TPRO

indicate body's ability to regulate temp, maintain blood flow, and oxygenate body tissues in response to physical, environmental, and psychological stressors

changes in the pt over time

• pt is admitted into the hospital
• on a routine schedule per dr order
• before and after surgical procedure or invasive diagnostic procedure
• before during and after transfusion of blood, getting meds, or therapies that affect cardiovascular, respiratory, and temp control functions
• when pain increases or loss of consciousness
• before and after nursing interventions
• pt reports physical distress "feeling funny"

• mouth and ear
• 36-38 C or 96.8-100.4 F

• 36.5 C or 97.7F
• slightly lower

• 37.5 C or 99.5
• Slightly higher and most accurate.

• age: decrease with increasing age
• physical activity: increase with activity
• status of hydration: increase with dehydration
• state of health (presence of infection)
• cardiac rhythms (24 hour cycle): increase temp is most accurate between (5pm-7pm)

• temp with normal (EU) range.
• Body cells function within a small rage of normal temps
• cells benefit from short term change in temp (fever to kill bacteria, hypothermia in drowndings)
• long time heat/cold temps can lead to tissue damage and death

low temp <36 C or 96.8 F

same as fever. abnormal elevation of temp above 37 C or 98.6 because of disease

dangerously high temperature.

is to have a fever

is when the fever breaks, or there is no more fever

• pt must be able to close lips (no mouth trauma or epilepsy)
• temp is altered by ingestion of cold and warm liquids, smoking, and chewing gum (15 min)
• -use automatic ejector to dispose of probe cover, do not touch with hand.

• ear wax (cerumen) decreases accuracy
• Blue Thermometer
• -get temp in pt right ear if right handed
• -adult pull pinna back and up child back and down
• -hold snug or in figure 8.

• stool decreases accuracy
• pt embarrassment and anxiety
• RED thermometer
• -lubricate 1-1.5 inches of probe
• -insert probe 1-1.5 in aiming towers umbilicus, NEVER force

sweating (diaphoresis) decreases accuracy

pressure wave in the peripheral arteries generated by the left ventricle as it contracts.

• indication of heart function and tissue perfusion
• reflects clients metabolic rate, physiologic responses to stress, exercise, blood loss, pain

• 60-100 beats per min
• easily palpable
• regular

• less than 60 beats.
• Brady:slow

• more than 100
• tachy: fast

• regular or irregular
• arrhythmia and dysrthmia

• 0: absent, non-palpable (no pulse)
• 1+: weak feeble thread (barley palpable)
• 2+: normal (expected)
• 3+: full/strong
• 4+: bounding (very strong)

• adults: radial (wrist)
• infants: brachial or apical (elbow and heart)

pulse felt in the neck

apex of the heart or PMI

elbow area

wrist thumb side

where leg and hip meet

flex knee, deep within behind knee area

top of foot between big toe and the next

side of foot under ankle knob

• age: infant 180, preschool 160, school age 120, older children 110, adult 100
• sex: females under 12 have higher HR
• exercise: high so wait 5-10 min before assessing
• fever: faster pulse
• medications, hemorrhaging, and stress

radial pulse is irregular and prior to digoxin(medication)

30 sec if reg and 60 if irregular

exercise, anxiety, pain, smoking, meds

• number of breaths per min
• one inhale and one exhale is ONE respiratory cycle
• Normal: 12-20 breaths per min

• depth: shallow, normal, deep
• effort: labored or unlabored
• labored: use of accessory muscles, flared nostrils, pursed lips.
• Men, kids, athletes: belly breathers, diaphragmatic
• women: chest breathers

• Rhythm: Regular or irregular
• Patterns-
• Eupnea: normal
• Tachypnea: more than 20 breaths per min
• bradypnea: less than 12 breaths per min
• hyperventilation: deep and rapid
• apnea: no breaths
• cheyne-strokes: periods of rapid breathing followed by no breathing. irregular

abnormally deep but regular

• % of hemoglobin that is bound with oxygen.
• correlates with arterial oxgen saturation: level of oxygen in the blood available to the body tissues

more than 90% we want it to be 95-100

• when the doctor orders
• adventitious breath sounds
• signs of altered oxygen saturation: cyanotic(blue) nails lips and skin, restlessness, and dyspnea (difficulty breathing SOB)

• finger on same side as electronic BP cuff
• edema, altered skin integrity, hypothermia
• nail polish, bad capillary refill

• BP baseline wait 30 seconds do below
• temperature
• radial pulse
• respirations
• check BP