Vital Signs

VITAL SIGNS
o Under the tongue, beside the

frenulum (right or left)
Total Time:
o Two (2) to three (3) minutes
TEMPERATURE
Oral
Axillary
Rectal
Oral Method
Most convenient
Most accessible
Nursing Alert!
o Applicability is for children
aged six (6) years and above
o Not applicable for children
below six (6) years old
Contraindicated in patients with:
o Oral surgery
o Mouth breathers
o History
of
convulsive
seizures
o Unconscious
o Incoherent
o Irrational
o Mentally disrupted
o Insane
Procedure
o Nothing Per Orem for about
thirty (30) minutes before
taking temperature
o No food intake
o No drinks
o No smoking
o No chewing gum
o No whistling
o No gargling
Rationale:
o Any of the above would alter
the result
Placement:
Axillary Method
Least realiable
Safest method
Nursing Alert!
o During application, be sure
that axilla is dry
o Dry using a patting motion
Nursing Alert!
o Do NOT RUB!!!
Rationale:
o This increases heat due to
friction
o Rubbing increases blood
supply to the area
o Therefore, there will be
increase
in
temperature
reading
o Rubbing provides a falsepositive
elevation
of
temperature reading
Duration:
o In adults nine (9) minutes
o In children five (5) minutes
Rectal Method
Most reliable (except for tympanic
thermometer)
Most accurate (except for tympanic
thermometer)
Concept!
o If tympanic method is used
using
a
tympanic
thermometer,
the
rectal
method is only second most
reliable and second most
accurate
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Disadvantage:
o Placement on a different site
yields a different reading
o Therefore, ensure that the
bulb
of
the
rectal
thermometer rests on the
mucous membrane
Contraindications:
o Hemorrhoids
o Rectal Surgery
o Certain Cardiac ailments due
to stimulation of the vagus
nerve; valsalva maneuver
leads to arrhythmias
Position of Patient when taking the
reading:
o Sims left position
o Sims right position
o For Newborn, lift up ankles
to keep buttocks up
o In Toddlers, set on prone
position on adults lap
Duration:
o Two (2) minutes
Conversion of Centigrade to Fahrenheit

Centigrade = (5/9)F 32
Centigrade = (F/1.8) 32
Conversion of Fahrenheit to Centigrade

Fahrenheit = (9/5)C + 32
Fahrenheit = (1.8)C + 32
Concepts!!!
Peak body temperature occurs at
12NN to 3PM or 4PM
Lowest body temperature occurs in
the early morning hours of the day
FEVER
Normally, the hypothalamus is able
to adjust body temperatures between
37C to 40C
But due to the presence of pyrogenic
materials like the following:
o Pathogenic microorganisms
o Toxins
o Foreign substances
o Any substance capable of
increasing body temperature
Creates a deficiency of -3C, making
a person enter the FIRST STAGE OF
FEVER
First Stage of Fever

Typical signs and symptoms indicate
the bodys compliance mechanism to
increase and conserve heat:
o Chills
o Shivering
o Gooseflesh
Contraction
of
arectores pilorum or
pilo arecti muscles
o Vasoconstriction
Decreases
blood
supply to the skin
Pallid Skin
o Cyanotic nail beds
Key Concept!!!
o Patient complains of feeling
cold
o Sweating will stop because
body will minimizes heat loss
Also called:
o Onset Stage
o Chill Stage
o Cold Stage
2
This stage is characterized by low

febrile temperatures
Nursing Management
o Key Concept
Aim is to minimize
heat loss
o Key Concept
Do
NOT
apply
TEPID
SPONGE
BATH because this
would make patient
progress to SHOCK
Provide additional clothing as
necessary
Provide additional blankets as
necessary
Provide something warm to drink
These measures would result to a
gradual increase in body temperature
Question:
o When
will
you
start
application of TSB?
Answer:
o If there is a 1C to 2C
increase in body temperature
Second Stage of Fever

Also called:
o Coarse Stage of Fever
o Peak Stage of Fever
Key Concept!
o Patient does not feel hot or
cold
o Skin is warm to touch
o Skin is flushed
o Fever blisters are present
Herpetic lesions
o Absence of shivering
o Possible dehydration
Important Concept!!!
o For every increase of
temperature, there is a
corresponding increase in
pulse rate
Rationale:
o Increase
in
temperature
results in an increase in pulse
rate due to
increased
metabolic rate
o Increased metabolic rate
increases oxygen demand
o Due to increased oxygen
demand of susceptible brain
cells,
CONVULSIVE
SEIZURES
may
occur.
These may also be due to
irritation of nerve cells
FEBRILE CONVULSIONS
Increased oxygen demand also leads
to an increase in respiratory rate
Patient complains of:
o Loss of appetite
o Myalgia or muscle pains due
to increased catabolism
Nursing Management
o Tepid Sponge Bath
o Cooling Bed Bath
Tepid Sponge Bath

Temperature of water is 32C
o This
temperature
is
maintained
throughout
the procedure
How to apply:
o Done by patting
Rationale:
o To avoid friction, which
increases temperature
Important Concept!
o Do NOT use ALCOHOL
when applying TSB
Rationale:
o Alcohol dries the skin and
leads to irritation
Key Concept!
3
o TSB should not be done

hurriedly
Rationale:
o When done hurriedly,
TSB
will
stimulate
shivering
o Shivering would lead to
increased muscle activity
o Increased muscle activity
would lead to increased
temperature
3. Relapsing Fever
Short periods of febrile episodes
alternated by one (1) to two (2)
days of normal temperature
4. Constant Fever
Minimal
fluctuations
of
temperature, all of which are
ABOVE NORMAL
Cooling Bed Bath

Water temperature will start at
32C
Procedure will go on with
gradual decrease in water
temperature until it is maintained
at 18C
Therefore, to achieve this drop in
temperature, utilize ice
Same procedure of application as
in Tepid Sponge Bath
Types of Fever
5. Staircase or Spiking Fever

Common in patients
TYPHOID FEVER
with
PULSE ASSESSMENT
Concepts!
1. Intermittent Fever
A fever that is alternated at
regular intervals by periods of
normal
and
subnormal
temperature
2. Remittent Fever
Fever alternated by wide range of
fluctuations in temperature, all of
them are ABOVE NORMAL.
Duration is within a 24-hour
period
If pulse is regular, count or

monitor pulse for thirty (30)
seconds and multiply by two (2).
This is legal!
If pulse is irregular, count or

monitor the pulse for one (1)
FULL minute
Assessment of the Pulse Deficit

This is the most accurate method
Involves two nurses using one watch
Starts at the same time
4
Ends at the same time

Comparison of results ensues
Count is done for one (1) full minute
Scale in Pulse Assessment
0 - Absent or cannot be felt

1+ - Weak or thready
2+ - Normal
3+ - Grounding
BLOOD PRESURE
Systolic
Produced by ventricular contraction
Pressure on blood vessels during
depolarization
or
ventricular
contraction
Diastolic
Pressure that remains in the walls of
the blood vessels during relaxation
or repolarization or resting
Broadly two (2) types:

Direct
o By insertion of a catheter
Indirect Method
o Auscultatory method
o Palpatory method
o Flush Method
Auscultatory Method
Uses Korotkoff sound
o A popping sound
o NOT the heart beat
o It is a phenomenon an
unknown phenomenon!
Determining Amount of Inflation

Using auscultatory method
o Ask patient what is his last
BP reading and then add 30
40 mmHg from last systolic
reading.
o Deflate gradually rate is
approximately 2 3 mmHg
per second
Alternative auscultatory method
o Auscultate for the last sound
as you go up. Then add 30
40 mmHg
o Then deflate
Tripartite Blood Pressure

Done if patient is an adult.
Example:
140 mmHg systolic first loudest
sound
100 mmHg 1st diastolic muffling
70 mmHg 2nd diastolic last sound
o Therefore, the tripartite blood
pressure is 140 / 100 / 70
If there is no muffling, an example
would be:
o 160 / no muffling / 110
Concepts!!!
5
Take systolic on loudest sound if

patient is an adult
If patient is pediatric or up to ten
(10) years old, take the first sound,
whether it is faint or loud
If, for example, first sound is at 190
mmHg and there is silence up to 140
mmHg and then there is a sound at
130 mmHg down to 80 mmHg
then
Use the PALPATORY METHOD in
combination
with
the
AUSCULTATORY
METHOD
because there is an auscultatory gap
Repeat using:
Auscultatory method
Palpatory method
How to do the Palpatory Method

Inflate
o Determine up to what point
to inflate
o Palpate pulse
o If pulse is absent, add 30 40

mmHg
Deflate
o First palpable pulse is true
systolic pressure
For diastolic pressure, proceed using
the auscultatory method
Flush Method
Represents the mean blood pressure
Represents the average of the
systolic and diastolic pressures
When done:
o When you have a BP
apparatus
without
a
stethoscope
o Used for pediatric patients
How done:
o Inflate up to the point where
extremity becomes pale
o Deflate slowly and look for a
REBOUND FLUSH when
extremity becomes red again
This is the true reading!!
Note that there is only ONE
reading!!!
6

Vital Signs

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VITAL SIGNS

o Under the tongue, beside the

Conversion of Centigrade to Fahrenheit

Conversion of Fahrenheit to Centigrade

First Stage of Fever

This stage is characterized by low

Second Stage of Fever

Tepid Sponge Bath

o TSB should not be done

Cooling Bed Bath

5. Staircase or Spiking Fever

If pulse is regular, count or

If pulse is irregular, count or

Assessment of the Pulse Deficit

Ends at the same time

Scale in Pulse Assessment

0 - Absent or cannot be felt

Broadly two (2) types:

Determining Amount of Inflation

Tripartite Blood Pressure

Take systolic on loudest sound if

How to do the Palpatory Method

o If pulse is absent, add 30 40

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