Comprehensive Notes on Vital Signs: Temperature, Pulse, Respiration, and Blood Pressure

Oral Temperature with Electronic Thermometer

• Introduction and Patient Identification

  • Introduce yourself and identify the patient to ensure correct patient care.

  • Example: "Hi, I'm Stephanie, your medical assistant. Can I get your name and date of birth to verify?"

• Pre-Measurement Instructions

  • Confirm the patient hasn't eaten, drank (hot or cold), or smoked in the last 15 minutes to avoid inaccurate results. Make sure that if they have, you wait the appropriate amount of time to get an accurate oral temperature.

• Thermometer Placement

  • Place the thermometer probe under the patient's tongue in the designated heat pocket.

• Instructions During Measurement

  • Instruct the patient to close their mouth and not bite the probe to ensure proper temperature measurement and to avoid damaging the device.

• Reading and Interpretation

  • Read the temperature on the display before removing the thermometer.

  • Example reading: 98.9 degrees Fahrenheit. Note any deviations from the normal range and follow up according to the provider's instructions.

• Post-Measurement Hygiene

  • Dispose of the single-use probe cover properly to prevent cross-contamination.

• Thermometer Storage

  • Store the thermometer properly, usually in its charging cradle, to conserve battery life and keep the device ready for the next use.

Alternate Temperature Measurement Methods

Temporal Artery

• Common Use

  • Often used for babies and children due to its non-invasive nature and speed.

Rectal Temperature

• Usage

  • Less common, especially with the availability of temporal artery thermometers.

• Procedure for Infants

  • Lube the tip of the rectal thermometer with KY jelly to facilitate insertion.

  • Hold the baby's feet up gently to align the rectum.

  • Insert the thermometer into the rectum gently and not too far (approximately 1/2 inch) to avoid injury. Follow the provider's guidelines for insertion depth according to the infant's age and size.

• Accuracy

  • Rectal temperature readings are very accurate due to the closed environment.

• Policies and Guidelines

  • Provider guidelines determine the age for rectal temperature measurement.

• Equipment

  • Electronic thermometers are used for rectal measurements.

  • A probe cover is always required for rectal thermometers to prevent contamination.

• Insertion Depth

  • Adults: approximately 1 inch.

  • Small children and infants: approximately 1/2 inch.

• Lubrication

  • Lubricant is recommended to ease insertion and ensure patient comfort but sometimes optional based on specific clinical contexts.

• Disposal

  • After measurement, dispose of the probe cover in the appropriate waste container.

Considerations for Oral Temperature

• Technique

  • The thermometer needs to be held in place due to its top-heavy design and cord, ensuring the probe remains in the heat pocket under the tongue.

• Inaccuracy

  • If not held, the probe can slip from heat pocket and give inaccurate results.

Rectal Temperature Considerations for Adults

• Common Settings

  • Usually performed in nursing homes or with elderly patients.

• Patient Positioning

  • Lateral or Sims position (on their side, generally left side due to rectum angle) is preferred for easier access and patient comfort.

  • Drape for privacy to maintain patient dignity.

• Documentation

  • Record as rectal temperature using "r" in parenthesis e.g., 98.6(r) degrees Fahrenheit or Celsius to clearly indicate the method used.

• Contraindications

  • Recent rectal surgery (to avoid damage to the operative site).
    Chronic diarrhea (to avoid contamination).

Patient Modesty

• Patient Sensitivity

  • Patients are often sensitive about rectal procedures.

• Privacy Measures

  • Use drapes to provide privacy and maintain dignity throughout the procedure.

Axillary Temperature

• Location

  • Taken under the armpit (axilla).

• Accuracy

  • Least accurate method because it's not a tight fit and influenced by movement and external factors.

• Technique

  • Hold the patient's arm down to ensure a tight fit, which helps to improve the accuracy of the measurement.

• Normal Range

  • Normal axillary temperature is generally 0.5 to 1 full degree below normal oral temperature.

• Documentation

  • Abbreviate as "ax" in parenthesis, then record the reading. e.g., 97.6(ax).

• Adjustment

  • Adding a degree is usually a recommendation to adjust the reading, but always follow the provider's guidelines.

Oral Temperature

• Standard Method

  • Generally the standard method, so "o" is not typically noted in documentation.

• Alternate Route Notation

  • If an alternate route is used, it must be noted.

Tympanic Temperature

• Normal Range

  • Normal range: 99.1 to 99.6 degrees Fahrenheit.

• Comparison to Oral

  • Generally, 0.5 to 1 degree higher than normal oral temperature.

• Documentation

  • Use "T" or "tym" in parenthesis. e.g., 99.2(T).

• Procedure

  • Remove the thermometer from charging cradle.

  • Put a disposable sheath on the probe.

  • Position inside the auditory canal.

  • Adults: pull the ear up and back to straighten the ear canal. Children: pull the ear down and back.

  • Ensure the probe is snug, then press scan.

  • Infrared beam measures heat waves.

  • The result is displayed on a digital screen.

  • Eject the probe cover with the release button.

• Technique Considerations

  • Getting a proper seal in the ear is essential to ensure an accurate reading.

  • Hold the ear up and back (adults) or down and back (children) to properly align the ear canal.

  • If not done correctly, you won't get a good signal, leading to inaccurate readings.

  • Ensure no leaks in the ear canal that might affect the reading.

Temporal Artery Temperature

• Procedure

  • Gently slide the probe across the forehead between the eyebrow and hairline, maintaining contact with the skin.

  • Keep the button depressed during the scan to continuously measure the temperature.

  • The device measures the highest temperature detected during the scan.

• Accuracy

  • Considered close to a true internal body temperature when performed correctly.

  • The accuracy depends on the technique; proper technique is crucial.

• Comparison to Oral and Rectal

  • Normal TA measurement is equivalent to a rectal temperature, typically one degree higher than oral.

• Documentation

  • Note as "TA" after the temperature in parenthesis.

• Advantages

  • Suitable for all ages (infants to elderly).

  • Convenient, easy, fast, comfortable, and safe.

  • Highly accurate when performed correctly.

  • No contact with mucous membranes, reducing cross-contamination risk.

  • Unaffected by oral factors (hot or cold fluids).

  • Can be sanitized with antiseptic wipes for infection control.

• Limitations

  • Do not use over burns, open sores, or scars due to compromised skin integrity.

  • The forehead must be exposed to the environment without hats, bangs, or bandages to ensure accurate measurement.

  • Perspiration can affect accuracy; if present, measure behind the earlobe on the neck.

  • The device must be acclimated to room temperature before use to ensure accurate readings.

  • Some models should not be used near aerosol products or oxygen administration due to potential interference.

• Taking a Temporal Artery Temperature

  • Wash hands and gather supplies.

  • Clean the probe with antiseptic wipes.

  • Identify the patient and introduce yourself, explaining the procedure.

  • Observe the forehead for perspiration or obstructions.

  • Position the probe at the midline of the forehead, keeping it flush against the skin.

  • Press and hold the scan button while slowly moving across the forehead to the hairline.

  • Document the temperature in the patient's chart with "TA" in parentheses.

• Device Considerations

  • The reading stays on the screen briefly, so documentation needs to be immediate.

  • These devices are more expensive and delicate, requiring careful handling and storage to prevent damage.

Temperature Conversions

• Celsius to Fahrenheit

  • F = (C \times \frac{9}{5}) + 32

  • Example: 37°C \times \frac{9}{5} = 66.6 + 32 = 98.6°F

• Fahrenheit to Celsius

  • C = (F - 32) \times \frac{5}{9}

  • Subtract 32 from your Fahrenheit, and then multiply by 5/9.

• Normal Body Temperature

  • 37 degrees Celsius

  • 98.6 degrees Fahrenheit

Pulse

• Pulse is the alternating expansion and contraction of artery walls as blood is forced into the aorta with each heartbeat.

• Pulse sites can be felt where arteries are close to the body surface over bony prominences or firm surfaces.

Pulse Sites:

• Radial: Located on the thumb side of the wrist; most frequently used for measuring pulse rate.

• Brachial: On the inner part of the elbow; used for CPR on babies.

• Carotid: In the neck area; used on adults for CPR.

• Femoral: Midway in the groin.

• Dorsalis Pedis: On the instep of the foot.

• Popliteal: Behind the knee.

Pulse Characteristics:

• Normal artery feels elastic.

• Pulse rate: Number of heartbeats per minute.

• Normal pulse: 60 to 100 beats per minute.

Factors Influencing Pulse Rate:

• Activity: Increased activity raises the heartbeat by 20 to 30 beats per minute.

• Age: Pulse rate is faster in infants and decreases with age. (Example: 1-11 months can be up to 160).

• Sex: Female's pulse is about 10 beats per minute more rapid than a male's at the same age.

• Tachycardia: Consistent rate more than 100 beats per minute.

• Bradycardia: Consistent rate below 60 beats per minute.

Pulse Volume and Rhythm:

• Volume: Force or strength of the pulse (normal, full, bounding, weak, thready).

• Rhythm: Regularity (equal spacing between beats).

• Arrhythmia: Irregular pulse.

  • If regular, measure for 30 seconds and multiply by two.

  • If irregular, measure for the full 60 seconds.

Measuring Radial Pulse:

• Patient should be relaxed and sitting comfortably or lying down with arm supported.

• Place tips of fingers (not thumb) over the pulse site about an inch above the thumb on the wrist.

• Apply appropriate pressure (not too much to cut off circulation).

Apical Pulse:

• Measured using a stethoscope.

• Contraction of atria and ventricles is heard as “lub dub”. (Counted as one beat).

• If measured at a point other than the radial, the location should be noted.

• Apical pulse measurements are indicated for:

  • Infants and small children due to rapid rates.

  • Patients with heart conditions, especially those medicated with cardiac drugs like digoxin, due to accuracy.

  • If you have a difficult time with radial.

  • Excessively rapid or slow rate or quality of your pulse.

  • Irregular pulse.

Locating Apex:

• Apex (bottom of the heart) is the point of maximum impulse against the chest wall at the left fifth intercostal space in line with the middle of the left clavicle.

  • Located by pressing fingers between the ribs and counting down five spaces on the left chest wall.

  • Felt with fingertips or listened to with a stethoscope.

Quick Apex Location Method:

• Place the top of your finger which covers the top of the sternum, and when you do that and you spread your fingers open, it's gonna be where the thumb is when you are feeling for their Apex (do not do on yourself for practice).

Pulse Oximetry

• Measures arterial oxygen saturation in the blood (SpO2).

• A small handheld unit with a clip attaches to the patient's index finger.

• Uses infrared light to measure pulse oxygen levels.

• Normal range: Usually 95-100%.

• If the reading is outside the normal range, it should be taken manually for confirmation.

• Inaccurate results can be caused by flaking fingernail polish, long fingernails, or incorrect placement.

Respiration

• The process of breathing (inspiration/inhalation and expiration/exhalation).

• Part of the total vital signs assessment.

• Patients can voluntarily control their breathing, so accurate measurement requires observation without the patient's awareness.

• Performed immediately after measuring pulse without removing fingers from the wrist.

Procedure:

• After pulse rate is measured, keep fingers on the pulse site, and observe the patient's breathing pattern to count respirations.

• Use peripheral vision (side vision) to see movement.

• Different when doctors tells you to do deep breaths for you can control it.

• Normal respiration rate: 14 to 20 breaths per minute (not 12 to 20).

Quality of Respiration:

• Hyperventilation: Excessively fast, deep breathing.

• Dyspnea: Difficult or labored breathing.

• Rales: Noisy breathing, often due to constricted bronchioles (smaller than it should be) or fluid accumulation.

Depth of Inhalation:

• Described as normal, shallow, or deep.

• Apnea: Absence of breathing.

• Cheyne-Stokes: (Dead breath) Abnormal breathing pattern with alternating periods of apnea and deep, rapid breathing, often seen in patients with acute brain, heart, or lung damage, disease, or poisoning. Often seen in patients who are dying.

Respiration Rates:

• Normal is 14 to 20 (not 12 to 20)

• Newborns rates are higher than normal. Rates go lower each year as they age.

• Tachypnea: Fast breathing.

• Bradypnea: Slow breathing.

Counting Respirations:

• Done while holding the pulse (or before and holding it, or after and holding it) but respirations are part of the TPR (temperature, pulse, respiration) assessment.

  • Very important to remember the number of heartbeats that you've just counted, and then you follow by assuming the pulse measuring position.

• Determine characteristics.

• Repeat the pulse to yourself as you measure respirations.

Blood Pressure

• Quiz is to be given on this information. No check offs until the end of semester.

• 15 blood pressures to master (10 on the mannequin arm (Tuesdays to work on), 5 on live people, (can be instructors or each other).). Need to get 5 accurate on five people to successfully pass, all with instructors.

Definition and Measurement

Definition and Measurement:

-Blood pressure: Fluctuating pressure the blood exerts against the arterial walls as it alternately contracts and relaxes.

• Reflects:

  • Condition of the heart.

  • Amount of blood forced from the heart at contraction.

  • Condition of the arteries.

  • Volume and viscosity of the blood.

• Measured in the brachial artery of the arm at the antecubital space.

• A normal different 5-10 millimeters of mercury. MM stands for millimetres of mercury. (MMHG).

Maintaining Blood Pressure

Maintaining Blood Pressure:

-Two main factors:

-The pump or heart, is exerting pressure on the blood.

• The brain: Controls heart rate and the caliber of the arteries through the autonomic nervous system.

Blood Pressure Phases (Basis):

Blood Pressure Phases (Basis):

• Contraction (Systole): Corresponds to the beat phase of the heart (top number). Greatest pressure.

• Relaxation (Diastole): Resting or filling back the blood in the heart phase (bottom number). Least pressure.

Phases (Korotkoff Sounds):

Phases (Korotkoff Sounds):

• Phase 1: Sharp tapping sound (systolic pressure).

• Phase 2: Softer as blood flows. Includes the oscillatory gap (possible silence, but the sound will come back).

• Phase 3: Becomes louder again, similar to the first phase.

• Phase 4: Becomes muffled. Most do not use this one, but those that do, record this as diastolic pressure.

• Phase 5: Disappearance of sound (diastolic pressure).

• Normal Blood Pressure Reading: Shown as a fraction. Example (120/80, 120 being the phase one (systolic and contraction), and 80 being diastolic or relaxing and recording. Medical world for the first number (starting) you hear is Systolic, and for the last number (stopping) you hear is diastolic.

Stages of Blood Pressure

Stages of Blood Pressure:

• Stage 1:

  • Hypertension due to stress, obesity, high salt intake, sedentary lifestyle, aging.

  • Physical condition due to thyroid dysfunction, neurological disorders and circulation conditions of the blood flow.

Hypertension Terminology:

Hypertension Terminology:

• Elevated pressure without apparent condition - Idiopathic/essential stage one hypertension.

• No identifiable cause - primary hypertension.

• Have underlying disease that increases blood pressure - Secondary.

• Severe, difficult to control, impossible to control - Malignant Hypertension. (May have to look into exploring Arteries/Scarring).

*New technology has been created to detect damage to the heart. Not all insurances cover this in its testing phases.

Hypotension:

Hypotension:

• Low blood pressure.

  • The greater a high the reading, the greater chance for strokes, heart attacks, etc.

  • Related to Kidney disorders.

• 90/60 indicates low blood pressure (hypotension), with possible causes:

  • Heart failure, severe burns, dehydrated, depression, hemorrhage.

• Orthostatic hypotension: Drop in blood pressure when changing from sitting to standing (whooh, spinning).

Pulse Pressure:

Pulse Pressure:

-Difference between systolic and diastolic (120/80, equals 40, is normal).

• Over 50 or less than 30 is abnormal.

Essential Equipment Factors::

Essential Equipment Factors::

• Need Stethoscope and sphygmomanometer.

• Need to be calibrated with manometer (dial sphygmomanometer, pressure gauge - need to be calibrated). At resting, if the hand on dial is on zero, it correctly calibrated.

• Can't correct it if off, need a new one.

Dials::

Dials::

• Larger longer lines - Represent twenties.

• Medium lines - Represent tens.

• Smaller lines - Represent twos.

• Manual Android: Electronic model.

Main Key Points: The Bladder, Cup and Bulb.

Main Key Points: The Bladder, Cup and Bulb.

• Android manual - Means manually inflation.

• The bladder is the air reservoir in the cup, and inside the cup is where the pressure comes from.

• Inflate the cup using a bulb, used for release.

  • Need to tighten cup, but do not tighten completely.

Different cup sizes::

Different cup sizes::

• Neonates, Infants, Children, Adults, Obese Adults, Adult Thigh..

• If the size it too small, the reading is falsely high. If the size is two high, reading is falsely low.

• Need the bladder to be 80% of arm.

  • Too small of a cup, measure the width of the forearm, get reading in forearm by locating radial artery with a stethoscope.

Electronic Sphygmomanometer:

Electronic Sphygmomanometer:

• The electronic device automates manual inflation, requiring a stethoscope, but requires the MA to hit a button to activate blood pressure.

Measuring Techniques

Measuring Techniques:

Need the strict procedures for an accurate reading of BP (blood pressure)

The cuff has to be deflated before reading. Patient's arm needs to be relaxed, slightly flexed, with brachial artery level and free of restricted sleeve. Hand needs to be up, need access to reach artery at brachial height.

Fold the bladder area of the cup. This will make it easy to line the cup with the brachial artery markings.

Manometer should not be further than 3 feet from you and it is important NOT to stare at the dial.

You would do palpatory reading first, to determine for inflation. This can be done by inflating a bit, using valves with fingers to feel radial from arm becoming constricted. Where feel radial pulse on Sphygmomanometer, is the radial.

Deflate, wait 30 seconds. Inflate, but the mm mercury 30 higher."