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Temperature (T)
 Pulse (P)
 Respiration (R)
 Blood pressure (BP)
 Pain (often called the fifth vital sign)
 Oxygen Saturation
Upon admission to a healthcare setting
 When certain medications are given
 Before and after diagnostic and surgical
 Before and after certain nursing
 In emergency situations
Definition: the heat of the body measured
in degrees
› The difference between production of heat and
loss of heat
› Normal temperature: 97.0ºF (36.0ºC) to 99.5ºF
Process: heat is generated by metabolic
processes in the core tissues of the body,
transferred to the skin surface by the
circulating blood, and dissipated to the
Core temperatures
› Tympanic and rectal
› Esophagus and pulmonary (invasive
monitoring devices)
Surface body temperatures
› Oral (sublingual)
› Axillary
Oral: impaired cognitive functioning,
inability to close lips around
thermometer, diseases of the oral cavity,
and oral or nasal surgery
 Rectal: newborns, small children,
patients who have had rectal surgery, or
have diarrhea or disease of the rectum,
and certain heart conditions
 Tympanic: earache, ear drainage, and
scarred tympanic membrane
Pulse rate
› Measured in beats per minute
Pulse quality (amplitude)
› The quality of the pulse in terms of its fullness
Pulse rhythm
› Pattern of the pulsations and the pauses
between them
 Normally regular
Palpating the peripheral arteries
 Auscultating the apical pulse with a
 Using a portable Doppler ultrasound
 Carotid
 Brachial
 Radial
 Femoral
 Popliteal
 Posterior tibial
 Dorsalis pedis
› Patient is receiving medications that alter heart
rate and rhythm
› A peripheral pulse is difficult to assess accurately
because it is irregular, feeble, or extremely rapid
› Count the apical rate 1 full minute by listening
with a stethoscope over the apex of the heart
› Most reliable method for infants and small
children; can be palpated with fingertips
› Adults: 12 to 20 times per minute
› Infants and children breathe more rapidly
› Varies from shallow to deep
› Regular: each inhalation/exhalation and the
pauses between occur at regular intervals
› Inspection (observing and listening)
› Listening with the stethoscope
› Counting the number of breaths per minute
› If respirations are very shallow and difficult to
detect visually, observe sternal notch
› Patients should be unaware of the
respiratory assessment to prevent altered
breathing patterns
 Medications
 Smoking
 Chronic illness or conditions
 Neurologic injury
 Pain
 Anxiety
 Nasal flaring
 Grunting
 Orthopnea (breathing more easily in an
upright position)
 Tachypnea (rapid respirations)
Ineffective Breathing Pattern
 Impaired Gas Exchange
 Risk for Activity Intolerance
 Ineffective Airway Clearance
 Excess Fluid Volume
 Ineffective Tissue Perfusion
› The force of the blood against arterial walls
Systolic pressure
› The highest point of pressure on arterial walls
when the ventricles contract
Diastolic pressure
› The lowest pressure present on arterial walls
during diastole (Taylor, 2007).
Blood pressure is measured in millimeters
of mercury (mm Hg)
 Blood pressure is recorded as a fraction
› The numerator is the systolic pressure
› The denominator is the diastolic pressure
Pulse pressure
› The difference between the systolic and
diastolic pressure
Using a stethoscope and
 Using a Doppler ultrasound
 Estimating by palpation
 Assessing with electronic or automated
Use a cuff that is the correct size for the
 Ensure correct limb placement
 Use recommended deflation rate
 Correctly interpret the sounds heard
 Exercise
 Position
 Weight
 Fluid balance
 Smoking
 Medications
› Measure the arterial oxyhemoglobin
saturation of arterial blood
› A sensor or probe, uses a beam of red and
infrared light which travels through tissue and
blood vessels
› The oximeter calculates the amount of light
absorbed by arterial blood
› Oxygen saturation is determined by the
amount of each light absorbed
Monitoring patients receiving oxygen
 Titrating oxygen therapy
 Monitoring those at risk for hypoxia
 Monitoring postoperative patients