temperature, pulse, respirations
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Transcript temperature, pulse, respirations
THE VITAL SIGNS:
TEMPERATURE, PULSE,
RESPIRATIONS AND BLOOD
PRESSURE
Abbreviated: TPR BP or
simply VS
THE VITAL SIGNS
Take a moment and close your eyes and
concentrate on your breathing, the heat of
your body and the flow of blood through
your blood vessels as your heart beats.
These are the crucial, automatic processes
that occur continuously to maintain your
life.
They are indeed vital to life—and thus
called the Vital Signs
SIGNS VS. SYMPTOMS
Symptoms can only be described / validated
by the patient.
– Pain, nervousness, dizziness, fatigue
Signs are able to be measured / observed by
others besides the patient
– Vital signs, wound drainage, color of sputum,
blood cell counts
TEMPERATURE
The measurement of core body
heat
ROUTES TO MEASURE
TEMPERATURE
Axillary: Under the arm in the armpit
Orally: By mouth
Rectally: By rectum
Tympanic: In the ear
Temporal: through the skin of the temple
TYPES OF
THERMOMETERS
Digital Electronic: To be used for oral,
rectal, and axillary
Thermoscan - Digital: To be used for
tympanic /temporal
Mercury or glass: To be used for oral,
rectal, and axillary. Rarely used anymore
due to health risks r/t mercury and risk of
sharps injury if broken
NORMS
Orally: 97.6 - 99.6 degrees Fahrenheit
Rectally: 98.6 - 100.6 degrees Fahrenheit
Tympanic - manufacturers say to measure
as for rectal
Axillary: 96.6 - 98.6 degrees Fahrenheit
Temporally: Manufacturers say to measure
as axillary.
HOW SHOULD
THERMOMETER BE USED?
Tympanic: Special device with plastic
covers, placed snugly in ear canal.
Electronic: Oral, rectal & axillary routes.
Probes that are red in color for rectal
temperatures; blue in color for oral and
axillary, always retain hold of thermometer.
Mercury: same as electronic. Red ends are
rectal; blue ends oral and axillary, always
retain hold of thermometer.
DURATION FOR TAKING
TEMPERATURES
Tympanic: As long as it takes to push a
button
Temporal: Until the thermometer beeps
Electronic: Until the thermometer beeps
Mercury Oral: Three minutes
Mercury Rectal: Three minutes
Mercury Axillary: Ten minutes
BE CAREFUL ON RECTAL
AND AXILLARY TEMPS
Always hold the thermometer in place while
measuring temperatures by these routes
Always use lubricant with rectal
temperatures
Always remove clothing around axilla and
maintain arm pressed to side of torso
READING THE
THERMOMETER
Mercury Fahrenheit thermometers are read
by degree and 0.2 of a degree
Long lines indicate degrees
Short lines indicate 0.2 of a degree
Four short lines between each long line (0.2,
0.4, 0.6, 0.8)
All other types give a digital display to the
tenth of a degree.
PULSE
The felt wave of blood created by
the heart pumping, that travels
along the arteries.
WHERE TO FIND PULSES
Locations called “pulse points”
Felt at areas where the artery is between
finger tips and a bony prominence or
section
Felt with 2-3 fingers, but never the thumb
PULSE POINTS AND THEIR
LOCATIONS
Temporal
Femoral
Carotid
Popliteal
Apical
Post Tibial
Brachial
Dorsal Pedalis
Radial
HOW TO MEASURE?
Measured in beats per minute
Count the felt waves for 60 seconds
Or, count the felt waves for 30 seconds –
then multiply by 2
NORMS
Pulse norms are 60 - 100 beats per minute
Pulses between 90 - 100 are in a gray area - high
normal
Faster than 100 - tachycardia
Slower than 60 – bradycardia
Caveat: well trained athletes may have “normal”
pulse rates of 45-60, depending on level of fitness
QUALITY OF PULSE
Rhythm: regular or irregular
Rate: Bradycardic, Within the normal
limits, Tachycardic
Strength: Thready, Weak, Strong,
Bounding
WHAT AFFECTS PULSE
RATES AND QUALITY
Body Temperature
Emotions
Activity Level
Health of the Heart / vascular volume
RESPIRATION
The exchange of gases at the
alveolar-cellular level that results
from the mechanical act of
breathing in air (inspiration) and
expelling air (expiration) from the
body
RESPIRATION
Measured in breaths per minute
Normal range is 12 - 24 breaths per minute
Count for 1 full minute or for 30 sec. x 2
Greater than 24 is tachypnea
Less than 12 is bradypnea
Watch for rate, depth, listen for quality of
breath (adventitious vs. vessicular sounds),
and difficulty in breathing (SOB/labored)
METHOD OF MEASURING
TPR
If using a mercury thermometer, measure
the pulse and respiration while waiting for
the temperature
If using another method of measuring the
temperature, complete the temperature then measure the pulse and respiration
Keep your fingers on the pulse while
measuring the respiration
BLOOD PRESSURE
The measurement of the force of blood
against artery walls.
Measured using device called
sphygmomanometer and a stethescope.
Measured as a fraction in mm/Hg
Upper number (numerator) called the
Systolic blood pressure.
Lower number (denominator) called the
Diastolic blood pressure.
MEASURING BLOOD
PRESSURE
The last sound heard (diastolic blood
pressure) – is the measure of the pressure in
an artery when the heart (ventricles) relaxes
between contractions.
Normal Ranges SBP: 90-130, DBP: 60-80
Hypertensive: 140/90 and above
Hypotensive: 80/50 and below
Grey areas: between norms and hyper/hypo
CAUSES & S/S
HYPOTENSION
Causes may include:
– Medications
– Illness
– Injury
– dehydration
Signs & symptoms may include:
– Dizziness / light-headedness
– Lethargy / fatigue / generalized weakness
– might faint
CAUSES & S/S
HYPERTENSION
Hypertension is called the silent killer
because there are often no symptoms.
Causes may include:
– family history / high salt diet / overweight
– emotional upset /physical pain
– illness / medications / fluid overload
Some people might experience:
– Headache / Pressure in the head / Tinnitis
– General feeling of malaise
CAUSES OF HTN-(CON’T)
Genetics: More prevalent in African Americans
than other ethnicities
Age: More prevalent in middle-aged and elderly
people than younger people
Body size: More prevalent in obese people than
thinner people
Lifestyle: More prevalent in heavy drinkers than
moderate to non-drinkers
Co-morbidities: People with diabetes, gout or
kidney dx
.
CHARTING
Chart in order: temperature - pulse – respiration –
blood pressure.
Do not write T =, etc.
Number for temp with no route designation=oral
Write (Ax) after axillary temperatures
Write (R) after rectal temperatures
Write (Tymp.) for tympanic
Write (Temporal) for temporal
ABBREVIATIONS
SOB - Short of breath
QID - Four times a
day
QS - Every shift
pulse, and respiration
QD - Every day
WNL-Within normal
limits
PRN - As needed
VSS-Vital signs stable Ad Lib - At liberty (as
desired)
P.O. - By mouth
B/P - Blood Pressure
BID -Twice a day
TID -Three times a day VS - Vital Signs
HTN-hypertension
TPR - Temperature,
TERMS
Eupnea - Normal
breathing
Orthopnea - Sitting
upright to breath more
easily
Apnea - No breathing
Hyperpnea - Fast, deep
breathing
Hypopnea- slow shallow
breathing
Tachypnea – Fast
breathing
Bradypnea - Slow
breathing
Dyspnea - Painful or
difficult breathing
Tachycardia - Pulse
rate in excess of 100
bpm
Bradycardia - pulse
rate less than 60 bpm
TERMS
Bounding pulse -
excessively strong pulse
Weak pulse – softer
pulsation than normally
felt
Hypertensive – blood
pressure 140/90 & above
Hypotensive-blood
pressure 80/50 & less
Thready pulse - Pulse rate
difficult to palpate because the
heart is not beating hard
enough to produce a strong
wave of blood. Feels as
though there is “a piece of
thread” running or fluttering
under the fingertips.