Temperature- Pulse- Respiration and Blood pressure.

Temperature- Pulse- Respiration and Blood pressure

Temperature is a measurement of the balance between heat lost and heat produced in the body.

Temperature may be measured in the mouth (oral), rectum (rectal), armpit (axillary), or ear (aural)

Normal temperature is 97 to 100 degrees Fahrenheit.

Above 101 F indicates fever

Mouth under tongue 3-5 min Most common Clean thermometer or dispose of sheath

after each use

Rectum Internal measurement Most accurate 3-5 minutes Insert 1-11/2 inches Have pt lie on left side with right knee

bent up. Infants on their back Avoid exposure Lubricate thermometer

Armpit/ close to body between skin folds Groin between skin folds of inner thigh and

lower abdomen. 10 minutes Less accurate

In the ear or auditory canal Special thermometer measures the thermal

infrared energy radiating from the blood vessels in the tympanic membrane or eardrum

Less than 2 seconds

Most temperatures are measured in Fahrenheit, however, it may be necessary to convert to Celsius.

To convert Fahrenheit to Celsius subtract 32 from the Fahrenheit temperature and then multiply the result by 0.5556. Example to convert 98.6 F to Celsius you subtract 32 from 98.6 which leaves 66.6 and multiply by 0.5556 which equals 37 degrees Celsius.

To convert Celsius to Fahrenheit you multiply the temperature by 9/5 or 1.8 and then add 32

Low body temperature is called hypothermia

Temperature below 95 degrees F measured rectally

If below 93 rectally for extended period death may occur.

Elevated temperature above 104 degrees F rectally

Above 106 can lead to convulsions and brain damage

Different thermometers used Record accurately with type of temp. 98.6 ® or 98.6(Ax) or 98.6 (T) If taken orally no need to indicate/

understood Eating /drinking/smoking can alter temp Wait 15 minutes

Pulse is the pressure of the blood felt against the wall of an artery as the heart contracts and relaxes.

The rate rhythm and volume are measured and recorded.

Rate refers to the number of beats per minute

Rhythm refers to the regularity of the beat Volume refers to the strength of the beat

Temporal- at the side of the forehead Carotid- at the neck Brachial- crease of the elbow/inner aspect

of forearm Radial- inner aspect of wrist, above thumb Femoral- inner aspect of the upper thigh Popliteal- behind the knee Dorsalis pedis- at the top of the foot arch ( pulse is usually taken over the radial

artery)

Adults- 60-100 Children aged over 7 years: 70-90 Children aged 1-7: 80-110 Infants 100-160 Bradycardia: under 60 Tachycardia: over 100 except children

Irregular or abnormal rhythm Usually caused by a defect in the electrical

conduction system of the heart Strength observed also: strong, weak

thready or bounding Various factors affect pulse

Palm turned down Use tips of first two or three fingers Locate pulse on the thumb side of wrist Do not use your thumb Locate pulse and exert slight pressure and

begin counting for a full minute and record Note rate, rhythm, volume, date and time

when recording

Taken with a stethoscope over the apex of the heart

Two sounds heard: lubb-dupp One heart beat Sounds caused by closing of the heart valves as

the heart beats and blood flows thru the chambers of the heart

Pulse deficit is the difference between the apical rate and the radial rate

Caused by heart disease not enough blood being pumped thru the heart to produce a pulse

Place stethoscope 2-3 inches to the left of the breastbone below the nipple line

Rate that a person breaths during process of taking oxygen into the lungs and expelling carbon dioxide

Count for one minute by observing rise and fall of the chest with each breath

Also check regularity and character. Normal range is 12-20 Children range is 16-25 Infants 30-50 Do not make pt aware that you are

recording respiration.

Deep, shallow, labored, stertorous, moist and difficult Abnormal respirations usually indicate lung problems Dyspnea- difficult breathing Apnea- absence of breathing Tachyapnea- >25 breaths per minute Bradyapnea- <10 breaths per minute Orthopnea- difficult breathing in any position other than erect or standing Cheyne –Stokes- periods of dyspnea followed by periods of apnea (frequently noted in the dying pt) Rales- bubbly or noisy sounds caused by fluid or mucus in the air passages

Measurement of the pressure that the blood exerts on the walls of the arteries during various stages of heart activity

Read in millimeters of mercury Sphygmomanometer Two types of blood pressure: systolic and

diastolic.

Pressure occurs in the walls of the arteries when the heart is contracting and pushing blood into the arteries

Normal reading is 120 Range: 100-140

Pressure that is constant against the walls of the arteries when the heart is at rest and between contaractions.

Blood volume in the arteries has decreased Normal reading is 80 Range is 60-90

Pulse pressure is the difference between the systolic and diastolic pressure

Normal range is 30-50 Hypertension: high blood pressure >140/90.

Causes; stress, anxiety, disease of kidney or thyroid, obesity

Hypotension: low blood pressure<100/60. causes; heart failure, dehydration, depression, severe burns, shock and bleeding .

Other factors influencing B/P are:disease, excitement, drugs, exercise, rest/sleep, positioning

Place pt in comfortable position Place appropriate size cuff on patients arm

between shoulder and 1-1.1/2inches above the elbow and over the brachial artery

Find the brachial artery and place the stethoscope over the artery

Inflate the cuff to approximately 160mm Hg or 30 mm Hg above the palpatory pulse.

Slowly release the air from the cuff and note the first sound on the manometer and this is your systolic pressure.

Note when the sound stops and this is your diastolic reading. At this point release the air quickly from the cuff