TPR and Peripheral Pulses PN 1 Nursing Skill Labs

Equipment glass thermometer - consider mercury spills electronic thermometer tympanic thermometer others - patch, tape, single use watch paper and pen for recording

Sites and Methods Oral wait 15 – 30 min after hot or cold drink smoking or chewing gum do not use oral site if unconscious seizure prone irrational child - very young O2 by mask recent oral surgery

if using glass thermometer, shake down and wipe down!! place in sublingual pocket and close lips must wait 3 minutes when using glass thermometer; others alarm or indicate when ready always indicate the site used in your documentation

Rectal (not used for newborns!!) shake down and wipe glass thermometer and insert 1 1/2 inches (adults) after lubricating well!!! (check depth depending on age/size) - hold 2-3 mins hold thermometer in place to ensure accurate reading considered most accurate reflection of core temp

Axilla if using glass thermometer, shake, wipe and hold for 10 mins make sure axilla is dry place tip of thermometer in center of axilla and place arm close to body considered as accurate as oral or rectal when done correctly

Tympanic pull pina up and back (for adults) most common site currently used uses infrared sensers does not actually touch the typmanic membrane

Factors affecting Pulse Rate & Rhythm Tachycardia pulse of 100 - 180 bpm may be caused by pain, emotions, exercise, prolonged heat, decreased blood pressure, pyrexia, reduced O2 in blood, some medications

Bradycardia pulse below 60 bpm pulse is generally slower at rest may be related to thin body size, gender ( males slower than females), increased age and some medications this is often considered normal for people in great physical shape!!

Equipment Stethoscope, doppler, cardiac monitor cleanse earpieces with alcohol swab warm before use point ear pieces toward nose ensure bell is “on” bell – low freq. Heart & BP diaphragm – hi freq. Resp & bowel sounds watch with second hand

Sites and methods never use your thumb to palpate a pulse use the pads of three middle fingers count for 1 full minute exception - if peripheral pulse irregular or abnormal for that patient repeat at apical site and count for 1 full minute Pulse deficit = difference between apical and radial pulse

Radial Carotid Apical ease of access, circulation of hand make sure arm is resting comfortably Carotid most easily palpable if blood pressure is low (only palpate one side at a time) Apical audible with stethoscope measured at 5th intercostal space, slightly left of pts. midclavicular line

Brachial - used in infants Femoral - often used in cardiac arrests Popliteal - peripheral circulation Posterior tibial (tibial) and Dorsalis pedis (pedal) - assesses peripheral circulation always document location of pulse assessment

Pulse Points

Respirations one respiratory cycle = from beginning of one inspiration to beginning of the next inspiration important that patient not be aware you are counting his/her respirations normal ratio is 1 breath to 4 heartbeats count for 1 full minute document rate and depth

Factors affecting Respiration Increases  rate if in pain  in BMR exercise sympathetic stimulation smoking require more oxygen pyrexia Decreases  depth if in pain pathologies sedatives and analgesics parasympathetic relaxation increased ICP

Terms related to Respiration tachypnea - rapid > 24 per min bradypnea - slow < 10 per min apnea - periods of no breathing - brain damage in 4-6 mins orthopnea - breathing easier in upright position dyspnea - labored or difficult breathing

hyperventilation - increased rate and depth hypoventilation - decreased rate and depth Cheyne-Stokes - deep rapid breathing followed by periods of apnea