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 Example to convert 98.6 F to Celsius you subtract 32 from 98.6 which leaves 66.6 and multiply by 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  Children aged over 7 years:  Children aged 1-7:  Infants  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  Children range is  Infants  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:

 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  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