the nurse have to get the temperature of the patients to make sure the patients body temperature is right
This lesson introduces the learner to the rules for taking body temperature, pulse readings and respiratory rates. Body temperature rises when heat production increases or when heat loss decreases; both may be going on at the same time. This lesson provides the learner with an overview of the Equipment, examination techniques and procedures applied in the diagnostic process to determine a patients health status from Vital Sign readings.
After completing this lesson, the learner will be able to:
Understand the rules applied to taking body temperature.
Identify Types of Thermometers used when taking body temperature.
Identify the methods and procedure and precautions, which must be taken when obtaining an oral, rectal, and axillary temperature.
Identify anatomical sites where a pulse may be taken.
Cite from a list, factors which affect the pulse rate.
Match terms describing a pulse with the correct definition.
Understand the Respiratory process and techniques applied to diagnosis irregularities.
Identify breathing patterns, difficult breathing and the medical terms applied.
Match terms related to breathing patterns with the correct definition.
TAKING THE TEMPERATURE
Regardless of the type of thermometer or measuring probe used, certain rules apply.
1. Place the bulb or electronic probe so it is completely surrounded by body tissues.
2. Remove the cover and discarded after the temperature is taken. (Multi-use thermometers and temperature probes are covered when used.) Prelubricated covers are used for rectal thermometers.
3. Record the temperature on the patient's graphic chart to the even two tenths of a degree (unless the electronic thermometer is used). An electronic thermometer is not calibrated with multiple numbers. It displays only the measured temperature. Record the measured temperature.
TYPES OF THERMOMETERS
Clinical. The clinical thermometer is a glass bulb containing mercury, with a stem in which the mercury can rise. The stem has lines representing the measuring scale. It must read below normal range before the temperature is taken. It should be rinsed in cold water to avoid distribution of the mercury and breakage. If the thermometer is kept in a chemical solution, dry it with a wipe in a twisting motion starting at the bulb. The clinical thermometer may be oral or rectal.
• The oral thermometer has a long, slender bulb. It may also be used for axillary measurement.
• The rectal thermometer has a blunt, short, fat bulb. It should not be stored with the oral thermometers.
Figure 4-1. Clinical thermometers.
Electronic. The electronic thermometer is portable and battery operated. It registers the temperature in 10 seconds or less and displays it digitally. It must be fully charged to give an accurate reading, so be sure the thermometer's base is plugged into an electrical outlet between uses. Separate oral and rectal probes are supplied with each unit.
Disposable. The disposable is single-use and has a sensor at the end of the shaft, which measures the temperature.
Patch. The thermometer patch is a strip, which contains liquid crystals that change colors as the temperature changes. It is usually placed on the forehead. The scale is adjusted to convert skin-surface temperature to inner-body temperature. The calibration is not as detailed as that of a glass thermometer.
METHODS OF OBTAINING A TEMPERATURE
To obtain an oral temperature, place the thermometer in the sublingual pocket and have the patient close his mouth around it. Instruct him not to bite down. Leave the thermometer in place 3 to 4 minutes. If the patient has been eating, drinking, smoking, brushing his teeth, or chewing gum within the past 15 minutes, wait at least 15 minutes to take the temperature.
To obtain a rectal temperature, lubricate the bulb and the area up to 1 inch above it. Use a lubricated probe cover with an electronic thermometer. Turn the patient on his side, fold back the bedding and separate the buttocks so that you can easily see the anal opening. Insert the thermometer approximately 1.5 inches into the anus. Hold the thermometer in place for 3 to 4 minutes.
To obtain an axillary temperature, place the thermometer in a dry axilla. Keep the arm close to the body to ensure contact with the bulb or probe for 8 to 10 minutes. Axillary is the method of choice for an infant.
• Oral temperatures are contraindicated for an unconscious patient, for an infant, or when the patient must breathe through the mouth.
• The rectal method of obtaining the temperature is contraindicated if the patient has diarrhea, rectal disease, or has recently had rectal surgery.
The pulse is the vibration of each wave of blood going through the arteries as the heart beats. The pulse rate is usually equal to heart rate, but may be lower if there is an obstruction of the artery or if the heart rhythm is weak or irregular. You can feel it by placing your fingers over one of the large arteries that lie close to the skin, especially if the artery runs across a bone and has very little soft tissue around it.
There are eight common arterial pulse sites. (See figure 4-2).
• Apical (listening to the heart directly).
• Pedal (dorsalis pedis)
Figure 4-2. Arterial pulse sites.
The rate that the heart beats varies with the patient's age, size, and weight. The normal rate for an adult is 60 to 80 beats per minute. Women have a slightly higher average rate than men. The pulse of an infant ranges from 120 to 140 beats per minute. Rates for children vary according to the size and the age of the child.
Activity affects the pulse rate. Exercise or heavy physical work cause the heart to beat faster and the pulse rate to increase. Excitement, anger, and fear increase the rate. Some drugs, such as caffeine, may also increase the pulse rate. If the patient has a fever, the pulse rate increases in proportion to the body's temperature: the pulse rate goes up about 10 beats for every 1ºF (0.56ºC). These conditions cause a temporary increase in the heartbeat and pulse rate. The heartbeat and pulse rate that is consistently above normal may be a sign of heart disease, heart failure, hemorrhage, an overactive thyroid gland, or some other serious disturbance. The term for an abnormally rapid heartbeat is tachycardia. When the heartbeat is continuously slow, below 60 per minute, the condition is called bradycardia.
DESCRIBING THE PULSE
Pulse rate describes how often the heart beats.
Pulse volume describes the force with which the heart beats. The volume of the pulse varies with the volume of blood in the arteries, the strength of the heart contractions, and the elasticity of the blood vessels. A normal pulse can be felt with moderate pressure of the finger. When every beat is easily felt, the pulse is described as strong. When greater pressure exerted by the finger cannot blot out the pulse, it is called full or bounding. A pulse with little force is described as weak or thready.
Pulse rhythm is the spacing of the heartbeats. When the intervals between the beats are the same, the pulse is described as normal or regular. When the pulse skips a beat occasionally, it is described as intermittent or irregular. A pulse may be regular in rhythm but irregular in force, with every other beat being weak. To obtain an accurate assessment of the heart rate, the pulse is counted by listening directly to the heart (apical pulse).
FACTORS, WHICH AFFECT THE PULSE RATE
The pulse rate is an indicator of how fast the heart beats. The pulse rate is affected by several factors.
• Age. A normal pulse for infants range from 90 to 170 and the rate gradually decreases up to age 14 when it is equal to the normal adult pulse rate of 60 to 100.
• Body Build and Size. A short, fat person may have a higher rate than a tall, slender person.
• Blood Pressure. As the blood pressure decreases, the pulse will frequently increase.
• Medications. Stimulants will increase the pulse rate; depressants will decrease the pulse rate.
• Exercise and Muscular Activity. An increase in pulse rate will occur with increased activity to meet increased oxygen and nutrient demands. A regular aerobic exercise program can lower the resting pulse. A person, who exercises a great deal, such as an athlete, will develop bradycardia that is a normal, health condition. The body slows the heartbeat to compensate for the greater volume of blood pumped with each beat.
• Food Intake. Digestion increases the pulse slightly.
• Elevated Body Temperature. The pulse increases approximately 10 beats per minute for every 1 F (0.56º C) increase in body temperature. These conditions cause a temporary increase in the heartbeat and pulse.
• Emotional Status. Fear, anger, and anxiety will all increase the pulse rate.
• Pain. When the patient is in pain, the pulse rate will increase.
MEASURING THE PULSE
Measuring a Radial Pulse.
1. Wash your hands to prevent the spread of infection.
2. Supporting the patient's arm and hand with the palm down, press the first, second, and third finger of your dominant hand gently against the radius bone until you feel the contraction and expansion of the artery with each heartbeat. Do not use your thumb; it has a strong pulse of its own and you may be counting your pulse.
3. Count the pulsations for 30 seconds using a watch with a second hand or digital display to time yourself. Multiply the count by 2 to determine the rate for 1 minute. If the pulse is abnormal in any way, count for a full minute to get a more accurate reading.
4. The pulse rate may also be determined by the electronic vital signs monitor (see figure 4-3).
5. If there is any doubt about the rhythm or rate of the heart, take an apical pulse.
Figure 4-3. Electronic vital signs monitor.
Measuring an Apical Pulse.
1. Warm the stethoscope in your hands. A cold stethoscope may surprise the patient and alter the pulse rate.
2. Place the stethoscope at the apex (pointed end) of the heart, in the left center of the chest, just below the nipple. The pulse can usually be heard best at the apex.
3. Count the pulse for one full minute.
Measuring the Apical-Radial Pulse.
If the apical-radial (A-R) pulse is ordered by the physician, two nurses carry out the procedure together.
Using the same watch, one nurse counts the patient's apical pulse for 1 minute while the other nurse counts the radial pulse for 1 minute. One nurse gives the signal to start counting, and both start at the same time. The two figures are identified and charted (A-R pulse 76/72, for example). Normally, these two readings should be the same. If there is a difference, it is called the pulse deficit.
NOTE: An apical pulse will never be lower than the radial pulse.
Respiration is the process that brings oxygen into the body and removes carbon dioxide waste. The exchange occurs in the lungs. Respiration occurs in two phases: internal and external.
• Internal respiration is the process by which oxygen is taken from the bloodstream into the cell and carbon dioxide is removed from the cell to the bloodstream.
• External respiration refers to delivery of oxygen to the lungs so that it can be taken into the bloodstream. External respiration (breathing) has two components: Inspiration, the process of taking air into the lungs; and expiration, expelling air from the lungs.
• It is the rate of external respiration that is measured. The normal adult rate is 14 to 20 breaths per minute. Women have a more rapid rate than men. Newborns have a normal rate of about 40. Children have a normal rate of 25 to 30.
• Respiration is controlled and regulated by the respiratory center in the brain and by the amount of carbon dioxide in the blood. Respiration is involuntary and automatic. You can control the action of your breathing to some extent, but only for a limited time. If automatic breathing does not occur, a breathing disorder exists.
• Normal breathing is relaxed, effortless, and regular.
• Rapid breathing is a rate above 20 breaths per minute, associated with increased activity or a disease process. The medical term is tachypnea.
• Slow breathing is a rate below 14. It may also be described as shallow if the patient takes in and breathes out small amounts of air.
• Dyspnea. Difficult breathing describes when a person is making a definite effort to get more oxygen and get rid of carbon dioxide. Dyspnea is the term for difficult breathing. Dyspnea is also the term used for painful breathing, a subjective pattern, which must be stated by the patient. Dyspnea may be a temporary condition, such as when a runner gasps at the end of a race or when a person pants "to get his breathe" after climbing stairs. In some diseases, such as pneumonia, emphysema, or some types of heart conditions, breathing difficulty is more or less constant. Signs of breathing difficulties are: heaving of the chest and the abdomen, and cyanosis (a bluish tinge in the skin).
• Orthopnea is the term used if the patient can breathe only when in an upright position.
• Apnea is the absence of respirations.
• Cheyne-Stokes is the term for cycles of breathing characterized by deep, rapid breaths for about 30 seconds, followed by absence of respirations for 10 to 30 seconds. Cheyne-Stokes respirations constitute a serious symptom and usually precedes death in cerebral hemorrhage, uremia, or heart disease.
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