond to the client’s changing condition. It also serves as a quick and handy reference for the entire healthcare team.
The nurse needs to know the format for documenting vital signs in his or her agency. Steps for recording vital signs in the paper record include:
• Locate the current date on the graphic record.
• Record temperature by making a dot on the scale parallel to the temperature value under the designated time. Connect the dot to the previous reading with a short line. (In many facilities using a paper record, the temperature and pulse are graphed in different color inks.)
• Record pulse rate by making a dot on the scale parallel to the pulse rate under the designated time. Connect the dot to the previous reading with a short line.
• Record respiratory rate at the bottom of the graph with numbers.
• Record BP with written numbers (e.g., 120/80) or graph the numbers in a manner similar to that used for the temperature graph.
• Record other information, such as weight, bowel movements, and the totals for I&O, with written numbers in the spaces provided.
On the electronic graphic record, enter TPR, BP, and all other information as designated on the computer. Sometimes BP is stated on a graph with dots or check marks. The graph is marked in increments similar to the increments seen in the paper temperature graph. Often a BP graph is superimposed on the temperature graph.
NCLEX Alert You must be alert throughout the examination to integrate your knowledge of patient safety including the use of equipment and timeliness of procedures. Documentation must be timely accurate, and appropriate. The NCLEX may suggest ways of recording your findings.
Frequent Vital Signs
Sometimes a client’s condition is serious enough to require taking vital signs every 5, 10, or 15 minutes. The frequent vital signs sheet may be a paper document (most often in critical care areas, after surgery, or in the immediate postpartum period). Graph vital signs in the same way on the frequent vital signs sheet as you would on the regular record. In many cases, space is available to record other information, such as intravenous (IV) fluids, I&O, weight, medications, and notes. Frequent vital signs are entered on the computer in a similar manner.
ASSESSING BODY TEMPERATURE
Body temperature is the measure of heat inside a person’s body (core temperature); it is the balance between heat produced and heat lost. The body generates heat as it burns food and loses heat through the skin and lungs. Body temperature using oral (O; or per os, PO) measurement normally remains at approximately 37°C or 98.6°F However, variations may occur and still be considered “normal” for an individual. Temperature measurements that are significantly higher or lower mean that some change in the body’s regulatory system is upsetting the balance. The signs of an elevated temperature are easy to recognize: flushed face, hot skin, unusually bright eyes, restlessness, chills, and thirst. A lifeless manner and pale, cold, clammy skin are often signs of a subnormal temperature.
Temperature is measured on the Celsius (centigrade—C) or the Fahrenheit (F) scale. Most Americans are more familiar with Fahrenheit values. If a nurse works in an agency that uses Celsius measurements, it is important to learn the Fahrenheit equivalents to translate measurements easily for clients and their family members. Converting measurements from Celsius to Fahrenheit and vice versa is often necessary. Figure 46-1 explains conversions and gives equivalents.
Regulation of Body Temperature
The hypothalamus, which is the brain’s heat-regulating center, controls body temperature by controlling blood temperature.
FIGURE 46-1 · Celsius and Fahrenheit conversions and equivalents.
Heat is a product of metabolism. Muscle and gland activities generate most body heat. When the body is cold, exercising the muscles warms it; if a person is angry or excited, the adrenal glands become very active, and he or she feels warm. The digestive process increases body temperature. Cold, shock, and certain drugs depress the nervous system and decrease heat production. The hypothalamus senses these changes and makes appropriate adjustments.
Normal Body Temperature
Normal temperature variations are quite small. A difference of a degree or more (Fahrenheit) is considered to be within normal limits if the client is not showing symptoms of fever or hypothermia. The significant factor is the “normal” temperature for that individual. Most clients can tell when they have a fever or do not feel well. The key is to follow the temperature variations for that person and make sure these values do not significantly deviate from that person’s baseline. Normal body temperature is often lowest in the morning and highest in the late afternoon and evening. Normal temperatures for newborns are higher than for adults. The body temperature gradually lowers to the adult normal temperature as the child matures.
Key Concept In general, rectal temperatures are being discouraged in infants if the temperature must be taken frequently Axillary temperatures are used instead.
TABLE 46-1. Range of Normal Temperatures
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ROUTE |
TEMPERATURE RANGES |
TIME |
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Oral (mouth) |
35.5°C-37.5°C (95.9°F-99.5°F) |
0.5-1.5 min |
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Rectal (anus) |
36.6°C-38°C (97.9°F-I00.4°F) |
0.5-1.5 min |
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Axillary (armpit) |
34.7°C-37.3°C (94.5°F-99.I°F) |
1-3 min |
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Tympanic (auditory canal)* |
35.8°C-38°C (96.4°F-I00.4°F) |
1-2 sec |
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Temporal artery* |
35.8°C-38°C (96.4°F-I00.4°F) |
1-2 sec |
*Temporal artery and tympanic: usually documented without conversion; possible tc convert to rectal equivalent.
Other influences on normal body temperature include ovulation, childbirth, and individual metabolism. Table 46-1 gives average normal temperatures for adults (who are known as afebrile, or without fever). The length of time to keep the temperature sensor in place for an accurate reading in different body areas is also listed.
Key Concept When using the electronic thermometer; the times are shorter for oral, rectal, and axillary temperatures. The device will indicate when maximum temperature is sensed.
Elevated Body Temperature
Temperature rises when the body’s heat production increases or heat loss decreases; both may occur simultaneously. If the temperature is elevated, fever (pyrexia) is present. The person is said to be febrile. Fever is a sign of some disorder within the body. It often accompanies illness and signifies that the body is fighting an infection. In some cases, a slightly above-normal temperature is useful for fighting microorganisms. For this reason, treating a fever may be delayed until a diagnosis is confirmed.
Oral temperatures in fever can range from 37.5°C to 39.4°C (100°F-103°F) or greater. A very high temperature can be life threatening. Figure 46-2 illustrates types of fevers.
• A temperature that alternates between a fever and a normal or subnormal reading is an intermittent fever.
• A temperature that rises several degrees above normal and returns to normal or near normal is a remittent fever.
• A constant fever stays elevated.
• A sudden drop from fever to normal temperature is called crisis.
• When an elevated temperature gradually returns to normal, it is called lysis.
• Fever that returns to normal for at least a day, and then occurs again, is a relapsing fever.
Key Concept Remember, everyone has a "temperature," but not everyone has a "fever" (elevated temperature).
FIGURE 46-2 · Common courses of fever and its resolution. The colored line represents average "normal” temperature (37°C or 98.6°F).
Lowered Body Temperature
A temperature significantly below normal is called hypothermia. A low body temperature may precede death or result from overexposure to the elements or cold water, as in near-drowning.
In some instances, body temperature slightly below normal indicates a desirable situation: The lowered body temperature slows metabolism and thus decreases the body’s need for oxygen. Clinical hypothermia is used to perform some surgical procedures; accidental hypothermia is life threatening and requires immediate treatment.
Nursing Alert An extremely high temperature (hyperthermia) or low temperature (hypothermia) can be fatal. Survival is rare if the core temperature is above I08°F (42.2°C) or below 93.2°F (34°C).
Hypothermia can also indicate impending death. This is a normal component of the dying process.
Equipment for Measuring Body Temperature
Several types of thermometers and indicators are available for measuring body temperature. Electronic sensors are most commonly used today.
Electronic and Other Automatic Thermometers
Healthcare facilities use some type of electronic or automatic thermometer. These thermometers and indicators are fast, accurate, easy, and safe to use. Digital electronic thermometers run on batteries and display the client’s temperature on a screen as an LED display. Usually, they can be set to display either Celsius or Fahrenheit temperature readings. (Many acute-care facilities record body temperatures in Celsius.) Regularly clean and sterilize electronic thermometers following the manufacturer’s instructions. Electronic thermometers must be charged on a regular basis. Often, they are plugged in every night.
Key Concept All electronic temperature probes are encased in a new cover for each client.They are discarded according to agency protocol. If the client is in isolation or deemed infectious, the temperature indicator is not shared. The disposable single-use thermometer is most often used in such environments.
Disposable Single-Use Thermometer
Temperature indicators made of paper are available for onetime use. These indicators are often used in isolation units and are inexpensive and convenient for use at home. They are also convenient when traveling. Disposable electronic thermometers are also available (Fig. 46-3).
To use, remove the wrapper and place the indicator under the client’s tongue. Some types of indicators are designed to be held against the client’s forehead (Fig. 46-4A and B). Follow the manufacturer’s instructions.
