temperature/pulse/respiration TPR temperature/pulse/respiration

TPR Pulse sites are: Temples Carotid Brachial Radial Femoral Popliteal Dorsalis pedis Apical when all else fails

TPR You take a radial on a walkin talkin You take a carotid/femoral on a bluebloater You take a popliteal/dorsalis pedis for circulation below the pulse site

TPR Correct pulse range is 60-100 beats per minute If the pulse is above 100- it is considered tachycardia If the pulse is below 60 it is considered bradycardia

TPR to determine pulse, palpate the appropriate artery On a watch with a second hand, time out 10 seconds as you count number of beats you feel. Multiply this number by 6. Example: I feel 10 beats in 10 seconds 10x6=60 normal Example I feel 12 beats in 10 seconds 12x6=72 normal

TPR Note the quality of the pulse….. Is it thready, weak, irregular? Is it strong, bounding, racing Note the skin temp as well…. Is it warm, hot Is it cool, clammy

TPR Temperature can be taken: sublingually-children and adults Tempanic- in the ear, children and adults Forehead via infrared, children and adults Axillary- babies and adults who have had something to eat or drink in last 5 minutes or who can’t receive it orally Rectally- babies, children adults who need a more accurate temp Foley cath temp- monitors core temp of the body and can be read on the box continuously

TPR Normal range for temperature would be 98.6 degrees, but may vary by 1 degree either direction throughout the day Add 1 degree to an axillary temp to determine if it is normal Subtract a degree from rectal temp to see if it is normal range

TPR Temperature above 100.4 F is considered hyperthermia or febrile Temperature is 95 degrees F and below Is considered hypothermia, brain and body function slows to a minimum at 85 degrees and body functions cease at 65 degrees F core temp

TPR Respirations- normal respirations will be between 12-24 breaths/min Anything below 12 would be considered bradypnea Anything above 24 would be considered tachypnea

TPR Note the quality of breathing Is the patient gasping- this is not breathing! Nasal flaring in infants and guttural sounds is not breathing! Start CPR Is the patient cyanotic? Indicates a lack of O2. Get a Pulse Oximeter on the patient ASAP. Normal reading needs to 95%-100% O2 and notify nearest supervisor

TPR Pain is always noted on vital sign assessments. It is considered the 5th VS. Remember, pain is relative, ALWAYS BELIEVE YOUR PATIENT! Instruct bp---http://www.youtube.com/watch?v=Gmic13mvsgo What is bp---http://www.youtube.com/watch?v=qWti317qb_w Record bp---http://www.youtube.com/watch?v=oioFVbsiwEk