A person’s body temperature says a lot about their health. For example, a fever is the most common form of increased body temperature. Show
Reasons for measuring body temperatureMeasuring body temperature is very important in medicine. A number of diseases are characterised by a change in body temperature. With other illnesses, the course of the disease can be followed by measuring body temperature. This allows the doctor to analyse the effectiveness of treatments based on body temperatures. A fever is the reaction to a disease-specific stimuli. The body changes its normal temperature to support the body’s own defence mechanisms. Fever is the most common form of disease-related (pathological) increase in body temperature. Important information for taking the measurementThe measured body temperature always depends on which part of the body the measurement was taken from. For this reason, and contrary to popular opinion, there is no general normal temperature. The body temperature of a healthy person also changes throughout the day and depending on what activities they undertake. With a rectal temperature measurement, the body temperature is normally 0.5 degrees Celsius higher in the evening than other times of the day for physiological reasons. In addition, body temperature is increased by any physical exertion. A fundamental distinction is made between:
Further information about human fever See our articlesCustomer supportContact customer support if you would like our friendly agents to help you resolve your issues. find support IntroductionThe measurement and recording of the vital signs is the first step in the process of physically examining a patient - that is, in collecting objective data about a patient's signs (i.e. what the nurse can observe, feel, hear or measure). This is a fundamental skill for nurses working in all clinical areas, but one which only develops with practice. This chapter introduces the knowledge and skills required by nurses to accurately measure and record a patient's vital signs - that is, their blood pressure (BP), pulse or heart rate (HR), temperature (T°), respiratory rate (RR) and blood oxygen saturation (SpO2). This chapter begins with an introduction to the importance of measuring the vital signs in nursing practice. It goes on to describe the measurement of each of the vital signs and the collection of other supporting data (e.g. height, weight, pain score), discussing key strategies and considerations. The chapter then reviews the processes involved in recording the data collected about the vital signs. Finally, the chapter discusses how a nurse should go about interpreting the data they have obtained, to build a clinical picture of the patient and plan for their care. Learning objectives for this chapterBy the end of this chapter, we would like you:
Important noteThis section of the chapter assumes a basic knowledge of human anatomy and physiology. If you feel you need to revise these concepts, you are encouraged to consult a quality nursing textbook.
Get Help With Your Nursing Essay If you need assistance with writing your essay, our professional nursing essay writing service is here to help! Find out more Measurement and recording of the vital signsAs described in the introduction of this chapter, the measurement and recording of the vital signs is a fundamental skill for nurses working in all clinical areas. The vital signs - blood pressure (BP), pulse or heart rate (HR), temperature (T°), respiratory rate (RR) and blood oxygen saturation (SpO2) - provide baseline indicators of a patient's current health status. It is important to note that some nurses measure and record the vital signs at the commencement of the physical examination, while others integrate the collection of vital signs data into the physical examination; either approach is fine, provided the nurse is systematic in the way in which they approach their assessment, and so collects accurate and complete health data. As you saw in the previous chapter of this module, health observation and assessment involves three concurrent steps:
The measurement and recording of the vital signs is the first step in the process of physically examining a patient. This step involves collecting objective data - that is, data about a patient's signs (i.e. what the nurse can observe, feel, hear or measure). Data collected during the physical examination, including measurements of the vital signs, is combined with that collected during the health history (as described in the previous chapter of this module), to build a complete picture of the clients' health status. The normal parameters for each of the vital signs of healthy adults are listed following:
Nurses should become thoroughly familiar with the parameters for each of the vital signs. However, it is important for nurses to remember that these are average values for healthy adults. Some adults may have values which fall outside of these ranges. For example, very fit adults may have a pulse or heart rate which normally sits at or below 60 beats per minute; similarly, adults with respiratory conditions often have an oxygen saturation which normally sits well below 98%. Children and neonates have differing normal parameters for each of the vital signs; nurses who work with these patient groups must become familiar with these. When interpreting vital signs, it is important that nurses use critical thinking to interpret the entire clinical picture of the individual patient with whom they are working. Measurement of blood pressureBlood pressure is often abbreviated to 'BP'. Blood pressure uses two measurements, each recorded in millimetres of mercury (mmHg) - for example, 120mmHg / 80mmHg, often abbreviated to 120/80. Blood pressure is defined as the pressure of the blood against the arterial walls:
Essentially, blood pressure is a measurement of the relationship between: (1) cardiac output (the volume of blood ejected from the heart each minute), and (2) peripheral resistance (the force that opposes the flow of blood through the vessels). Blood pressure also depends on factors such as the velocity of the blood, the intravascular blood volume and the elasticity of the vessel walls, etc. The difference between the systolic and diastolic blood pressures is referred to as the pulse pressure. This normally ranges between 30mmHg and 40mmHg. Blood pressure can be measured in a number of different ways. It is measured directly by inserting a small catheter into an artery - however, as a very invasive procedure, this strategy is typically only used for patients who are critically ill and for whom blood pressure is very difficult to measure accurately. In all other settings, blood pressure is measured indirectly using: (1) a sphygmomanometer and a stethoscope (a 'manual' measurement), or (2) a non-invasive blood pressure monitor (an 'automatic' measurement). This section of the chapter will teach both methods.
The manometer - the device used to read the blood pressure measurement - should be positioned at the nurse's eye level. The valve on the pressure bulb should be closed by turning it clockwise. Avoid closing the valve too tightly, or it may be too difficult to release when the time comes to do so. Place the stethoscope over the patient's brachial pulse, and hold it with your non-dominant hand. Place the binaurals (earpieces) of the stethoscope in your ears. Using your dominant hand, inflate the cuff to around 180mmhg (note that you may need to go higher if the patient's systolic blood pressure is >180mmHg, however this is rare). Then, release the valve to deflate the cuff, slowly and steadily (around 2 to 3mmHg per second to reduce measurement errors). You are listening for two things:
Once these two measurements have been made, the cuff should be completely deflated and removed from the client's arm. The two blood pressure readings should be promptly recorded.
It is important to highlight that although automatic blood pressure measurements are quick and convenient, they are not as accurate as manual blood pressure measurements. If a non-invasive blood pressure monitor returns a reading which is outside the expected parameters, it should always be checked with a manual measurement. Furthermore, it is worth noting that a cuff must fit correctly on a patient's arm, and be placed correctly so the bladder of the cuff is above the brachial artery, if a non-invasive blood pressure monitor is to return an accurate reading. As described in the above section, the upper arm is the most common site to measure blood pressure; however, if this is not possible, blood pressure may also be measured from the thigh. Research suggests that the systolic blood pressure is slightly higher in the leg than in the arm, but the diastolic blood pressures are roughly similar. Blood pressure is taken on the thigh using the same technique described above. In some cases, a patient may have their blood pressure taken a number of times in a number of positions (e.g. lying, sitting, standing). This is done to assess the client for orthostatic hypotension. This occurs when there is a 20 to 30mmHg drop in blood pressure when the client changes positions, and it may indicate health problems. It is important for nurses to note that there are a number of common errors associated with blood pressure measurement. Errors may result if:
As described above, the majority of the common errors associated with blood pressure measurement are related to the size and position of the cuff. Blood pressure cuffs come in a variety of sizes, and it is essential that nurses select the correct size for the individual patient with whom they are working - if the cuff is too large, blood pressure will be underestimated, and if it is too small, blood pressure will be overestimated. Ideally, the width of the cuff should be 40% of the circumference of the limb from which the blood pressure is being measured, and the bladder within must encircle at least 80% of the limb. As you saw in an earlier section of this chapter, the average blood pressure of a healthy adult is 120mmHg/80mmHg, typically written as 120/80. When measuring a client's blood pressure, a nurse may identify that it is high - a condition referred to as hypertension, or low - a condition referred to as hypotension. There may be a number of pathophysiological causes of hypertension (e.g. brain injury, systemic vasoconstriction, fluid retention, etc.) and hypotension (e.g. fluid / blood loss, dehydration, etc.). It is important for nurses to recognise that there are also a number of physiological factors which affect blood pressure measurement; for example, recent exercise, feeling anxious or angry, experiencing pain, ingesting caffeine or tobacco, and obesity can all result in a patient recording higher than normal blood pressure. Remember: when interpreting vital signs, it is important that nurses use critical thinking to interpret the entire clinical picture of the individual patient with whom they are working. Get Help With Your Nursing Essay If you need assistance with writing your essay, our professional nursing essay writing service is here to help! Find out more Measurement of pulse or heart ratePulse or heart rate is often abbreviated to 'HR'. It is defined as the number of times a person's heart beats in a one-minute period. It is recorded at a rate of 'beats per minute'. Each contraction of the heart results in the ejection of blood into the vascular system, and this is felt in key locations of the body as a 'pulse'. In addition to assessing the rate at which a person's heart is beating, when measuring a person's HR, a nurse should also assess for the rhythm and quality of the pulse. A patient's pulse may be measured using the same types of non-invasive, automatic monitors used to measure blood pressure, as described in the previous section of this chapter. However, it is generally preferred that heart rate is assessed by palpating a pulse, and it is this technique which will be taught in this chapter. To measure a pulse, a nurse should place their fingers over an artery and feel for the pulse. Generally, pulses are palpated with the pads of the index and middle fingers. Firm pressure is applied to the pulse, but not so much pressure that the artery is occluded. There are a number of locations on the body in which a nurse may palpate an artery to feel for a pulse; the most common are:
It is important for nurses to note that a patient's heart rate can also be assessed by auscultating the heart. This is referred to as measuring the apical pulse. When measuring the HR, a nurse may:
As described, it is important that a nurse assesses the pulse for regularity. If the pulse is irregular (i.e. the time between each beat varies, or beats are skipped, etc.), the pulse must be counted for one full minute (60 seconds). Additionally, an irregular pulse must be documented when recording the vital signs. It is also important that the nurse assess the quality of the pulse - that is, its key characteristics. A patient's pulse may be described using terms such as thready (meaning the pulse is 'weak') or bounding (meaning the pulse is 'full' and 'strong'). This is important information that is used, along with HR and regularity of the pulse, to assess the health of the cardiovascular and other body systems. The average pulse or heart rate for a healthy adult is 60 to 100 beats per minute. If a patient's pulse is >100 beats per minute, this is referred to as tachycardia; pain, infection, dehydration, stress, anxiety, thyroid disorder, shock, anaemia, certain heart conditions, etc. can all result in tachycardia. If a patient's pulse is <60 beats per minute, this is referred to as bradycardia; cardiac conduction defects, overdose (e.g. central nervous system depressants), head injury, severe hypoxia (with impending respiratory / cardiac arrest), shock, etc. can all result in bradycardia. Measurement of temperatureTemperature is often abbreviated to 'T°'. This is defined as the temperature, in degrees Celsius (°C), of a person's body. Temperature is typically measured using a thermometer, which may be either automatic or manual. Temperature may be measured by one of several different routes:
When using an automatic or electronic thermometer to record a patient's temperature, the nurse should place the thermometer in the location on the patient's body at which the temperature is to be recorded, press 'start', and wait for an audible signal and the measurement to register on a display screen. If using a manual thermometer, the thermometer must be located on the patient's body as described, and the nurse must wait at least one full minute before reading the measurement on the gauge of the thermometer. It is worth noting that manual thermometers are rarely used in most clinical settings in the United Kingdom. The average temperature for a healthy adult is 36.5°C to 37.5°C. If a patient's temperature is >37.5°C, they are said to have hyperthermia or a fever. If a patient's temperature is <36.5°C, they are said to have hypothermia. Causes of variations from normal temperature include infection, stress, dehydration, recent exercise, being in a hot or cold environment, drinking a hot or cold beverage, and thyroid disorders. Measurement of respiratory rateRespiratory rate is often abbreviated to 'RR'. This is defined as the number of times a person inhales and exhales in a 1 minute period. It is recorded at a rate of 'breaths per minute'. Respiratory rate is typically measured by counting the number of times a patient completes a full ventilatory cycle (inhalation plus exhalation) in a 1 minute period. This can be measured by watching the rise and fall of the patient's chest and / or abdomen, or (though less commonly) the breath sounds may also be auscultated. It is best that nurses measure a patient's respiratory rate when the patient is unaware that they are doing so, as this will prevent the patient unconsciously (or even consciously!) changing the way they breathe. When measuring the RR, a nurse may:
In addition to assessing a patient's heart rate, the nurse should assess:
The average respiratory rate for a healthy adult is 10 to 16 breaths per minute. If a patient's RR is >16 breaths per minute, this is referred to as tachpynoea; this may result from cellular hypoxia, acidosis, conditions that interfere with gas exchange / ventilation / perfusion (e.g. pulmonary oedema, pneumonia, pulmonary embolism), shock, pain, anxiety, asthma, respiratory disease, cardiac disease, etc. If a patient's RR is <10 breaths per minute, this is referred to as bradypnoea; this may result from head injury, stroke, overdose (particularly of central nervous system depressants), respiratory failure, etc. Measurement of blood oxygen saturationBlood oxygen saturation is often abbreviated to 'SpO2'. This is defined as the amount of oxygen present in a person's blood - specifically, bound to their haemoglobin - at a given time. It is measured as a percentage, using a non-invasive automatic measuring device called a pulse oximeter. The probe of a pulse oximeter is usually placed on the end of a patient's finger or toe or, less commonly, on their earlobe or their nose. A reading is given on the machine's screen after a period of approximately 15 seconds. The blood oxygen saturation of a healthy adult is typically 98%-100%. A variety of problems, particularly those related to the respiratory and cardiovascular systems (refer to the information on HR and RR, above), can result in a patient's blood oxygen saturation reducing below this normal range. Measurement of height, weight and body mass index (BMI)Although not strictly vital signs, a patient's height, weight and - subsequently - their body mass index (BMI) can provide a nurse with important information about their overall health and physical condition. A patient's weight is measured using a scale, whilst their height is measured using a platform ruler or tape measure. Body mass index can then be calculated, using the following formula: BMI = Weight (kg) / Height (m)2 It is worth noting that most clinical areas have charts which assist nurses to calculate BMI. BMI is a useful, objective measurement of a person's body condition, based on their unique height and weight. A patient's BMI is interpreted as follows:
It is worth noting that the accuracy of the BMI measurement - and, therefore, its utility in the clinical context - is subject to much conjecture. As always, it is important that nurses use critical thinking to interpret the entire clinical picture of the individual patient with whom they are working. Measurement of painIn many clinical areas, pain is considered the sixth 'vital sign'. Pain is generally assessed using a strategy which can be remembered using the 'OPQRST' mnemonic
It is also important to highlight that there are a number of visual scales which can be used to assess pain in patients who are non-verbal. In patients who cannot describe their pain or communicate that they are experiencing pain, nurses should look for other signs of pain - such as restlessness, agitation, tachycardia, diaphoresis, pallor, etc. Recording the vital signsSo far, this chapter has described in detail the processes involved in measuring a patient's vital signs. Once these have been measured, the information must be documented so that it can be used to: (1) assess the patient's condition, and (2) inform the care which is appropriate for that patient. As you saw in a previous chapter of this module, there are a variety of different ways that data can be recorded, and this generally differs between clinical settings and organisations; nurses are encouraged to familiarise themselves with the documentation strategies used in the organisation where they work. Regardless of how data is recorded, however, documentation must be complete, accurate, concise, legible and free from bias. You should revise the principles of documenting health observation and assessment data from the earlier chapter of this module, if required. Often in the United Kingdom, a patient's vital signs are recorded using early warning score tools. These pieces of documentation allow a nurse to graphically represent a patient's vital sign measurements to identify changes over time, and to calculate simple scores which describe a patient's risk of deterioration into serious illness. Early warning score tools may also provide a nurse with information about how they should respond if they identify that a patient's vital signs are outside the expected ranges - for example, by increasing the frequency of monitoring, by requesting a medical review or by initiating an emergency call. Interpreting the vital signsOnce you have measured and recorded a patient's vital signs, it is important that you are able to analyse and interpret the data you have collected. Essentially, this means attempting to understand and make sense of this data, based on the patient's physiological condition. Remember: it is important that nurses use critical thinking to interpret the entire clinical picture of the individual patient with whom they are working. Let's consider a case study example: ExampleElizabeth is a graduate nurse working in the Accident and Emergency Department (A&E) of a large tertiary hospital in London. She is caring for a young man, Luke, who has been transported by road ambulance following a high-speed motor vehicle accident. Luke has an open, mid-shaft femoral fracture which is bleeding heavily. Whilst receiving handover from the paramedics who attended the scene, Elizabeth measures Luke's vital signs, finding:
The paramedics estimate that Luke has lost 1000mL of blood. Elizabeth analyses and interprets this assessment data. She knows Luke has lost a significant amount of blood, which is likely to result directly in his low BP. Luke's high HR and RR are probably to compensate for his low blood pressure (i.e. his heart beats faster, and he breathes more rapidly, in an attempt to increase perfusion to his organs). Luke's high HR and RR may also be a response to the significant pain he is likely to be experiencing, and also shock at the situation in which he finds himself. In analysing and interpreting her measurements of Luke's vital signs in this way, Elizabeth can plan effective care for Luke. She also has a baseline which she can use to evaluate the effectiveness of the care provided. It is important to remember that learning to measure and record a patient's vital signs accurately, and to analyse and interpret the data collected, are skills which comes with practice. As a student and new graduate nurse, it is essential that you take every possible opportunity to practice collecting, recording and interpreting the vital signs of a variety of different patients, in a range of different clinical settings. Get Help With Your Nursing Essay If you need assistance with writing your essay, our professional nursing essay writing service is here to help! Find out more ConclusionAs you have seen in this chapter, the measurement and recording of the vital signs is the first step in the process of physically examining a patient - that is, in collecting objective data about a patient's signs (i.e. what the nurse can observe, feel, hear or measure). This chapter began with an introduction to the importance of measuring the vital signs in nursing practice. It went on to describe the measurement of each of the vital signs and the collection of other supporting data (e.g. height, weight, pain score), discussing key strategies and considerations. The chapter then reviewed the processes involved in recording data collected about the vital signs. Finally, the chapter discussed how a nurse should go about interpreting the data they have obtained, to build a clinical picture of the patient and plan for their care. In completing this chapter, you have become equipped with the knowledge and skills you require to accurately measure and record a patient's vital signs. ReflectionNow we have reached the end of this chapter, you should be able:
Reference listCox, C. (2009). Physical Assessment for Nurses (2nd edn.). West Sussex, UK: Blackwell Publishing, Ltd. Jensen, S. (2014). Nursing Health Assessment: A Best Practice Approach. London, UK: Wolters Kluwer Publishing. Wilson, S.F. & Giddens, J.F. (2005). Health Assessment for Nursing Practice (4th edn.). St Louis, MI: Mosby Elsevier. Reference Copied to Clipboard. Reference Copied to Clipboard. Reference Copied to Clipboard. Reference Copied to Clipboard. Reference Copied to Clipboard. Reference Copied to Clipboard. Reference Copied to Clipboard. Which is the most accurate and reliable means of taking body temperature?Rectal measurement. Taking a rectal measurement is the most reliable way to obtain a core temperature value. Result variation with this type of measurement is low and the precision is particularly high. The normal temperature range is approximately between 36.6 °C and 38.0 °C.
How should nurse ensure that the temperature measured reflects the core body temperature?By ear. A special thermometer can quickly measure the temperature of the eardrum, which reflects the body's core temperature (the temperature of the internal organs). By skin. A special thermometer can quickly measure the temperature of the skin on the forehead.
When taking an oral temperature the nurse should place the thermometer in which location?Oral Temperature
Take the temperature a different way. Place the tip of the thermometer in your child's mouth, under the tongue and close to the middle (Picture 3). Tell your child to keep the lips firmly closed.
Which signs and symptoms are observed in the human body with decrease in body temperature?Signs of mild hypothermia (95° F to 89.6° F // 35° C to 32° C) include:. Shivering and chattering teeth.. Exhaustion.. Clumsiness, slow movements and reactions; prone to falling.. Sleepiness.. Weak pulse.. Fast heart rate (tachycardia). Rapid breathing (tachypnea). Pale skin color.. |