MED/BNS:1301

PRINCIPLES OF NURSING AND FIRST AID

USE OF DIFFERENT EQUIPMENT: TAKING TEMPERATURE, PULSE,

RESPIRATION & BLOOD PRESSURE

October, 2021

Ms. Mbwali Immaculate

 Introduction
• Vital signs are a group of the four most important
medical signs that indicate the status of the
body’s vital functions.

• They are measurements of the body's most basic

functions

• They are taken to help assess the general physical

health of a person, give clues to possible diseases,
and show progress toward recovery
 Vital signs
• TPR + BP =body temp, pulse R.R + BP

• The normal ranges for a person’s vital signs vary

with age, weight, gender, and overall health

• VS are sensitive to alterations in physiology

(changing of our environment)

• There4 they need to be measured at regular

intervals.
 Body temperature
• Is the warmth of a human body

• Heat is produced from exercise and metabolism

• Heat is lost thru the skin, lungs and body’ waste

products
 Core temperature
• Is the body’s most inner temperature e.g brain and heart
– Remains relatively constant unless exposed to severe
extremes in environmental temperature
– Assessed using a thermometer

• Shell (surface) temperature is the surface temperature or

temperature of the outer skin
– May vary a great deal in response to environmental
– Assessed by touching the skin

• The core temperature should be warmer than the shell

or outer temperature
 How is temperature measured?
• In some states, temperature is measured in
Fahrenheit (e.g., 98.6oF)

• In medicine, temperature is measured in

Centigrade, which is called Celsius

• Normal adult’s core temperature ranges from

36.4oC to 37.3oC

• C = (F-32)
1.8
 Body Temperature
• Hypothalamus: structure in the brain that controls various
metabolic activities

• Temperature regulating centre – hypothalamus

• Heat production caused by:
– increasing cell metabolism
– Shiver
– Vasoconstriction
– Huddle position

• Heat losses (cool off process):

- evaporation (e.g sweating)
- radiation (heat loss from body to cold room)
- conduction (e.g when body is immersed in cold water)
- convection (e.g., wind blowing across exposed
skin)
 Decrease of body temperature
• Vasodilation
• Sweat
• Decreased activity; decreased metabolism
• Decreased appetite
• Stretch position
• Lungs
• Waste products
 Factors that affect body temperature
• Food intake; malnourished have low temps

• Age; young have no adipose tissue

• Climate colder climate = vasoconstriction

• Exercise; body heat produced from exercise

• Circadian rhythm; normal changes in V.S, temperature is always

higher after 4pm

• Illness; infection and WBCs increase temp

• Medication; may change the metabolic rate

 Routes for measuring body temperature
• Oral
 triangle shaped thermometer
 axillo – oral difference 0.3 °c
• Axillary
 more likely to be affected by the environmental temperature
 used in children/adults
• Rectal
 fast thermometer, used in infants/confused patients/receiving o2
therapy
 axillo – rectal difference 0.5 °c

• Aural/tympanic
• Fore head (temporal region)
• Vaginal
 used in gynecology
- NOTE: What are the advantages and disadvantages of taking temperature
at the given sites?
Oral temperature
• 3 – 5 minutes

• Sublingual; under the tongue, keep

lips closed

• Not appropriate for infant,

seizures, unconscious or confused
patient

• Wait 20 to 30 minutes after eating,

chewing gum, smoking, drinking
 Rectal temperature
• 2 minutes at least
• Insert 1 ½ inches for adults
• Lubricate
• Maintain control of the patient to prevent
injury
• Lay baby on back as if changing diaper, insert
and allow some movement
• Side lying position (lateral) can work
• Gives you core temperature
• Temperature will be slightly higher
Red tipped vs. Blue tipped
 Axillary temperature
• Under the armpit
• 7-10 minutes with a mercury thermometer
• Few minutes with the digital type
• Be sure that the bulb or tip is in the axilla
• Least closest to core
Digital axillary thermometer
 Tympanic (Ear) thermometers
• Uses an infrared sensor that detect warmth

• Have speed (temperature reading available

within seconds), safety, and ease of use.

• Cerumen can be a problem, not as reliable as

oral or rectal, are far from core temperature

• Facial thermometer rolls from temporal across

forehead to temporal, also not reliable
 Fever
• Aka febrile

• Pyrexia; to be feverish, temperature exceeds 37.4°C

• Risk of brain damage or death if temperature exceeds

40.6°c

• Afebrile = no fever

• If temperature drops below 34°C, there is high risk of

death
 PULSE
• A wavelike sensation that can be palpated or felt in a peripheral artery that
is produced by the movement of blood thru the aorta and then into smaller
arteries during the heart’s contraction

• Expansion of the arteries with each heart beat (during the heart’s
contraction). There is a rhythmic beating or vibrating movement. Note the
rate, rhythm and volume of the pulse

• Measuring techniques /places of assessing:

- Palpation (peripheral pulses; they are distant from the heart)
 Carotis
 Brachialis
 Radialis
 Femoralis
 Poplitea
- Auscultation (stethoscope)
 Apical pulse (apex of your heart)
 Pulse cont’d
PULSE RATE (average adult)
• Normal 60 – 100 beats/min PULSE RHYTHM
• Tachycardia (fast) >100 Beats/min • Regular
– PR >150bpm means the heart cannot • Irregular – arrhythmia
carry oxygenated blood to feed tissues due to irregular heart
and organs beat
• Bradycardia (slow) ↓ 50beats/min
• Asystolia PULSE QUALITY
• Strong (fever)
• Newborns 120-160 bpm • Weak (shock/heart
• 3-12 years 80-130 bpm failure)
• Teens and adults 60-100 bpm
 Pulse scale
0 Pulse is absent

1+ Pulse is weak

2+ Pulse is normal

3+ Pulse is bounding
Auscultating using a stethoscope
 Apical pulse
Count for I minute; use a 2nd hand
Is it strong and regular?
Carotid pulse
• Felt in lateral neck area

• Do not press too hard,

patient can pass out
from pressure and the
decrease in blood flow
to the brain

• Count for one minute

Obtaining radial pulse
What is wrong here?
Dorsalis pedis
• Most distant from the
heart, indicates how blood
flow to the periphery is

• Once you get this pulse,

you may mark it with a
pen for future use
Doppler ultrasound device
• Electronic instrument that
detects movement of
blood thru peripheral
blood vessels and convert
the movement to sound

• Used after vascular surgery

or if a clot is questionable

• Uses clear conductive jelly

to aid in sound mechanism
 Factors that affect pulse rate
• Age; the older, the slower

• Gender; women have slightly faster HR

• Body build; tall slender people have slower HR than

short people

• Exercise; heart muscles become efficient at supplying

blood cells with sufficient oxygenated blood with
fewer beats
 Factors that affect pulse rate cont’d
• Stress and emotions; stimulation of sympathetic
nervous system such as fear, anger, and excitement,
increase HR

• Body temp; every degree of F elevation, HR increases

by 10bpm

• Blood volume; excessive blood loss causes HR to

increase to move smaller volume around

• Drugs; some slow HR, others increase HR

 Pulse differences
• Thready pulse
– Pulsation not easily felt and slight pressure causes it to
disappear
• Weak pulse
– Pulsation is stronger than thread, light pressure causes
the pulse to disappear
• Normal pulse
– Pulsation is easily felt, moderate pressure causes it to
disappear (because you put pressure on it)
• Bounding pulse
– Pulsation is strong and does not disappear with
moderate pressure
 RESPIRATION
• Is the exchange of oxygen and carbondioxide

• Respiration should be automatic, noiseless,

effortless, but is not for some people

• Ventilation; movement of air in and out of the

chest, it involves breathing in (inhalation) and
breathing out (exhalation)
 What controls breathing
• The medulla in the brain is the respiratory
centre

It is sensitive to carbondioxide in the blood and

adapts the rate of ventilation accordingly
 Respiratory rate
• Is the number of ventilations per minutes

• Normal R.R in adults is 12-20 breaths per minute

• Children and infants have faster R.R as do they have faster

H.R

• Lay stethoscope over the chest and simply listen for

inspiration and expiration; this counts as 1 breaths

• Or simply count the respirations over the patient’s chest

and count them for 1 minute
 RESPIRATION
NORMAL RESPIRATIONS RESPIRATORY RATE
• Effortless • Normal 12 – 20 / min
• Regular • Bradypnea ↓ 10 / min
• Smooth • Tachypnea 25 / min
• Apnea

AVERAGE RESPIRATIONS RESPIRATORY RHYTHM

• Infant to 2 years 24–34/min • Normal
• To puberty 20-26/min • Dyspnea (exertion/rest)
• Adults 12-20/min • Cheynes-Stokes respiration
(irregular deep/slow/shallow )
• Kussmaul’s breathing (deep)
 Respiratory patterns
• Tachypnea: rapid R.R, usually related to increased
temperature or disease process

• Bradypnea: slower than normal R.R, can result from

narcotics, neurological disorders or hypothermia

• Cyeyne-stokes respiration; the depth of respirations

gradually increases, followed by patterns of gradual
decrease, and then periods when breathing stops
briefly, b4 resuming again
Respiratory patterns
 Dyspnea
• Difficult or labored breathing

• Usually starts out with rapid breathing as patient

tries to improve his breathing

• They appear worried and anxious, have flaring

nostrils as they fight to fill the lungs with air

• They work hard and even use neck muscles to

help get that oxygen in
 Problems with Dyspnea
• If a patient works too hard to breathe, he tires
out and becomes starving for air, they will flail
around in bed, try to sit up and this can lead to
seizures due to hypoxia

• Hypoxia (02 deficiency) = Hypercapnea (too

much carbondioxide in blood)
 Orthopnea
• Breathing facilitated by sitting up or standing.

• Occurs with patients who have dyspnea and

find it easier to breath this way

• The abdominal cavity moves down leaving

more room for the lungs to expand, allowing
the person to take in more air
 Apnea
• Absence of breathing

• Is life threatening if it lasts more than 4-6

minutes, causing brain damage

• Snoring also causes sleep apnea. If airway closes

during sleep=snoring-sleep apnea

• Patient receiving narcotics are at risk

 Cumulative effects of sleep apnea
• Loss of O2 to tissue, brain and organs such as
heart causes heart damage over time

• Myocardial infarction can occur from

weakened heart muscle and lack of O2, this is
not reversible
 Stridor
• Is harsh high-pitched sound heard on inspiration
when there is laryngeal obstruction

• Children with croup have this

• Swelling around the vocal cords makes it difficult

to breathe and causes a “barking” sound
BLOOD PRESSURE (BP)
 Blood Pressure cont’d
• Is the force that the blood produces within the artery walls

• The pressure of blood in the arterial wall

• Factors affecting BP:

- blood volume
- strength of contraction
- elasticity of artery wall
• Equipment:
- sphygmomanometer
- stethoscope

• Measurements stated in terms of millimetres of mercury

(mmHg)
 Blood pressure cont’d
BP reading:
- systolic pressure (ventricle contraction)
- diastolic pressure (ventricle at rest)

BP readings record: BP 120/80mmHg

(systolic/diastolic); think of Sit Down

• Assessment:
- Normal 120-140/60-80 mmHg
- Hypertension 150/90 mmHg
- Hypotension ↓100 mmHg
 Blood pressure cont’d
Places for measuring:
- upper arm (brachial artery)
- calf / thigh (popliteal artery)

Measuring techniques:
- auscultation (sphygmomanometer+stethoscope)
- palpation (sphygmomanometer)
- invasive methods (CVP)

Korotkoff sounds
- sounds listened for when taking BP using a
non-invasive procedure
Conditions associated with Hypertension
• Anxiety
• Obesity
• Vascular disease
• Stroke
• Heart failure
• Kidney disease
• Etc
 Hypotension
• Maybe good
• Can be caused by too much control
medication
• Athletes run low
• These patients need to continue to watch
their BP even though it is low, may indicate
shock, hemorrhage or medication effects
»The end