TEMPERATURE

PULSE
RESPIRATIONS
BLOOD PRESSURE

VITAL SIGNS MUST BE MEASURED, REPORTED, AND

RECORDED ACCURATELY
IF YOU ARE NOT SURE OF A MEASUREMENT,
RECHECK IT
o When a person is admitted to a health care facility
o Several times a day for hospitalized patients
o Before and after surgery
o After some nursing procedures
o before medications are given that affect the respiratory or
circulatory system
o Whenever the person complains of pain, shortness of breath, rapid
heart rate, or not feeling well
o With the person at rest in a lying or sitting position
 o Illness oEnvironment - weather
o Emotions – anger, o Food and fluid intake
fear, anxiety, pain
o Medications
o Exercise and activity
o Time of day – ↓ in the
o Age morning, ↑ in the
o Sex afternoon/evening
o noise

A CHANGE IN ONE VITAL SIGN WILL CAUSE A CHANGE IN

THE OTHERS
o ANY VITAL SIGN IS CHANGED FROM A PREVIOUS
MEASUREMENT
o VITAL SIGNS ARE ABOVE THE NORMAL RANGE
o VITAL SIGNS ARE BELOW THE NORMAL RANGE
MANY AGENCIES HAVE TEMP BOARDS OR TPR BOOKS
RECORD VITAL SIGN MEASUREMENTS AS SOON AS
POSSIBLE
CARRY A SMALL NOTEBOOK IN YOUR POCKET SO YOU
CAN RECORD THEM AS YOU TAKE THEM
ABBREVIATIONS
TEMPERATURE – T
PULSE – P
RESPIRATIONS – R
BLOOD PRESSURE - BP
BODY TEMPERATURE IS THE AMOUNT OF HEAT IN THE
BODY
IT IS A BALANCE BETWEEN THE AMOUNT OF HEAT
PRODUCED AND THE AMOUNT OF HEAT LOST
HEAT IS PRODUCED BY :
THE CONTRACTION OF MUSCLES DURING EXERCISE
THE BREAKDOWN OF FOOD DURING DIGESTION
THE ENVIRONMENTAL TEMPERATURE
HEAT IS LOST THROUGH :
URINE FECES
RESPIRATIONS PERSPIRATION
 BODY TEMPERATURE IS MEASURED IN ONE OF FOUR
AREAS OF THE BODY
THE MOUTH – ORAL
THE RECTUM – RECTAL
THE AXILLA (UNDERARM) – AXILLARY
THE EAR – TYMPANIC
WE NOW ALSO HAVE THE TEMPORAL SITE - FOREHEAD
MOST TEMPERATURES ARE TAKEN ORALLY
RECTAL TEMPERATURES ARE THE MOST ACCURATE
AXILLARY TEMPERATURES ARE THE LEAST ACCURATE
A SMALL HOLLOW GLASS TUBE THAT CONTAINS
MERCURY OR A MERCURY-FREE SUBSTANCE IN A
BULB AT ONE END.WHEN HEATED THE MERCURY
RISES IN THE TUBE.

Pear – shaped tip

o THE SCALE IS MARKED FROM 94° TO 108°
o THE LONG LINES REPRESENT ONE DEGREE
o THE SHORT LINES REPRESENT TWO TENTHS OF A DEGREE
o ONLY EVERY OTHER DEGREE IS MARKED WITH A NUMBER
o BATTERY OPERATED
o HAVE AN ORAL PROBE AND A RECTAL PROBE
o DISPOSABLE PROBE COVER IS PLACED ON THE PROBE
o THE TEMPERATURE REGISTERS IN ABOUT 30 SECONDS
USE A DISPOSABLE SHEATH
o MEASURES THE TEMPERATURE IN THE TYMPANIC MEMBRANE (EARDRUM)
o FAST AND ACCURATE - 1 TO 3 SECONDS

INFANTS – PULL
THE EAR
STRAIGHT BACK

ADULTS AND
CHILDREN OVER
ONE YEAR –
PULL THE EAR UP
AND BACK
 GLASS THERMOMETER
o Rinse with cold water
o Check the thermometer for breaks and chips
o Shake down the thermometer so the
mercury is below the lines and numbers
o Place a disposable cover on the thermometer
o Place the thermometer under the person’s
tongue
o Leave the thermometer in place for 2 – 3
minutes
o If the person has been eating, drinking, or
smoking, wait 15 minutes before taking
temperature
 DO NOT TAKE AN ORAL TEMPERATURE ON:
o An infant or young child ( under age 6)

o An unconscious patient
o A patient that has had oral surgery or an injury to the face, neck, nose, or
mouth
o A person receiving oxygen
o A patient with a nasogastric tube in place
o A patient who is confused or restless
o A patient who is paralyzed on one side of the body
o Has a history of seizures
o A patient who breathes through the mouth
o Lubricate the thermometer before inserting into the rectum
o Place the person in a side-lying position
o Insert the thermometer 1 inch into the rectum
o Hold the thermometer in place for 2 minutes
o Remove the disposable cover and read the thermometer
 Do not take a rectal temperature on:
o A person who has had rectal surgery or rectal
injury
o If the person has diarrhea
o If the person is confused or agitated
o If the person has heart disease ( stimulates the
vagus nerve which slows the heart rate )
o Taken only when no other site can be
used
o Make sure the underarm is clean and
dry
o The arm is held close to the body
o You need to hold the thermometer in
place while the temperature is being
taken
o The thermometer is left in place for
10 minutes
• PYREXIA (febrile) -
temperature above usual range
is an indication of infection.
• HYPERPYREXIA- very high
fever, 41C
• HYPOTHERMIA-
temperature below the lower
limit of normal range.
THE PULSE IS:
o The beat of the heart felt at an artery as a wave of blood passes through
the artery
o A pulse is felt every time the heart beats
o More easily felt in arteries that come close to the skin and can be gently
pressed against a bone
o The pulse should be the same in all pulse sites on the body
o The pulse is an indication of how the cardiovascular system is meeting the
body’s needs
o The pulse rate is affected by many factors – age, fever, exercise, fear.
Anger, anxiety, excitement, heat, position, and pain.
o Medications can be taken that either increase or decrease a person’s pulse
rate.
WE USUALLY COUNT A PULSE FOR 30 SECONDS AND
MULTIPLY THE NUMBER TIMES 2 TO GET THE PULSE
RATE FOR 1 MINUTE

We note THE RHYTHM

(PATTERN) of the heart beat – if the
heart beat is irregular we count the
pulse for a full minute
We also observe the FORCE
(STRENGTH) of the heartbeat.
o Most common site used for taking a
pulse
o Can be taken without disturbing or
exposing the person
o Place the first two or three fingers of
one hand against the radial artery
o The radial artery is on the thumb side of
the wrist
o Do not use your thumb to take a
person’s pulse
o Use gentle pressure
o Count the pulse for 1 full minute.
Always clean the earpieces of
the stethoscope with alcohol
before and after use
Warm the diaphragm in your
hand before placing it on the
person
Hold the diaphragm in place
over the artery
Do not let the tubing strike
against anything while the
stethoscope is being used
o Taken with a stethoscope
o Counted by placing the stethoscope over
the heart
o counted for one full minute
o The heart beat normally sounds like a
lub-dub. Each lub-dub is counted as one
heartbeat.
o Do not count the lub as one heartbeat
and the dub as another.
o The apical pulse is taken on patients who
have heart disease , an irregular pulse rate,
or take medications that can affect the
heart.
 The apical and radial pulse rates should be equal
Sometimes the heartbeat is not strong enough to create a pulse in the
radial artery
This would cause the radial pulse to be less than the apical pulse
One person counts the apical while the other person counts the radial
The difference in pulses is called the pulse deficit
NORMAL ADULT PULSE RATE IS – 60 TO 100 BEATS PER MIN.
TACHYCARDIA – HEART RATE OVER 100
BRADYCARDIA – HEART RATE BELOW 60

REPORT ABNORMAL HEART RATES TO THE NURSE

IMMEDIATELY
 Normal Pulse Rate
Adults 60-100 bpm
Children 70-150 bpm
infants 100-160 bpm
One respiration consists of one inspiration and one expiration
o The chest rises during inspiration (breathing in) and falls
during expiration (breathing out)
o Count each time the chest rises
o Count for 1 full minute.
o Do not let the person know you are counting their
respirations
o Count after taking the pulse – keep your fingers on the pulse
site
o normal respiratory rate for adult is 12 – 20 breaths per min.
 Normal Respiratory Rate
Adults 12-20 cpm
Children 15-30 cpm
infants 25-50 cpm
 RATE
 TACHYPNEA – RESPIRATORY RATE OVER 20

• BRADYPNEA – RESPIRATORY RATE BELOW 12

• APNEA – NO BREATHING

 VOLUME
• HYPERVENTILATION – FAST AND DEEP RESPIRATIONS
• HYPOVENTILATION – SLOW AND SHALLOW
RESPIRATIONS
 EASE OR EFFORT
• DYSPNEA – SHORTNESS OF BREATH – DIFFICULTY IN
BREATHING
• ORTHOPNEA- ABILITY TO BREATHE ONLY IN UPRIGHT
SITTING OR STANDING POSITION.
 The measurement of the amount of force the blood exerts
against the artery walls
o Systolic pressure – pressure exerted when the heart muscle is
contracting
o Diastolic pressure – pressure exerted when the heart muscle
is relaxing between beats
Blood pressure is recorded as a fraction with the systolic
pressure on top and the diastolic pressure on the bottom
SYSTOLIC SYSTOLIC /DIASTOLIC
DIASTOLIC 120/80 mmHg
BP IS MEASURED IN mm (MILLIMETERS) OF Hg
(MERCURY)
AVERAGE ADULT SYSTOLIC RANGE – 100 TO 140 mmHg
AVERAGE ADULT DIASTOLIC RANGE – 60 TO 90 mmHg

HYPERTENSION – MEASUREMENTS ABOVE THE NORMAL

SYSTOLIC OR DIASTOLIC PRESSURES
HYPOTENSION – MEASUREMENTS BELOW THE NORMAL
SYSTOLIC OR DIASTOLIC PRESSURES
o Age – blood pressure increases as a person grows older.
o Gender – women usually have lower blood pressure than
men
o Blood volume – severe bleeding lowers the blood
pressure
o Stress – heart rate and blood pressure increase as part of
the body’s response to stress
o Pain – increases blood pressure
oExercise – increases heart rate and blood pressure
o Weight – blood pressure is higher in overweight persons
o Race – black persons generally have higher blood
pressure than white persons do
o Diet – a high-sodium diet increases the fluid volume in
the body which increases blood pressure
o Medications – can be taken to raise or lower blood
pressure
o Position – blood pressure is lower when lying down
THE PROPER NAME FOR A BLOOD PRESSURE CUFF IS
SPHYGMOMANOMETER

MERCURY ANEROID
o Do not take a blood pressure on an arm with an iv, a cast, or a dialysis shunt.

o Do not take a blood pressure on the side that a person has had breast surgery
on.
o Measure blood pressure with the person sitting or lying.
o Apply the cuff to the bare upper arm. Do not apply the cuff over clothing.
o Make sure the cuff is snug.
o Use a large cuff if necessary.
o Make sure the room is quiet.
o If you do not hear the blood pressure, wait 30 to 60 seconds and try again. If
you still can not hear it or are unsure of your readings, have the nurse check
your measurements.
1. Clean the stethoscope earpieces and diaphragm with
alcohol.
2. Locate the brachial pulse. This is where the stethoscope
will be placed.
3. Wrap the cuff above the elbow with the arrow pointing
to the brachial artery. Fasten the cuff so it fits snugly.
4. Place the diaphragm of the stethoscope flat on the pulse
site, holding it in place with the index and middle
fingers of one hand.
5. Close the valve on the bp cuff by turning it to the right
(clockwise).
6. Inflate the cuff until you can no longer feel the radial pulse.
7. Then inflate the cuff 30 mm hg beyond this point.
8. Deflate the cuff slowly by opening the valve slightly and
turning it counterclockwise (to the left) with your thumb and
index finger. Allow the air to escape slowly while listening for a
pulse sound.
9. Note the reading at which you hear the first clear, regular pulse
sound. This number is the systolic pressure.
10. Continue listening until the sound disappears. This is the
diastolic pressure. Note this reading.
11. Open the valve completely to deflate the cuff. Remove the
cuff from the patient.
 MEASURING WEIGHT AND HEIGHT

• Standing, chair, and lift scales are used.

• Measuring weight and height
– The person only wears a gown or pajamas.
– The person voids before being weighed.
– Weigh the person at the same time of day.
– Use the same scale.
– Balance the scale at zero before weighing the
person.
 PAIN
• Pain means to ache, hurt, or be sore.
• Pain is a warning from the body.
• Pain is personal.
• Types of pain
– Acute pain – felt suddenly from an injury, disease,
trauma, or surgery
– Chronic pain – lasts longer than 6 months. Pain can
be constant or occur on and off.
– Radiating pain – felt at the site of tissue damage and
in nearby areas.
– Phantom pain – felt in a body part that is no longer
there.
• Signs and symptoms
– Location – Where is the pain?
– Onset and duration – When did the pain start?
– Intensity – Rate the pain on a scale of 1 to 10, with 10 as the
most severe
– Description – Can you use words to describe the pain?
– Factors causing pain – What were you doing when the pain
started?
– Vital signs – Take the person’s vital signs when they complain of
pain.
– Other signs and symptom
• Body responses - ↑ vital signs, nausea, pale skin, sweating,
vomiting
• Behaviors – crying, groaning, holding affected body part,
irritability, restlessness
 PRACTICE BLOOD
PRESSURE TAKING
 PRACTICE BLOOD
PRESSURE TAKING
 PRACTICE BLOOD
PRESSURE TAKING
 PRACTICE BLOOD
PRESSURE TAKING
 PRACTICE BLOOD
PRESSURE TAKING
 APPLICATION
ACTIVITY 1. BLOOD PRESSURE DETERMINATION
Each student will take their partner’s blood pressure and have their blood pressure
taken by their partner.
ACTIVITY 2. HEART RATE DETERMINATION
Working with their partner, students will determine both their apical and radial
pulse. The apical pulse is the actual counting of the heartbeats using the
stethoscope over the heart. The radial pulse is measured by counting the pulses of
blood in the radial artery. After that the students will record their apical and radial
pulses. A PULSE DEFICIT is the difference between the apical and radial pulse.
A pulse deficit greater than four can indicate some physiological problem.
ACTIVITY 3. EFFECT OF EXERCISE ON BLOOD PRESSURE AND
HEART RATE

After exercised for 3 minutes the students will measure the pulse rate and blood
pressure and recorded data on the worksheets provided.