Assessing Health
Vital Signs
Temperature
Pulse
Respiration
Blood pressure
Body Temp
• Reflects the balance between heat
production and heat loss.
• Core temp: in the deep tissues of the
body (abdominal cavity)(36-37.5°C)
• Surface temp. of the skin
Factors affect heat production
• Basal Metabolic Rate (rate of energy utilization
in the body required to maintain essential
activities): ↑ in younger persons.
• Muscle activity: shivering ↑ BMR
• Thyroxine output: (chemical thermo-genesis)
(stimulation of heat production through cellular
metabolism)
Factors affect heat production
• Fever: ↑ cellular metabolism
• Epinephrine and sympathetic stimulation
Heat Loss
• Radiation: b/w 2 surfaces without contact
• Conduction: from higher to lower temp
(swimming in cold water)
• Convection: dispersion of heat by air
currents.
• Vaporization: evaporation from respiratory
tract.
Regulation of body temp
• Sensors (detect heat/ cold & send signals
to reduce temp or increase heat production)
• Integrator in the hypothalamus
• Effector system to adjust production and
loss of heat
• Sensors detect cold → vasoconstriction,
shivering
• Sensors detect warmth → sweating,
peripheral vasodilatation
Factors affecting body temp
• Age (thermoregulation control)
(extreme age groups)
• Diurnal variation (early morningsleep)
• Exercise: increase temp
Factors affecting body temp
• Hormones (progesterone ↑ temp)
• Stress ↑ production of adrenaline
• Environment changes.
Alterations in body temp
• Average (36-38° C)
• Pyrexia (hyperthermia) (38-41° C) =
Fever= Febrile.
• Hyperpyrexia (more than 41° C)
• Hypothermia (below 36° C)
Common types of fever
• Intermittent: alteration of temp on
regular intervals
• Remittent: wide range of temp
fluctuation than 2 °C/24 hrs.
• Relapsing: short febrile periods of a few
days.
• Constant:always remains above normal
• Fever spike: rapid rise of temp.
S + S OF HYPERTHERMIA
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↑ HR
↑ Resp rate
Shivering
Cold skin, pallor
Photosensitivity
↑ thirst
Mild to severe dehydration
Nursing Care of ↑ thermia
• Monitor V/S
• Assess skin: color and temp.
• WBC’s
• Remove excessive clothes/blankets
• Adequate fluids and nutrition
•I&O
• Antipyretics as prescribed
• Tepid sponges
Hypothermia
• Excessive heat loss
• In adequate heat production
• Impaired hypothalamic control
(regulation)
Clinical S + S of ↓thermia
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↓ temp., pulse and resp.
Severe shivering
Chills
Pale, cool.
Hypotension
↓ urinary output
Drowsiness progressing to coma
Nursing Care of ↓thermia
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Warm environment
Dry clothes
Warm IV fluids
Warm pads
(sponges)
Assessing body temp
• Oral (food, fluids, smoking, exercise)
• Rectal (very accurate) (3.5 cm) (C/I in MI,
diarrhea, rectal surgery or diseases)
• Axillary (newborn) (inaccurate in fever)
• Tympanic (membrane injury)
Types of thermometers
• Long tip :oral
• Rounded : rectal/
Axillary
• Electronic
• Chemical
disposable
• Infrared
• Skin tape
Temp scales
• C = (Fahrenheit – 32) x 5/9
• F = (Celsius x 9/5)+ 32
Oral temperature
• Accessible and
convenient
• Easily break down
• Inaccurate if hot or
cold fluids or
smoke ingestion
• Injury post oral
surgery
Rectal temp
• Reliable and the
most accurate
measurement
• Inconvenient and
unpleasant
• Difficult to those
clients cannot turn
• Could injure
rectum post rectal
injury
• Presence of stool
may interfere
accuracy
Axillary temp
• Safe and non
invasive
• Must left long
period of time
Tympanic temp
• Accessible
• Reflects core temp
• Very fast
• Uncomfortable and
may be invasive to
membrane
• Varied repeated
measures
• Cerumen may
affect readings
General guidelines in temp
assessment
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Explain procedure
Hand washing
Privacy
Sim’s or lateral
position
• Protective sheath or
lubricant
• 2-3 min for an oral
(either side of
frenulum) or rectal
temp (deep breath
and 3.5 cm against
rectal wall)
• 6-10 min in axillary
(bulb in the center of
axilla) temp
• Pull pinna slightly
upward and backward,
anteriorly to ear drum
in tympanic temp.
• Wiping glass
thermometer
• Read temp
• Wash thermometer
• Documentation
General guidelines in temp
assessment
• Use axillary temp
in infants
• Tympanic or
axillary routs are
preferable in
children