2.  Temperature (T)  Pulse (P)  Respiration (R)  Blood pressure (BP)  Pain (often called the fifth vital sign)  Oxygen Saturation

3.  Upon admission to a healthcare setting  When certain medications are given  Before and after diagnostic and surgical procedures  Before and after certain nursing interventions  In emergency situations

4.  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 (37.5ºC)  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 environment

5.  Core temperatures › Tympanic and rectal › Esophagus and pulmonary (invasive monitoring devices)  Surface body temperatures › Oral (sublingual) › Axillary

7.  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

8.  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

9.  Palpating the peripheral arteries  Auscultating the apical pulse with a stethoscope  Using a portable Doppler ultrasound

10.  Temporal  Carotid  Brachial  Radial  Femoral  Popliteal  Posterior tibial  Dorsalis pedis

12.  Indications › 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  Method › 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

13.  Rate › Adults: 12 to 20 times per minute › Infants and children breathe more rapidly  Depth › Varies from shallow to deep  Rhythm › Regular: each inhalation/exhalation and the pauses between occur at regular intervals

14.  Method › Inspection (observing and listening) › Listening with the stethoscope › Counting the number of breaths per minute  Considerations › 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

15.  Exercise  Medications  Smoking  Chronic illness or conditions  Neurologic injury  Pain  Anxiety

16.  Retractions  Nasal flaring  Grunting  Orthopnea (breathing more easily in an upright position)  Tachypnea (rapid respirations)

17.  Ineffective Breathing Pattern  Impaired Gas Exchange  Risk for Activity Intolerance  Ineffective Airway Clearance  Excess Fluid Volume  Ineffective Tissue Perfusion

18.  Definition › 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).

19.  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

20.  Using a stethoscope and sphygmomanometer  Using a Doppler ultrasound  Estimating by palpation  Assessing with electronic or automated devices

22.  Use a cuff that is the correct size for the patient  Ensure correct limb placement  Use recommended deflation rate  Correctly interpret the sounds heard

23.  Age  Exercise  Position  Weight  Fluid balance  Smoking  Medications

24.  Purpose › Measure the arterial oxyhemoglobin saturation of arterial blood  Method › 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

25.  Monitoring patients receiving oxygen therapy  Titrating oxygen therapy  Monitoring those at risk for hypoxia  Monitoring postoperative patients