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Vital Signs
Temperature
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Measurement of balance of heat loss and
heat produced
Abbreviation T
Homeostasis
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Constant state of fluid balance
Body reacts to chemicals and influences
temperature
Sites to measure T
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Rectal - rectum
Mouth - oral
Axillary - armpit
Aural – ear
Temporal – forehead
Factors that affect body temp
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Individual people differ – metabolic rates
Time of day
Body Sites
Activities
Causes of increase T
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illness
infection
exercise
excitement
environment
Cause of decrease
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starvation of fasting
↓muscle activity
mouth breathing
exposure to cold
certain disease
Methods to Measure Temp
Oral
Most comfortable and common
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Questions pt about eating, drinking or
smoking prior to temp
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Leave in place 3-5 minutes if using
merciless thermometer
Digital – leave until beeps usually  one minute
Electronic – records within 2 – 4 seconds
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Continued
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Tympanic – record aural readings, placed in
the ear canal uses inferred reading of the
tympanic membrane. Must be used correctly
for accuracy
Temporal – measure the temporal artery
Terminology related to temp
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Hypothermia – low body temp ↓ 95°
Hyperthermia – high body temp 104° F
Fever – an elevated (↑) temp usually 101°F
Pyrexia – another term for fever
How to read a glass thermometer
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The long line represents a whole number ex
98°
The short line represents .2 ° (2 tenths) of a
degree
Normal Ranges
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Oral = 98.6° F
Rectal = 99.6° F
Axillary =97.6° F
(+ or - 1°) 37° C
(+ or - 1°) 37.6° C
(+ or - 1°) 36.4° C
Guidelines for Obtaining a Oral Temperature
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Standard Precautions – wipe with alcohol or facility
guideline before and after use; cover tip/probe;
check glass thermometer prior to use, make sure
the line is below 96° careful when shaking down not
to hit objects close by. Use cool water when rinsing
to prevent from breaking glass and destroying
contents inside of the thermometer
Record and Report
Supplies for Temperature
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Oral thermometer
Plastic sheath
Holder of with disinfectant
Tissues or dry cotton balls
Watch with second hand
Soapy cotton balls
Gloves
Paper and pen
Pulse
Pulse is defined as the pressure of the
blood pushing against the wall of an artery
as the heartbeats and rests
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Feel throbbing of the arteries caused by
contractions of the heart
More easily felt in arteries that lie close to the
skin and can be pressed against a bone.
Major arterial or pulse sites in the body
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Temporal: side of the forehead
Carotid: side of the neck, used for CPR
Brachial: inner aspect of forearm at the
antecubital space (crease of elbow), used for
blood pressure
Radial: inner aspect of wrist, above thumb,
most common site for measuring pulse
Femoral: inner aspect of upper thigh
Pulse sites continued
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Popliteal: behind knee
Dorsalis pedis: top of foot arch
Apex of the heart – inferior tip of the heart. Not
a pulse site, but a location to hear the heart rate
accurately using a stethoscope. This is called
an apical pulse
Posterior tibialis – behind the ankle
TEMPORAL
Carotid
Apex
4
Brachial
5
Radial
Femoral
Popiiteal
Dorsalis pedis
Posterior tobialis
Three items to note when
obtaining a pulse
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Rate
Rhythm
Volume
Pulse rate
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Noted as the number of beats per minute
Vary with individuals depending on age, sex, and body
size
Adults: wide range of 60 to 90 beats per minute
Adult men: 60 to 70 beats per minute
Adult women: 65 to 80 beats per minute
Children over 7to 12: 70 to 90 beats per minute
Children from 1 to 7: 80 to 110 beats per minute
Infants:
100 to 160 beats per minute
Related Terms
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Bradycardia: pulse rate under 60 beats per
minute
Tachycardia: pulse rate over 100 beats per
minute (except in children)
Pulse Rhythm
Should be noted along with rate
Refers to the regularity of the pulse, or the
spacing of the beats
Described as regular or irregular
Arrhythmia
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Irregular or abnormal rhythm
Usually caused by a defect in the electrical
conduction pattern of the heart.
Pulse Volume
Refers to the strength of the force
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Noted along with rate and rhythm
Described by words such as strong, weak,
thready, or bounding
Various factors will change the pulse rate
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Increased or accelerated rates caused by fever,
shock, nervous tension, exercise, stimulant
drugs and other similar factors
2.
Decreased or slow rates caused by sleep,
depressant drugs, heart disease, coma, and
physical training and other similar factors
Basic principles for taking radical pulse
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Position patient’s arm supported comfortably
with palm of hand turned down
Use tips of two or three fingers to locate pulse
site on thumb side of wrist
Count pulse for one full minute
Note rate, rhythm, and volume of pulse
Record all information
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Include rate, rhythm, and volume
Example: Date, Time, P 82 strong and regular,
your signature and title
Respiration
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Measures the breathing of the patient
Process of taking in oxygen and expelling
carbon dioxide from the lungs and
respiratory tract
One respiration consists of one inspiration
(breathing in) and one expiration (breathing
out)
Normal Respiratory Rate
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Adults: 14 to 18 breaths per minute
Wider adult range: 12-20 breaths per minute
Children: 16-25 minutes
Infants: 30-50 per minute
Character of respirations
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Should be noted along with rate
Refers to the depth and quality of respirations
Described by words such as deep, shallow,
labored, moist, difficult, stertorous (abnormal
sounds like snoring), and moist
Rhythm of respirations
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Should be noted along with rate and character
Refers to the regularity or equal spacing
between breaths
Described as regular (or even) or irregular
Abnormal respirations
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Dyspnea: difficult or labored breathing
Apnea: absence of respirations, usually temporary
Tachypnea: respiratory rate above 25 respirations per minute.
Bradypnea: slow respiratory rate, usually below 10 respirations per minute
Orthopnea: severe dyspnea in which breathing is very difficult in any position
other than sitting erect or standing
Cheyne-Strokes: periods of dyspnea followed by periods of apnea; frequently
noted in dying patient
Rales: bubbling or noisy sounds caused by fluids or mucus in the air passages
Wheezing
Difficult breathing with a high pitched whistling or sighing sound during
expiration
Caused by narrowing of bronchioles (as seen in asthma) and/or an
obstruction or mucus accumulation in the bronchi
Cyanosis
Dusky, bluish discoloration of the skin, lips, and/or nail beds
Result of decreased oxygen and increased carbon dioxide in the
bloodstream
Voluntary control of respirations
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Respirations are partially under voluntary control
Patients may breathe faster or slower when they are
aware respirations are being counted
Important to keep patient unaware of this procedure
Do not tell a patient you are counting respirations
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Keep your hand on pulse site while measuring
respirations
Patient will think you are still counting pulse
Will not be as likely to alter respiration
Record all information
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Include rate, character, and rhythm
Example: Date, Time, R 18 deep and regular,
Your signature and title
Report any abnormalities immediately to your
supervisor