CHAPTER FIVE VITAL SIGNS
1. Intermittent fever: the body temperature alternates at regular intervals between periods of fever and periods of normal or
2. Remittent fever: a wide range of temperature fluctuation (more than 2 0c) occurs over the 24 hr period, all of which are above normal
3. Relapsing fever: short febrile periods of a few days are interspersed with periods of 1 or 2 days of normal temperature.
4. Constant fever: the body temperature fluctuates minimally but always remains above normal
Factors Affecting Body Temperature 1. Age
• Children’s temperature continue to be more labile than those of adults until puberty
• Elderly people, particularly those > 75 are at risk of hypothermia
• Normal body temperature of the newborn if taken orally is 37 0C.
2. Diurnal variations (circadian rhythms)
• Body temperature varies through out the day
• The point of highest body temperature is usually reached between 8:00 p.m. and midnight and lowest point is reached during sleep between 4:00 and 6:00 a.m.
3. Exercise
• Hard or strenuous exercise can increase body temperature to as high as 38.3 – 40 c – measured rectally
4. Hormones
• In women progesterone secretion at the time of ovulation raises body temperature by about 0.3 – 0.6oc above basal temperature.
5. Stress
• Stimulation of skin can increases the production of epinephrine and nor epinephrine – which increases metabolic activity and heat production.
6. Environment
• Extremes in temperature can affect a person’s temperature regulatory systems.
Measuring Body Temperature
Sites to Measure Temperature Most common are:
• Oral
• Rectal
• Axillary
• Tympanic
Thermometer: is an instrument used to measure body temperature
Types
1. Oral thermometer
• Has long slender tips 2. Rectal thermometer
• Short, rounded tips 3. Axillary
• Long and slender tip 4. Tympanic
In other way it is also divided as mercury, digital and electronic types. In developed countries, mercury type thermometers are no more use in hospital setup but in our context still very important.
1. Rectal Temperature:
Readings are considered to be more accurate, most reliable, is >
0.650 c (1 0F) higher than the oral temperature.
Procedure
• Explain the procedure to the patient
• Wash hands and assemble necessary equipment and bring to the patient bedside.
• Position the person laterally;
• Apply lubricant 2.5 cm above the bulb;
• Insert the thermometer 1.5 – 4 cm into the anus. For an infant 2.5cm, for a child 3.7 cm – for an adults 4 cm
• Measured for 2-3 minutes
• Remove the thermometer and read the finding
• Clean the thermometer with tissue paper
• A rectal thermometer record does not respond to changes in arterial temperature as quickly as an oral thermometer
Contraindications
• Rectal or perineal surgery;
• Fecal impaction – the depth of the thermometer insertion may be insufficient;
• Rectal infection;
• Neonates –can cause rectal perforation and ulceration;
2. Oral
Procedure
• Explain the procedure to the patient
• Wash hands and assemble necessary equipment and bring to the patient bedside.
• Position the person comfortably and request the patient to open the mouth;
• Hold the thermometer firmly with the thumb and fore finger; shake it with strong wrist movements until the mercury line falls to at least 35 oc .
• Place the bulb of the thermometer well under the client’s tongue. Instruct the client to close the lips (not the teeth) around the bulb. Ensure that the bulb rests well under the tongue, where it will be in contact with blood vessels close to the surface.
• Remove the thermometer after 3 to 5 minutes, according to the agency guidelines.
• Remove the thermometer, wipe it using it once a firm twisting motion
• Hold the thermometer at eye level. Read to the nearest tenth
• Dispose the tissue. Wash the thermometer in lukewarm, soapy water. Dry and replace the thermometer in a container at bedside. Wash your hands.
• Record temperature on paper or flow sheet. Report an abnormal reading to the appropriate person.
Contraindication
• Child below 7 yrs
• If the patient is delirious, mentally ill
• Unconscious
• Uncooperative or in severe pain
• Surgery of the mouth
• Nasal obstruction
• If patient has nasal or gastric tubs in place
4. Axillary Procedure
• Wash hands
• Make sure that the client’s axilla is dry, If it is moist, pat it dry gently before inserting the thermometer.
• After placing the bulb of the thermometer in to the axilla, bring the client’s arm down against the body as tightly as possible, with the forearm resting across chest.
• Hold the glass thermometer in place for 8 to 10 minutes. Hold the electronic thermometer in place until the reading registers directly
• Remove and read the thermometer. Dispose of the equipment properly. Wash hands
• Record the reading
N.B. The axillary method is safest and most noninvasive.
Tympanic Temperature
The tympanic temperature is placed snugly in to the client’s outer ear canal. It records temperature in 1 to 2 seconds. Many pediatric and intensive care units use this type of thermometer because it records a temperature so rapidly.
Procedure
• Wash the hands
• Explain the procedure to the client to ensure cooperation and understanding
• Hold the probe in the dominant hand. Use the client’s same ear as your hand (e.g. use the client’s right ear when you use your right hand).
• Select the desired mode of temperature. Use the rectal equivalent for children under 3 years of age Wait for “ready”
message to display.
• With your nondominant hand, grasp the adult’s external ear at the midpoint. Pull the external ear up and back. For a
child of 6 years or younger, use your nondominant hand to pull the ear down and back.
• Slowly advance the probe in to the client’s ear with a back and forth motion until it seals the ear canal.
• Point the probe’s tip in an imaginary line from the client’s sideburns to his or her opposite eyebrow.
• As soon as the instrument is in correct position, press the button to activate the thermometer.
• Keep the probe in place until the thermometer makes a sound or flashes a light.
• Read the temperature and discard the probe cover. Replace the thermometer and wash your hands.
• Record the temperature on the client’s record.