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Vital Signs (VS)

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Assessment of vital or critical functions.

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Surface Temperature

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*Temperature of skin, varies with environmental conditions

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Core Temperature

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*Temperature of interior body tissues, remains almost constant (within 1 degree F) ***PRODUCT OF THE PRECISE BALANCE BTW HEAT PRODUCTION AND HEAT LOSS

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Why is a baseline important?

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1. A change in a vital sign may be caused by a disease,effect of therapies, changes in activity and enviroment

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Normal Ranges of Temperature:

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Oral/Tympanic Temp: 96.8-100.4 degrees F (36-38 degrees C) Axillary-typically one degree F lower than oral, less reliable Rectal**BEST REFLECTS CORE TEMP, one degree F higher than oral

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Body temperature

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Degree of heat maintained by the body

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Heat Production

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**Must equal heat loss in order for core temperature to remain normal **produced as a by product of chemical reactions (metabolism) **rate of heat production determined by metabolic rate

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Factors affecting Heat Production

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-activity/age -hormones -psychological well being -nutritional status -body and environmental temperature

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How is heat produced in the body?

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Interaction of metabolism, movement of skeletal muscles and non-shivering thermogenesis

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Basal Metabolic Rate (BMR)

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*Amount of energy used by the body during rest in an awake state

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Basal Condition

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Npo for 12 hours, no exercising after waking, restful nights sleep, environmental temperature 68-80 degrees F and patient relaxed

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BMR Factors

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-varies with age, sex & temperature, increased temp=increased BMR -exercise increases bodys heat production -thyroid hormone metabolism (hyper increases bmr) -sympathetic nervous system increases bmr (fight or flight)

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Heat loss through 4 process:

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1. Radiation 2. Convection 3. Evaporation 4. Conduction

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Radiation

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Objects facing each other are radiating heat towards one another

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Conduction

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Transfer of heat from one object to another through direct contact (heating blanket)

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Convection

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Transfer of heat through currents of air or water (ie fan, open window)

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Evaporation

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Water converted to vapor and lost through the skin (600 ml per day) ie. sweat in response to temperature elevations/ temperature of surroundings is greater than temp of skin surface

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Normal Temperature

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Oral 97.3 F (36.3 C) , in practice 98.6/37 Rectal- 98.6 Core- 97 F (36.1 C-38.2C) -100.8F

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Factors Effecting Body Temp Age:

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-Infants have unstable body temperatures because thermoregulatory mechanisms are immature -Normal temperature drops as a person ages -Chronic illnesses and medications may alter body temp

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Factors Effecting Body Temp Enviroment:

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-Changes in Environment do not effect core temp due to internal regulatory mechanism -However exposure to extreme heat/cold affect body temperature **if a core temp is less than 77 degrees F= DEATH

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Factors Effecting Body Temp Time of Day/Exercise:

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-Body temp fluctuates throughout the day, decreased in am and increased in late afternoon -could be due to circadian rhythm, muscle activity, digestion **Exercise elevates temp due to heat production

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Factors Effecting Body Temp Stress:

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Emotional/Physical stress can increase body temp -stress increases stimulation of the SNS which increases epinephrine/norepinephrine which increases BMR leading to increased heat production

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Factors Effecting Body Temp Hormones:

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-Progesterone (female hormones) increases temp by 1 degree F -Thyroxin: BMR depends on the thyroid hormone Hyper elevates temp and Hypo decreases temp -Epinephrine/Norepinephrine: increases heat production, increase body temp

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Hypothalamus

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"Body's Thermostat" Anterior-heat loss Posterior-heat promoting

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Skin

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-Major role in thermoregulation -Mainly COLD receptors -BV that transport heat from core to surface

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Shivering Mechanism

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-Involuntary motor activity increases body temp via increasing heat production -impulses sent down spinal column to increase muscle tone and shivering occurs from a feedback mechanism

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Sweat Glands

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-located beneath dermal layer -secrete solution (NA & CL)

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Behavioral Response

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-Can help regulate body temperature: -To Increase: more clothes, change room temp, increase physical activity -To Decrease, remove clothes, fan, cooler enviroment

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Other Physiologic Process Factors

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-smoking -oxygen administration -hot/cold drinks (slight change in oral temp, wait 15-30m before taking temp

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Hyperthermia

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-Core temperature increases above acceptable range **dry air w/breeze, can only tolerate 105F for few hrs **humid temp 94F, can only tolerate briefly **can become acclimated to temp, Africa -NEED TO COOL A HYPERTHERMIA VICTIM (cold compresses axillary and groin)

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Hypothermia

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-core body temperature lower than acceptable range -lower the temp, decreases BMR which decreases heat production & further decrease in BMR occurs -temp less than 95 F or 35 C (core) **LESS than 75-77F or 23-24 C=DEATH

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CNS Impairment

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Any condition interfering with the nervous system control over temp regulation (tumor, severed spinal cord)

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Malignant Hyperthermia

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Temp 11-131F or 43.8-55C, elevated heart rate, muscle rigidity

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What is pyrexia?

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Fever, a regulated state in which core temperature is above average

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Low Grade Fever

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98.8-100.6 F or 37-38C

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High Grade Fever

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100.6-105.8F or 39-41C

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Hyperpyrexia

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105.8 F or 41C

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Name for types of fever

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1. intermittent 2. remittent 3. sustained/constant 4. relapsing fever

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Intermittent Fever

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temperature spikes, periods of elevation with periods of normal/below normal temps

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Remittent

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Temp is always elevated but amount of elevation fluctuates >3.6F or 2C

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Sustained/Constant

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Remains elevated

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Relapsing Fever

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Elevated temp for 1-2 days then normal for 1-2 days

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Afebrile

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Without fever

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3 Phases of a febrile episdoe

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1. Initial phase-attempting to increase core, lay on couch/shiver 2. second phase-set point, skin flushed/warm 3. 3rd/crisis phase-fever breaking,fluid deficit, shiver decrease *potential for febrile convulsions if temp elevates

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Heat Cramps

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painful spasms from vigorous exercise leads to altered sodium balance from sweating

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Heat Exhaustion

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Occurs from exercising in heat, leads to water loss and dehydration S/S: BP drops, HR elevates, Cool Skin, SOB

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Heat Stroke Temp? S/S? Tx?

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Temp: 104-109F or 40-42.2C *exposure to increased environmental temps S/S hot dry skin, increased HR, low bp, delirium, dizziness Tx: decrease environmental temp

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Frostbite assessment?

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Bathe immediately in warm water, if not could develop gangrene and need amputation

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Oral/Mouth Temperature

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-Most common route/easily accessible -affected by hot/cold liquids (wait 15-30 min) -placed in posterior sublingual pocket under tongue to L or R -electronic type 2-60 s and glass 3-8 min

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Rectal Temp

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-Most reliable -Contraindicated w/ pts having diarrhea, rectal sx, obstructions, seizures ect. -Insert Adult 1.5", Child 1/2", use lubricants -Electronic type: 20-30 s, glass 3-5 min -Blunt tip to decrease trauma risk

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Axillary

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-least accurate -too many factors may alter readings -used in infants (least traumatic) -electronic type 20-30s, glass 5 min child and adult 9min

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Bladder Temp

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*Good reflection on core body temp *foley catheters used with built in temp probes

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Pulmonary artery Temp

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-catheter placed via heart into pulmonary artery to monitor pressures -VERY ACCURATE FOR CORE MEASUREMENT

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Tympanic Thermometer Placement

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-Child-pull pinna down and back -Adult-pull pinna up and back *insert into ear canal, make sure its snug, press scan button and release cover

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Celsius Formula

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(F-32)5/9

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Fahrenheit Formula

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(9/5 x C) +32

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Normal Rectal Temp

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98.6F, 36.7 C

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Normal Pulmonary Artery Temp

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99.2F, 37.3 C

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Normal Oral Temp

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98F, 36.7C

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Axillary

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97F, 36 C

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Assessment

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-gather data for screening -determine if there is a problem -monitor existing problems -subjective/objective data

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Temp Assessments Dx NANDA approved:

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-hypo/hyperthermia, ineffective thermoregulation, risk for imbalanced body temp

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Implemation

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focus on preventing thermoregulation problems and educate patient to manage/prevent these problems

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Evaluation

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Ongoing process, any revisions or interventions

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