Intro and Temp Flashcards
reflects the physiologic
state which govern the
body’s organs
Vital Signs
temperature, pulse,
respiration, & blood pressure
Vital Signs
What are these?
❖Identify problems
❖Monitor condition
❖Evaluate response/s to intervention/s
❖Basis for clinical problem-solving
❖Part of care in any setting
Purposes of Vital Signs
When to measure VS (there are 9)
- On admission to a health care facility
- When assessing the patient during
home visits - In a hospital on a routine schedule
according to a physician’s or hospital’s
standards of practice - Before and after a surgical procedure
or invasive diagnostic procedure - Before, during, and after transfusion
of blood products - before, during, and after the
administration of medications or
applications of therapies - when the patient’s general
condition changes
-before and after nursing
interventions that influence a VS - when the patient reports
nonspecific symptoms of physical
distress
What is the 1st Guidelines in taking VS?
KNOW THE CLIENT’S NORMAL/ USUAL
RANGE/ LAST MEASUREMENT
what is the 2nd guideline of taking VS?
KNOW THE CLIENT’S MEDICAL HX, THERAPY
& MEDICATION HE IS RECEIVING
CONTROL ENVIRONMENTAL FACTORS THAT
MAY INFLUENCE V/S VALUES
3rd Guideline
MANNER OF APPROACH TO THE CLIENT
MAY ALTER V/S
4th Guideline
What’s the 5th and 6th Guideline?
- MAKE CERTAIN THAT EQUIPMENT IS
FUNCTIONAL & APPROPRIATE - DECIDE FREQUENCY OF VITAL SIGNS
ASSESSMENT
What’s the 7th & 8th Guidelines?
- USE AN ORGANIZED, SYSTEMATIC
APPROACH TO MEASURE VITAL SIGNS - VERIFY & COMMUNICATE SIGNIFICANT
CHANGES
Reflects balance
between the heat
produced and heat lost
from the body
Body Temperature
2 types of temperature
Core & Surface Temperature
What type pf Body Temperature?
- Temperature of the deep tissues of
the body - Remains relatively constant within
a range of 36 C– 37.4 C
CORE
What type of Body Temp?
- Measured in the tympanic or
rectal sites
CORE
Is Core Temperature relatively lower than Surface Temperature?
No, it’s relatively higher
What type of Temperature?
- Temperature of the skin,
subcutaneous tissue and fat - Rises and falls in response to the
environment
Surface
Temperature measured at oral and axillary sites
Surface
What are the 3 regulations of Body Temperature?
- Neural and
vascular control - Maintaining heat
production and
heat loss - Behavioral
control
What happens if your temperature increases?
Sends signal to hypothalamus -> sweating and vasolidation
What happens if your temperature decreases?
sends signal to hypothalamus -> shivering and vasoconstriction
MECHANISMS OF HEAT LOSS
• Transfer of heat by means of waves
• Transfer of heat from one surface to another surface, without contact
Radiation
MECHANISMS OF HEAT LOSS
• Process by which water is converted into steam / vapo
Evaporation
MECHANISMS OF HEAT LOSS
• Transfer / dispersion of heat away by air currents
Convection
MECHANISMS OF HEAT LOSS
• Transfer of heat from one object to another during direct contact
Conduction
adjustments initiated by an individual to
maintain appropriate body temperature
Behavioral Control
What are the 10 factors affecting temperature?
- Environment
- Diurnal variation / circadian rhythm
- Exercise
- Specific dynamic action of food
- Hormonal activity
- Sex
- Age
- Stress
- Illness or injury
10.Medications
Normal Range of Body Temperature (Oral)
Fahrenheit 97.6– 99.6
Celsius 36.5 – 37.4
Normal Range of Body Temperature (Rectal)
Fahrenheit 98.6 – 100.6
Celsius 37.0– 38.1
Normal Body Temperature (Axillary)
Fahrenheit 96.6 – 98.6
Celsius 36.0-37.0
- Body temp. above usual range
- Related terminologies: pyrexia,
fever, febrile vs afebrile - Occurs when heat prod > heat loss
Hyperthermia
T OR F
Hyperthermia is harmful if it stays below 39 C in
adults; 40 C in children
F - Not harmful
Can result from infection, but can
also arise from heat exhaustion
and heat stroke
Hyperthermia
very high fever, occurs at 41 C
Hyperpyrexia
- Body temp. below usual range
- Mainly due to excessive heat loss,
inadequate heat production, or an
from an impaired hypothalamic
thermoregulation
Hypothermia
Types of Hypothermia
Induced & Accidental
- As body temp falls, so are HR, RR
and BP - Chemical reactions are slowed =
decreased O2 demands - Death may occur at temp < 34 C
Hypothermia
What are the 4 Methods/Sites for taking body temp?
- Oral/ by mouth
- Rectal/ from the rectum
- Axilla/ from the armpit
- Tympanic membrane
WHAT TYPE OF METHOD/SITE
• More accessible and convenient
• Most practical clinical preferred method
• Measures around 0.5 C – 0.6 C below core body temp.
• Area under the tongue is in direct proximity to the sublingual artery
• Contraindications: uncooperative, unconscious, very young, shivering, prone to
seizures, mouth breather, post mouth surgery patients
Oral Site
What type of method/site
• Most accurate and reliable
• Differs about 0.1 C from core body temperature
• Done for newborns to also check for an imperforate anus
• Contraindications: rectal surgery, diarrhea or hemorrhoids and other diseases
of the rectum
Rectal Site
What type of method/site is used for taking body temp for newborns?
Rectal Site
What type of Method/Site
• Safe and non-invasive
• Preferred site for newborns because it is safe and accessible
• Less potential for spreading microorganisms
• Thermometer must be left in place longer to obtain an accurate measurement
• Make sure that the area is dry and not wet with perspiration, deodorants,
cream, or the like; do not rub the area dry vigorously as friction will increase
the temperature
Axillary Site
What type of Method/Site
• Readily accessible; reflects core body temperature; very fast
• Can be uncomfortable and may injure the membrane if probe inserted too far
• Presence of cerumen can affect reading
• Right and left measurements can differ
• Must employ proper technique when straightening the ear canal for children
below 3 years old (back & down) and children above 3 years old (back & up)
Tympanic Membrane
What direction is used to get body temperature in tympanic membrane for adults?
Up and Back
Direction used to get body temp in tympanic membrane for children
Down and back
Recommended placement time per site for glass thermometers
Oral 3 minutes
Rectal 2-3 minutes
Axillary 5 minutes
➢ Looks like a glass thermometer & can be used at oral, axillary, and rectal sites
➢ It has a sensing tip at the end of the stem, an on/off button, and a display that
lights up during use.
➢ It takes 1-60 seconds to measure body temperature, depending on the site and
product used.
➢ Needs to wipe rather than soaked with alcohol when cleaning
Digital Thermometer
➢ Has a temperature sensitive probe covered with a disposable sheath and
attached by a coiled wire to a display unit
➢ Has probes for oral / axillary as well as rectal use
Electronic Thermometer
➢ Uses infrared technology that detects
warmth radiating from the eardrum
➢ Probe is covered with a probe cover
prior insertion to the ear canal
➢ Ready may take 1-3 seconds
Tympanic / Infrared Thermometer
➢ Varies from liquid crystal dots, bars,
or heat-sensitive tape / patches that
change color
➢ Can be reused several times
Chemical Thermometer
Thermometer that are used for temples
Temporal Thermometer
Thermometer that are mostly used for babies
Pacifier Thermometer
3 equipment for measure body temp
- Thermometer
- Automated Monitoring Devices
- Continuous Monitoring Devices
Freezing & Boiling Point in Fahrenheit
freezing point @ 32 F & boiling point of water @ 212 F
Freezing and Boiling point of water in Celsius
freezing point @ 0 C & boiling point of water @ 100 C
Conversion of Celsius to Fahrenheit
multiply by 9/5 & add 32
Conversion of Fahrenheit to Celsius
subtract 32 & multiply by 5/9
Common Measurement of Temperature
- Using a glass thermometer
a. oral
b. rectal
c. axillary - Using a tympanic thermometer
- Using a digital thermometer
a. Oral
b. rectal
c. axillary
