tVITAL SIGNSOVERVIEW

tVITAL SIGNS o V – vasodilation;
OVERVIEW o A – adjustment;
When To Take (VSIGNS): o S – sweating;
Sources of Heat Production (BEFAT):
 V – vital signs upon admission;
 S – surgery;  B – basal metabolism;
 I – institutional policies;  E – epinephrine release;
 G – giving medications;  F – fever;
 N – nursing interventions;  A – activity (muscular activity);
 S – status changes;  T – thyroxine;
Commonly Used Equipment: Causes of Heat Loss (CREC):

 Thermometer;  C – conduction:
 Stethoscope;
o Mechanism –
 Sphygmomanometer;
 Transfer of heat from
 Wristwatch (with second hand);
warmer object to a cooler
Preparations When Taking VS: object;
o Example –
1. Wash hands before and after taking vital
 Heat loss from sleeping on
signs;
the cold ground;
2. Identify the patient and inform about the
o Prevention –
procedure;
 Use insulating materials like
3. Provide patient privacy;
sleeping pad or blanket to
4. Position the patient correctly;
create a barrier between the
5. Explain the procedure and evaluate the
body and the cold ground;
procedure accordingly;
6. Document data;  R – radiation:
o Mechanism –
 Emission of heat as infrared
BODY TEMPERATURE rays;
o Example –
Definition:  Body naturally radiating
 The balance between heat production and away heat in a cold room;
heat loss; o Prevention –
 Wear clothing or use
Body Temperature Types: blankets that reflect body
heat, such as thermal or
 Surface temperature (superficial) –
reflective materials;
o Characteristic: fluctuating;
o Normal: 36.5° C – 37.5° C;  E – evaporation;
o Example: skin; o Mechanism –
 Core temperature –  Loss of heat due to moisture
o Characteristic: relatively constant; evaporating from skin and
o Normal: 37.0° C or 98.0° F; lungs;
o Example: deep tissues; o Example –
 Sweating after an intense
Thermoregulation: exercise results in heat loss;
 From skin receptors  hypothalamus, o Prevention –
then;  Stay dry and use moisture-
 From hypothalamus  effectors to wicking clothing to help
regulate body temperature; manage sweat;
 Layering clothes in cold
Effectors Responses: environment;

,  Use barriers like
windbreakers or insulating
clothing to reduce exposure
to air; Physiology of Fever:
Kinds of Thermometer:  Infection/injury/inflammation  cell
damage  release of prostaglandins into
 Digital thermometer;
the blood  hypothalamus stimulation 
o Blue color – for oral use;
⬆️body temperature: > 37.5° C  ⬆️core
o Red color – for rectal use;
temperature < ⬆️surface temperature 
 Mercury-based thermometer;
shivering  core temperature == surface
 Temporal thermometer;
temperature  shivering stops;
 Tympanic thermometer;
 Rectal thermometer; Phases of Fever:

Routes in Checking Body Temperature: 1. Cold/chill stage –
a. Mechanism:
 Oral – (normal: 36.5° C – 37.5° C):
i. Physiologically ⬆️body
o Most accessible and convenient;
temperature by shivering;
o Place the tip at the posterior
b. Symptoms:
sublingual pocket of the mouth;
i. ⬆️HR, ⬆️RR;
o Duration: 2-3 minutes;
ii. Shivering, cold skin,
o Contraindications: goosebumps;
 Children < 3 years old; iii. Cyanotic nail beds;
 Unconscious patients; iv. Cessation of sweating;
 Inflammation or surgery to c. Interventions – prevent heat loss:
the mouth; i. No tepid sponge bath;
 Persistent or frequent ii. Warm fluids;
coughing; iii. Provide blanket;
 With epilepsy; 2. Plateau phase –
 After ingesting hot or cold a. Mechanism:
fluids or foods; i. Surface temperature is now
 Axillary – (normal: 35.8° C – 37.0° C): equal to core temperature
o Safe and non-invasive, but less (ST==CT);
reliable; b. Symptoms:
o Duration: 9-10 minutes; i. Warm skin;
o Contraindications: ii. Body malaise;
 Surgery; iii. Photosensitivity;
 Tight-fitting jeans; iv. Glassy eye appearance;
 Rectal – (37.3° C – 38.1° C): v. ⬆️PR, ⬆️RR, ⬆️thirst;
o Most accurate route, invasive, vi. Mild-severe dehydration;
requires insertion of the vii. Severe cases –
thermometer’s tip: drowsiness,
 For infant – 1.5 inches; restlessness, delirium,
 For adult – 2 inches; convulsions;
o Position: sim’s; c. Interventions – promote heat loss
o Contraindications: by:
 Rectal surgery; i. Applying principles of CREC;
 Hemorrhoids; 3. Fever
 Diarrhea; abatement/recovery/defervescent/flus
 Cardiac problems; h phase –
 Patient who can’t turn to a. Mechanism:
side; i. Source of fever is gone;
 Tympanic – (normal: 36.8° C – 37.9° b. Symptoms:
C): i. Flushed, warm skin;
o Conventional, readily accessible; ii. Sweating;
o Reflects the core body iii. ⬇️shivering;
temperature; c. Intervention – prevent heat
production:
Factors Affecting Body Temperature: i. Bed rest;
 Age; Types of Fever:

,  Constant –
o Narrow range of fluctuations above
o A – apply warm blankets;
normal (<2° C); o C – cover client’s scalp with a cap
o Example: Typhoid fever;
or turban;

 Relapsing – o E – environment should be
o Days of fever and normal blood warmed;
temperature;
o Example: Dengue fever;

Hyperthermia: PULSE
 Abnormally high body temperature: > Description:
40° C;  The palpable bounding of blood flow in a
 Types of hyperthermia – peripheral artery;
o Heat cramps:  A wave of blood created by the
 Fairly mild hyperthermia: contraction of the left ventricles;
 Often occurs in the arms,
hands, lower legs, and feet; Measures:
o Heat exhaustion:
 Pulse rate – acceptable ranges per
 More severe, causes minute:
hyperventilation; o Infant – 120 to 160 bpm;
 Can be as high as 40° C;
o Toddler – 90 to 140 bpm;
o Heat stroke:
o Pre-school – 80 to 110 bpm;
 Most serious form, may lead
o School age – 75 to 100 bpm;
to paralysis or death;
o Adolescent – 60 to 90 bpm;
 Nursing interventions (CARTTON):
o Adulthood – 60 to 100 bpm;
o C – clothing of client is adjusted  Stroke volume –
appropriately; o The amount of blood that enters

o A – antipyretics, as ordered; the aorta with each ventricular
contraction;
o R – rest and sleep provided; o Normal: 70 mL;
 Cardiac output –
o T – temperature and skin color o The amount of blood that enters
assessed frequently; the aorta per minute;
o Normal: 4 to 6 L;
o T – tepid sponge bath (lukewarm); o CO = Stroke Volume (SV) x Heart
o O – oral fluids increased (2-3 Rate (HR);

L/day); Nursing Considerations in Taking Pulse

o N – nutrition promoted; Rate:

 Use of three (3) fingers;
Hypothermia:  Length –
o 15 seconds x 4 = stable;
 Core BT below normal lower limits: <
35.0° C; o Full 1 min = unstable;
 Causes –  Grading –
o Excessive heat loss; o 0  absent;
o Inadequate heat production; o 1  weak;
o Impaired hypothalamic regulation; o 2  normal;
 Signs and symptoms – o 3  bounding;
o ⬇️body temperature, ⬇️pulse rate,
Factors Affecting Pulse Rate:
⬇️respiratory rate;
o Severe shivering, disorientation,  M – medications;
drowsiness progressing to coma;
o Feelings of cold and chills;  A – age;
o Pale, cool, waxy skin, frostbite;
 S – sex/gender;
o Hypotension, ⬇️urinary output, lack
of muscle coordination;  S – stress;
 Nursing interventions (LOADACE) –

,  Facial;  Diaphragmatic breathing –
 Carotid – emergency (adult); o
 Apical –
o Digoxin therapy/medicines with (-) Alterations in Breathing Pattern:
inotropic effect;  Tachypnea –
o Location - 5th ICS: o Rate above 20 cpm;
 < 4 years old = left MCL;  Bradypnea –
 4-7 years old = MCL; o Rate below 12 cpm;
 > 7 years old = right MCL;  Apnea –
 Brachial – infant emergency; o Cessation of breathing;
 Radial – for ABG analysis;  Hyperpnoea –
 Femoral – child emergency; o Labored, ⬆️depth, ⬆️rate;
 Popliteal;  Hyperventilation –
 Posterior tibial; o ⬆️depth of respiration;
 Dorsalis pedis;
 Hypoventilation –
Nursing Diagnosis Affecting Pulse Rate: o ⬇️depth of respiration;
 Cheyne-stoke respiration –
 Activity intolerance;
 Anxiety;
 ⬇️cardiac output;
 Acute pain;
 Ineffective gas exchange;
 Ineffective peripheral tissue perfusion;

o Gradual ⬆️and ⬇️ in depth, then a
RESPIRATION period of apnea;
o Due to: cerebral injury;
Description:
 Biot’s respiration –
 The act of breathing;
 Intake of oxygen and output of carbon
dioxide;

Measures:

 Respiratory rate – acceptable ranges per
minute:
o Hyperpnoea or normopnoea with
o Newborn/infant – 30 to 60;
periods of apnea;
o Toddler – 25 to 32;
o Irregular, no pattern, near death;
o Child – 20 to 30;
o Due to: medulla oblongata injury;
o Adolescent – 16 to 20;
 Kussmaul respiration –
o Adult – 12 to 20;
o Older adult – 12 to 18;
 Tidal volume –
o Air taken by an adult during normal
respiration;
o Normal: 500 mL;

Factors Affecting Respiration: o Hyperpnoea;
 Central neurogenic hyperventilation –
 ⬆️respiratory rate (SEEL) –
o S – stress;
o E – environment;
o E – exercise;
o Fast and deep respiration;
o L - ⬇️O2 concentration at ⬆️ o Due to: midbrain injury;
altitude;  Apneustic respiration (gasping) –
 ⬇️respiratory rate (MEI) –
o M – medication;