Download Temperature

Vital Signs
 Vital
Signs are measurements reflecting the
patient’s physical well-being and condition.
 Vital Signs include the following:
 Pulse
 Respiration
 Blood pressure
 Temperature
 Upon
admission
 When ordered by
MD or outlined in
plan of care
 Any time there is a
change in the
patient’s condition
or c/o pain
 Patient
falls or
incident occurs
 Monitoring the
patient’s response
to a new
medication
 At check up or
physical
examination
 Caffeine
 Medications
 Emotions
 Exercise
 Age
Temperature
 Body
temperature is the measurement of the
amount of heat in the body
 Measured
 Normal
in Fahrenheit or Celsius
body temperature is 98.6ºF or 37ºC
 Variations
in temperature are caused by
individual differences, time of day, part of
body
Four Ways to Take Temperature
 Glass
thermometer
 Battery-operated
 Other
electronic thermometer
electronic thermometers (ear, forehead)
 Chemically
treated plastic/paper thermometer
Oral Temperature (O)
 Measured
in the mouth
 Most
common, comfortable and convenient
method
 May
be inaccurate if the patient has had
anything to eat or drink
Axillary Temperature (A)
 Temperature
measured under the armpit
 Less
accurate reading because measures
external temperature
 Record
an A by the reading
Rectal Temperature
 Measured
in the rectum
 Most
accurate because it is an internal
temperature
 Use
red rectal thermometer
 Record
R by reading
 Pulse
is the rhythmic expansion and
contraction of the arteries caused by the
beating of the heart; the expansion and
contraction show how fast, how regular, and
with what force the heart is beating.
 Before
birth/birth
 4 weeks to 1 year
 Childhood years
 Adult years
120-160
80-160
80-115
60-100
 Rate:
the number of pulse beats per minute
 Rhythm: used to describe the regularity of the
pulse beats
 Force: strength or power; used to describe the
beat of the pulse
 Bradycardia: heart rate below 60
 Tachycardia: heart rate over 100
 Carotid
 Apical
 Brachial
 Radial
 Femoral
 Popliteal
 Dorsalis
pedis/posterior tibial
 Pulse
at the wrist
 Patient’s arm should be well supported and
resting comfortably.
 Find the pulse by placing the tips of your
first three fingers on the palm side of the
patient’s wrist in a line with the thumb, next
to wrist bone.
 If you press too hard, you will stop the flow
of blood and not feel the pulse.
 Never use your thumb
 Note the rhythm and force
 Look
at the position of the second hand on
your watch. Start counting the pulse beats
that you feel until the second hand comes
back to the same number on the clock.
 Apical
pulse is a measurement of the
heartbeats at the apex of the heart,
located just under the left breast.
 Uncover the patient’s chest
 Place the diaphragm of the stethoscope
under the left breast. Listen for the heart
sounds.
 Count the heart sounds for a full minute.
 Report
to immediate supervisor the
following:
 The pulse rate
 If the pulse was regular or not
 Report anything unusual.
 The
difference between the apical and radial
pulse
 The heart is contracting but the pulse is not
reaching the extremities. (A-Fib)
 Best obtained by having 2 people count the
radial and apical pulses at the same time.