LO5.

Managing patient safety and comfort

 This learning unit is developed to provide the
trainees the necessary information regarding
the following contents
 Taking patient's vital signs

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 Measuring Patient Vital Signs
• Vital signs reflect the body’s physiologic status
and provide information critical to evaluating
homeostatic balance
• The four vital signs are:
→Body temperature (T)
→Pulse (P)
→Respiratory (R) rates
→Blood pressure (BP)

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 1. Body Temperature
• Body temperature reflects the balance between heat
produced & heat lost from the body
• There are two kinds of body temperature:

1. Core temperature
• Is the temperature of the deep tissues of the body
such as abdominal cavity and pelvic cavity
• It remains relatively constant.
• Are measured tympanic or rectal sites 3
 Cont…

2. The surface temperature

 Is the temperature of the skin, the
subcutaneous tissue, and fat.
 It rises &falls in response to the environment.

 Are measured by oral or Axillary sites

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 Cont…
Alterations in Body Temperature
• Normal body temperature is 37 0c (Average)
the range is 36-37.5 0c
• Pyrexia: a body temperature above the usual
range (37.5 0C ) is called pyrexia, hyperthermia
or fever.
– febrile: client who has a fever
– afebrile: a person who has not fever
• Hypothermia: – body temperature less than
35.99 0C
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 Sites to Measure Temperature

1. Oral
2. Rectal
3. Axillary
4. Tympanic

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 1.Oral site
• Advantage:
→Convenient and accessible
• Disadvantage:
→Can break in bitten
→Inaccurate if the patient been smoking,
eating hot or cold food or drinks

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 Contra indication of oral temperature

→Child below 7 yrs.

→If the patient is mentally ill
→Unconscious
→Surgery of the mouth
→Nasal obstruction
Precaution:
• Never use oral thermometer for rectal and
vise verse
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 2. Rectal site

• Advantage:
– Most reliable
– is considered the most accurate
• Disadvantage
– can be embarrassing for alert client,
(inconvenient) and can injured the rectum.
• Its above than the oral site by 0.5 0c

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 Rectal……
• Contraindications
– rectal surgery
– diarrhea
– rectal disease
– heart disease
– Fecal impaction – the depth of the
thermometer insertion may be insufficient
– Neonates – can cause rectal perforation and
ulceration
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 3. Axillary

• Advantage:
– safest and most noninvasive.
– is recommended for infants, children and
unconscious patient.
• Disadvantage:
– it takes long time to obtain an accurate
reading.
– Least accurate & least reliable of all the sites
• Its less than the oral site by 0.5 0c
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 4. Tympanic

• Advantage:
– Very fast and accessible
– Its suitable for children above 6 years
• Disadvantage:
– right and left measurement can differ
– there is risk of membrane injury in inserted
too far.
• Contraindication
➢ Ear infection(otitis media)
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 Factor affecting body temperature

1. Age
• The infant is greatly influenced by the
temperature of the environment and must
be protected from extreme changes.
• Elderly people are at risk of hypothermia
for variety of reasons. Such as inadequate
diet, loss of subcutaneous fat, lack of
activity, and reduced thermoregulatory
efficiency
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 Factors affecting….….…

2. Exercise : Hard work or strenuous exercise can

increase body temperature.
3. Hormones: in women progesterone secretion at the
time of ovulation raises body temperature by about
0.3 – 0.6 0C above basal temperature.
4. Stress: Stress can increases the production of
epinephrine and nor epinephrine – which increases
metabolic activity and heat production.
5. Environment
– Extremes in temperature can affect a person’s
temperature regulatory systems.
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2. Pulse rate (PR)
• Pulse: is a wave of blood created by contraction of the
left ventricle of the heart.
• The pulse rate is expressed in beats per minute (b/m)

A. Peripheral pulse is pulse located in peripheral of the

body, foot, hand.
B. Apical pulse is centered pulse located above the apex
of the heart.
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PULSE
SITES

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 Pulse Sites
1.Temporal
– Passes over the temporal bone of the head.
The site is superior and lateral to the eye.
– Used when radial pulse is not accessible
2. Carotid
– At the side of the neck between the trachea
and the sternocleidomastoid muscle.
– Used in cases of cardiac arrest
– Used to determine circulation to brain
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 Cont…..
3. Brachial
– At the inner aspect of the biceps muscle of the
arm
– Used to measure BP, used during cardiac arrest
for infant
4. Radial
– On the thumb side of the inner aspect of the wrist
– Is most commonly used
5. Femoral
– Alongside the inguinal ligaments
– Used to determine circulation to leg
– Used in cardiac arrest 18
 Cont…
6. Popliteal
– Behind the knee
– Used to measure BP
– Used to determine circulation to lower leg
7. Posterior tibial
– On the medial surface of the ankle
– Used to determine circulation to foot
8. Pedal (Dorsalis pedis)
– Over the bones of the feet
– Used to determine circulation to lower leg
9. Apical 19
 Normal and abnormal Pulse

– This is the number of pulse beats per minute

(60 –100 beats/min in the adult).
– An excessively fast heart rate (≥ 100
beats/min) is referred to as tachycardia.
– A heart rate in the adult of 60 beats/minute
or less is called bradycardia.

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 Factors affecting pulse

1. Age:- as age increase the pulse rate gradually

decreases
2. Exercise:- PR increases with exercise
3. Medications:- sedatives preparations deceases PR;
Epinephrine, caffeine and nicotine increases PR
4. Fever:-increase PR that results from peripheral
vasodilatation.
5. Hypovolemia; loss of blood from the vascular
system normally increase pulse rate.
6. Stress: increase the sympathetic nerve stimulation
increase the heartbeat
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3. Respiratory rate (RR)

– This is described in breaths per minute.

– A healthy adult normally takes between 12
and 20 breaths per minute.
– Eupnea: breathing with normal rate
– Bradypnea: abnormally slow respirations
– Tachypnea: abnormally fast respirations
– Apnea –absence of breathing

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Respiratory rate (RR)……
Depth:
– It is described as normal, deep, or shallow checked
by watching the movement of the chest .
• Deep: a large volume of air inhaled & exhaled,
inflates most of the lungs.
• Shallow: exchange of a small volume of air
• Hyperventilation; refers to very deep, rapid
respiration.
• Hypoventilation; refers to very shallow
respirations

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 Factor influence respiratory rate
Factor increase respiratory rate
– exercise
– stress
– increased environmental temperature
Factor decrease respiratory rate
– decrease environmental temperature
– certain medication(analgesic )

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4. Blood Pressure (BP)
• Blood pressure (BP) is the pressure or tension exerted
on the arterial walls as blood pulsates through them.
• There are two blood pressure measures:
– Systolic blood pressure (SBP) – pressure exerted
on the arteries during the contraction phase of the
heartbeat.
– Diastolic blood pressure (DBP) – the resting
pressure on the arteries as the heart relaxes
• Measured in millimeters of mercury (mmHg)
• Recorded as systolic over diastolic
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 Factors Affecting Blood Pressure

1.Age.
– The pressure rises with age, reaching a peak at the
onset of puberty, & then tends to decline somewhat
3. Stress.
– Stimulation of the sympathetic nervous system
causes vasoconstriction of the arterioles. thus
increasing the blood pressure
5.Obesity.
– Pressure is generally higher in obese people than in
people of normal weight
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 Equipment for Measuring BP

– Blood pressure is measured using a

sphygmomanometer, also called a BP cuff,
or cuff.
– Stethoscope; is used to auscultated and
assess body sounds including the apical
pulse and the blood pressure

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 Cont…
Types of Sphygmomanometers
– Mercury – has a calibrated glass tube
containing mercury.
– Aneroid – has a calibrated dial with a needle

that points to numbers on the face of the

dial.
– Electronic – uses a digital display and

usually includes the pulse rate.

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 Sites for BP measurement

– Brachial: taken on the upper arm; most

common site.
– Radial: taken on the lower arm; possible site
for infants or clients who have very large
upper arms.
– Popliteal: taken on the thigh
– Dorsalis pedis and posterior tibial: taken on
the lower leg.

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 Abnormalities in blood pressure

• Hypertension – a condition in which blood

pressure is chronically (measured more than
two times) higher than normal, >140/90
mmHg
– Normal range of adult BP: 90 –140 mmHg
60 –90
•Hypotension – when the blood pressure is
below normal(90/60mmHg)
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