Presentation on theme: "Temperature, Pulse and Respirations"— Presentation transcript:
1 Temperature, Pulse and Respirations TPRTemperature, Pulse and Respirations
2 TemperatureIs the measurement of the balance between heat lost and heat produced by the body
3 Temperature Can be measured by four basic routes 1. Oral Mouth- leave in place for 3-5 minutes2. RectalRectum- leave in place for 3-5 minutes3. AxillaryAxilla or groin- leave in place for 10 minutes4. TympanicEardrum-5. TemporalAcross forehead-
4 Types of Thermometers 1. Electronic/Digital 2. Glass 3. Thermoscan for Tympanic measurement4.Temporal measurementthermometers
6 Normal temperature ranges Oral 97.6 F – 99.6 F( C)Axillary or Groin F – 98.6 F( C)one degree Fahrenheit lower than OralRectal & Temporal 98.6 F – F( C)one degree Fahrenheit higher than Oral
7 Normal Temperature Ranges Rectal & Temporal 98.6 F – F( C)one degree Fahrenheit higher than OralAural or TympanicAn ear (tympanic) temperature is 0.5°F (0.3°C) to 1°F (0.6°C) higher than an oral temperature F( C)
8 Need to Know-Temperature Terms HypothermiaBelow 95F ( 35C)Death at 93F (33.9)FeverElevated above 101 (38.3)Pyrexia= febrile= fever presentAfebrile= normal temp or no fever presentHyperthermiaTemp exceeds 104 F (40C)Convulsions & death at 106 F ( 41.1 C)
9 Do not take oral temperatures on preschool childrenpatients with oxygendelirious, confused, disoriented patientscomatose patientspatients with nasogastric tubes in placepatients who have had oral surgerypatients who are vomiting or nauseated
10 Do not take rectal temperatures on infants or children unless a core temperature is neededpatients who have had rectal surgerycombative patients
11 Abnormal temperatures Fever, febrile, hyperthermia all indicate someone who has an elevated temperature (>100 Fahrenheit).High fever would include anything over 103 degrees Fahrenheit.Moderate fever would include anything 100 – 103 degrees Fahrenheit.Hypothermia (<96F)is subnormal temperature. This can be equally problematic for a person
12 Need to Know Conversion Formulas Fahrenheit to CelsiusC=(F-32)/ 1.8Celsius to FahrenheitF=(C X 1.8) + 32
14 Assessing Temperatures With a partnerTake both an oral and axillary temperature using a digital thermometerRecord each temperature reading in both Fahrenheit and Celsius using the correct formulaTake a tympanic temperatureDocument your temperature
15 PulseWave of blood produced and felt along the artery when the heart contracts and rests ( relaxes) BEATSCan feel at points where the artery is between finger tips and a bony area
16 Need to Know Pulse Terms RateNumber of bests/per minuteRhythmRegularity of the pulseVolumeRefers to the strength of the pulseApical pulsePulse take at the apex of the heart with a stethoscope
17 Pulse Points- NEED TO KNOW Temporal --either side of forehead2. Carotid- at neck- either side of trachea3. Apical- at apex of heart4. Brachial-inner aspect of antecubital space5. Radial- inner aspect of the wrist6. Femoral- inner aspect of the upper thigh where it meets trunk-- groin7. Popliteal- behind the knee8. Dorsal Pedis -at the top of the foot arch
19 Measuring PulsesMeasured by index, middle, and ring fingers over pulse point.Do not take with the thumb, since it has a pulse of its own.Count for 30 seconds and multiply by 2, or count for 60 seconds
20 Pulse Ranges Normal = > than 100 = tachycardia Adults beats/minuteChildren 7 year & older /minuteChildren 1- 7 years / minuteInfants –birth – 1 year /minute> than 100 = tachycardia< than 60 = bradycardia
21 Quality of Pulse Rhythm – regular or irregular Strength – Bounding or thready
22 What do you think????Jot down at least 5 factors that you think may contribute to your pulse rateacceleratingdecelerating
23 Circumstances affecting pulse rate 1. Body temperature2. Emotions3. Activity level4. Health of heartMedicationSleepComaExerciseShock states
24 Assessing Pulses Pick a partner Assess the following pulses for one full minuteRecord – rate, rhythm, volume of the pulseTemporalCarotidApicalBrachialRadialPoplitealDorsalis pedisRepeat all pulses after your partner has done 25 jumping jacks
26 Respirations Process of taking in O2 and expelling CO2 one respiration consists ofOne inspirationOne expirationPlease note the following when mearusing each and every respiration:RateCharacterRhythm
27 Respirations Each breath includes inspiration and expiration. Measure by observing chest rise and fall.Measured in breaths per minute.
28 Respirations Rate Character Rhythm number of breaths/ minute Depth and quality of respirationsDeep-shallow-difficult-stertorous-moistRhythmRegularity of respirations
29 Need to Know Respiration Terms DyspneaDifficult or labored breathingApneaAbsence of respirationsTachypneaRapid, shallow respirations-- < 25/minuteBradypneaSlow respiratory rate- > 10/minuteOrthopneaDifficulty breathing in all positions except sitting or standing
30 Need to Know Terms Cheyne- stokes Rales Wheezing Cyanosis Abnormal respirations in a dyspnea and apnea patternRalesNoisy & bubblingWheezingDifficult breathing with high pitch whistlingCyanosisDusky, bluish discoloration of skin, lips, nail beds
31 Ranges in Respirations Normal = adults12-24 breaths per minuteChildren-16-30/ minuteInfants / minute> than 24 = tachypnea – if breathing in great depth then called hyperpnea< than 12 = bradypneaAssess rate, character and rhythm always!!!
32 Quality of breathing 1. Depth 2. Clarity of breath sounds 3. Pain with breathing4. Difficulty breathing – use of accessory muscles
33 Assessing Respirations Assess the radial pulse rate of the patient for one minuteAfter the pulse rate have been counted– leave your hand in the pulse positionCount the number of respirations- chest rise and fall for one minuteEach complete cycle is ONE respiration
34 Pulse OximetryPulse oximetry is a procedure used to measure the oxygen level (or oxygen saturation) in the blood. It is considered to be a noninvasive, painless, general indicator of oxygen delivery to the peripheral tissues (such as the finger, earlobe, or nose).
35 How it works…….Pulse oximetry technology uses the light absorptive characteristics of hemoglobin & the pulsating nature of blood flow in the arteries to aid in determining the oxygenation status in the bodyThere is a color difference between arterial hemoglobin saturated with oxygen, which is bright red, and venous hemoglobin without oxygen, which is darker.with each heartbeat there is a slight increase in the volume of blood flowing through the arteriesPulse Oximetry measures the maximum amount of oxygen-rich hemoglobin pulsating through the blood vessels
36 Normal / Abnormal Values Normal pulse oximeter readings range from 95 to 100 percent, under most circumstancesValues under 90 percent are considered lowHypoxemiadescribes a lower than normal level of oxygen in your blood.
37 Pain Assessment Pain is subjective Pain is also multidimensional, so the clinician must consider multiple aspects (sensory, affective, cognitive) of the pain experience.the nature of the assessment varies with multiple factors so no single approach is appropriate for all patients or settings.
38 Pain Assessment Onset & duration Location Quality-what does it feel like?Intensity- give a numeric readingAlleviating or exacerbating factors
39 Common Assessment Tools Wong Baker ScaleNumeric Scales