Measuring Body Temperature

• Vital signs measure the body’s basic functions.
• Vital signs include temperature, pulse, respiration, blood pressure (BP), and oxygen saturation.
• Vital signs indicate a person's hemodynamic status and are monitored by health professionals.

Temperature

• Temperature is the balance between heat produced and heat lost.
• Use a thermometer to measure temperature.
• Normal temperature is considered to be 98.6°F (37°C).
• Acceptable range is between 97.6° F (36.4°C) to 99.6°F (37.5°C).
• Temperature over 100.4 °F (38°C) indicates a fever caused by illness or injury.
• Hypothermia (low temperature) occurs when the body temperature dips below 95 degrees F (35 degrees C).
• Digital thermometers are most commonly used.
• Do not use glass thermometers or forehead strips, because they aren't accurate and glass thermometers can be dangerous.
• Needed Equipment: tray with thermometer, jar of cotton balls soaked in water, jar of cotton balls in soap suds solution, jar with cut tissue paper, waste receptacle, wristwatch with second hand, notebook and pen.

Oral Temperature Measurement

• This method is typically not used on infants.
• This method is typically not used on unconscious or irrational patients, or those with a history of seizures.
• This method is typically not used on patients who breathe through the mouth.
• This method is typically not used on those with disease of the oral cavity or surgery of the nose or mouth.
• This method is typically not used on patients who have had cold or hot foods/fluids.
• Encourage the patient to refrain from drinking, eating, or smoking. This is because cold or hot liquids and smoking alter circulation and body temperature
• Put the tip under the patient's tongue in the posterior sublingual pocket, because sublingual pocket contains superficial blood vessels.
• Instruct the patient to close mouth with the lips and not the teeth around the thermometer, which is done to hold the thermometer in place.

Axillary Temperature Measurement

• This method is indicated with oral inflammation or recovering from oral surgery.
• This method is indicated for those who cannot breathe through the nose
• This method is indicated for irrational patients.
• This method is indicated for whom other temperature sites are contraindicated.
• Cleanse the patient's armpit and by gently wiping or patting it with tissue (you may ask the patient to do it , if able).
• If the axilla has just been washed, delay for a few minutes the taking of temperature to make sure it is dry.
• Place the thermometer well into the patient's axilla, bring the patient's arm down close to his body and place his forearm over his chest to keep the patient's arm tight against his body, as this helps get a more accurate temperature.
• For children under 5 years old , Hold the child comfortably on your knee and put the thermometer in their armpit, and gently, but firmly, hold the child's arm against their body to prevent any undue movement and to keep the thermometer in place.

Tympanic/Aural Temperature Measurement

• This method is contraindicated in an infant or child who has significant ear pathology
• This method is contraindicated in the presence of a foreign body in the ear or has moisture in the ear, such as cerebrospinal fluid or blood.
• Advantages: more accurate reflection of core temperature, non-invasive, relatively easy to use and is comfortable for children and is more hygienic, less invasive and safer than other forms of thermometry.
• Place a probe cover on the thermometer tip without touching the probe cover with your hands. Only the tip of the probe is inserted in the opening this is important to prevent damage to the ear canal.
• Gently pull the patient's ear before putting the thermometer in the ear straighten the ear canal. Adults: up and back, Children: down and back.
• Slowly insert the tip of the probe just inside the opening of the ear until it perfectly snugs in place to prevent ambient air interfering with the temperature reading and causing a false low temperature measurement.
• Never force the thermometer into the ear and do not occlude the ear canal, because The ear canal is a sensitive and a highly innervated part of the body, so it is important not to force the tympanic probe into the ear.
• Activate the device.
• Discard the probe cover(without touching the cover) and place the device back into the holder.
• Where possible, use same type of equipment and same ear each time to ensure consistency in temperature readings. Switching between sites and changing from one type of thermometer to another can produce misleading results.

Rectal Temperature Measurement

• Indication: Used to obtain the first temperature in newborns to check anal patency
• the method is indicated when oral or other routes cannot be used
• This method is contraindicated in patients with diarrhea, rectal disorder or injury, hemorrhoids, with heart disease or any cardiovascular alteration as the thermometer may stimulate the vagus nerve causing bradycardia or rhythm disorder, who just had rectal surgery, with leukemia – may traumatize the rectal mucosa causing bleeding and or who is confused or agitated
• Disadvantage: slightly uncomfortable
• Close the door of the patient's room or if the patient is in a ward, screen to ensure privacy
• Position in lateral. Drape, exposing only the rectum to allow accurate visualization of the rectum
• Lubricate thermometer prior to inserting to reduce friction and facilitates insertion of the thermometer and minimizes irritation of the mucus membrane of the anal canal
• Fold back the bed linen and separate the buttocks so that the anal sphincter is seen clearly
• Insert the thermometer approximately 0.5 to 1 inch into the rectum. Further insertion can be painful and may damage rectal tissues.
• Press the patient's buttocks together using your gloved hand to hold and keep the thermometer in place and remove thermometer when beeping indicates the reading is complete and wipe it dry from stem to bulb, because Fecal matter and lubricant may be present.

Other Types of Temperature Measurement

• Strip-Type ThermometersThese are held against the forehead and are not an accurate way of taking a temperature. They show the temperature of the skin, rather than the body.

Temperature Conversion

• To convert from Fahrenheit to Celsius, deduct 32 from the Fahrenheit reading and then multiply by the fraction 5/9: C = (Fahrenheit temperature -32) × 5/9.
• To convert from Celsius to Fahrenheit, multiply the Celsius reading by the fraction 9/5 and then add 32: F = (Celsius temperature × 9/5) + 32.

Monitoring Temperature Action and Rationale

• Explain to the patient that vital signs will be assessed, this encourages participation, allays anxiety, and ensures accurate measurements.
• Gather equipment, which facilitates organized assessment and measurement.
• Perform hand hygiene/wash hands, and apply gloves when appropriate reduces transmission of microorganisms. Gloves are worn to avoid contact with bodily secretions and to reduce transmission of microorganisms.
• Clean the thermometer, from the bulb downward to the stem in a firm twisting motion,with cotton balls in soap suds solution, then rinse it with cotton balls soaked in water, because Cleaning for the cleanest to the dirtiest minimizes the spread of microorganism to the cleaner area.
• Turn the thermometer on.
• Wait until the thermometer beeps or flashes, then check the temperature reading on the display and inform patient of temperature reading promotes patient's participation in care.
• Clean or sterilize the thermometer from the stem downward to the bulb in the same firm twisting motion with cotton balls in soap suds solution, then rinse it with cotton balls soaked in water, and alllow to dry
• Do after care: Discard all used cotton balls and tissue paper in the waste receptacle and return equipment
• Returning equipment helps to reduce the spread of contamination
• Remove gloves and wash hands to reduce transmission of microorganisms.
• Record the temperature obtained on the jot down notebook, including the date, time and method used as follows: "O" for oral, "R" for rectal, "E" for ear, “А” for axillary to document the procedure done.

Pulse

• Pulse is a rhythmical throbbing that results from a wave of blood passing through an artery as the heart contracts.
• Heart rate or pulse is the number of times a heart beats per minute (bpm).
• The purpose of checking the pulse is to obtain an estimate of the quality of the heart's action per minute. Irregularities might indicate a heart problem
• The second purpose is to have an initial recording (a "baseline") that will enable to compare future measurements and monitor changes in our patient's condition

Pulse Assessment

• Rate is checking the pulse rate for 1 full minute, and the normal pulse rate in an adult is 60-100 bpm.
• Strength/Tension is grading the strength of the pulse and check the pulse points bilaterally and compare them. 0: absent; 1+: weak; 2+: normal; 3+: bounding
• Rhythm or Regularity: is the pulse regular or irregular
• Volume: many things-such as anxiety, injury, pain and fever-can raise the patient's pulse (heart rate) and certain medications such as beta blockers or digoxin can lower it; even the temperature of the room can affect heart rate so all of these reasons should be considered when assessing and recording the patient's pulse.

Pulse Ranges By Age

• Newborn (resting) 100-180 bpm
• Infant (resting) 80-150 bpm
• Child 2- 6 years 75-120 bpm
• Child 6-12 years 70-110 bpm
• Adolescent-adult 60-90 bpm
• Equipment needed: wrist watch with second -hand, jot down notebook and pen, stethoscope(for apical pulse)

Radial Pulse

• Have the patient rest their arm long side their body with the rest extended and the palm of the hand facing downward, or place arm on top of the patient's upper abdomen because This position places the radial artery in the inner aspect of the patient's wrist.
• Position client, locate and palpate site correctly by placing the first, second and third fingers (not thumb) along the radial artery to palpate, with the thumb resting on the back of the patient's wrist because The fingertips are sensitive to touch will feel the pulsation of the patient's radial artery . If the thumb is used to palpate the patient's pulse, the nurse may feel her own pulse.
• Press gently against the radial artery. Take your time to note any irregularities in strength or rhythm
• Using the watch with a second hand, wait until the second hand is on the 12, then count the number of pulsations felt for ONE (1) FULL MINUTE for at leats 1 minute to be able to fully see irregulaties

Apical Pulse

• Allows access to the patient's chest for proper placement of the stethoscope.
• Position on supine and drape. Raise the patient's gown to expose the sternum and the left side of the chest
• Warm the diaphragm of the stethoscope with your hand before applying it to the patient's chest, because Placing a cold diaphragm against the patient's skin may startle him and momentarily increase the heart rate
• Instruct the patient to relax and refrain from talking.
• Place the diaphragm of the stethoscope on the apex of the heart located at the fifth intercostal space in line with the middle of the clavicle, this gives the loudest and most distinctive sound of the heart.
• d.Move the diaphragm to the site with the loudest beats and count for a full minute and note the rhythm and volume. Evaluate the intensity(loudness) of the heart sounds.
• Remove the stethoscope and make the patient comfortable.
• Apical heart rate should be taken for a full minute for accuracy. Apical pulse should be used as the parameter indicated in certain cardiac medications (e.g., digoxin).

Carotid Pulse

• This is best tested if is best to take when radial pulse is not present or is difficult to palpate or most commonly used during CPR
• Tilting the head the to the side and palpate below the jaw line between the trachea and sternomastoid muscle is the the best location to find the carotid pulse point,
• if the pulse is abnormal in any way, repeat the counting to determine accurately the rate, the quality and the volume.
• Longer counting and palpation are necessary to identify most accurately the unusual characteristics of the pulse
• Recording pulse rate in the jot down notebook, and describe its strength and rhythm helps to document the procedure done.
• Washing and drying hands helps Deterr the spread of microorganisims

Respiration

• Respiration is the exchange of oxygen and carbon dioxide between the atmosphere and the body
• Respiration rate is the number of breaths a person takes per minute
• The purpose checking respiration is to obtain the respiratory rate per minute and an estimate of the patient's respiratory status

Normal Respiration Ranges

• Adult person at rest range from 16-20 breaths per minute

• Infants: 30-40 breaths per minute

• Children: 20-25 breaths per minute

• The rate is usually measured when a person is at rest an dcount the number of breaths for one minute (counting how many times the chest rises).

• Equipment needed: wristwatch with second-hand and notebook and pen.

• When you still are still counting the pulse rate, observe the patient's respiration because Observe without awareness and counting respiration keeps the patient from becoming conscious of his breathing which can possibly alter his usual rate.

• Note the rising and falling of the chest with chest with each inspiration and experitation because A complete cycle of ispiration adn expiration constitutes an act of respiration.

• With a watch with second hand, count the number of respiration unobtrusively fo rone full minute, and because Sufficient time is necessary to observe rate, depth and other characteristics

• If the respirations are abormal, repeat to determine the rate and the characteristics of the breathing accurately to accurately identify characterisitics

• Record respiration rate in the jot down notebook including the abnormalities in rhythm and depth, if any because this helps provide documentation.

Blood Pressure

• Blood pressure is the lateral force exerted by the blood on the arterial walls during contraction and relaxation of the heart
• Aid in diagnosis is one of its multiple purposes
• Another purpose is It also monitors changes in the patient's condition
• Contraindications for brachial artery BP measurement: Surgery including the breasts, axilla, shoulder . arm or hands. Venous access device such as AV shunt and IVF and Injury or disease to the shoulder, arm or hands such as trauma, burn, application of cast or bandage.
• Sites for BP taking: Either arm on the antecubital space, either leg on the popliteal space and dorsalis pedis.
• Factors that can cause a variation in blood pressure: emotional state, temperature, respiration, bladder distension, pain, exercise, age, food consumption, race/ethnicity, tobacco use, diurnal variation (blood pressure is at its lowest during sleep), alcohol use and ‘white coat' hypertension (raised blood pressure when measured in clinical settings), sudden change in posture, underlying medical conditions and renal failure, diabetes, anaphylaxis, hypovolaemia
• Equipment needed: jot down notebook and pen and or sphygmomanometer and stethoscope (for manual BP taking) or digital BP apparatus. Always use the right cuff size

Classification of Blood Pressure

• Ask the patient if he just had any activity like walking or he has just eaten becuase this is to ensure accurate measurement of the blood pressure.
• Have the patient sit in a comfortable position, with legs and ankles uncrossed and the back supported because this places the brachial artery so that a stethoscope can rest conveniently on the antecubital area.
• Place correct size cuff around the extremity with the center of the cuff of the artery and Cuff should be placed around upper arm with the lower edge about 3 cm above the antecubital fossa because Pressure applied to the artery will yield most accurate readings.
• A twisted cuff and wrapping could produce inaccurate reading so make sure its not twisted
• Extend the patient's arm and have the palm face upward. Using the fingertips, locate the artery by palpation.
• Palpate a pulse distal to the cuff, e.g., brachial or radial and carefully place stethoscope gently over artery to ensure Accurate blood pressure reading is possible
• The importance of The stethoscope is directly over the artery as it produces the best sound transmission.

Common BP Errors

• Close air valve and inflate cuff to 30 mm Hg above where pulse no longer felt or above expected systolic blood pressure to apply pressure in the cuff, which prevents blood from flowing through the brachial artery.
• Open the valve and slowly release the air, permitting the pressure to drop 2–3 mm Hg per heart beat while auscultating for BP sounds or palpating for a pulse, because too-rapid deflation of the cuff yields inaccurate reading.
• Note on the manometer the point at which the first clear, loud sound is heard and this sound is systolic pressure because systolic pressure is that point which blood in the artery is first able to force its way through against the pressure exerted on the vessel by the cuff of the manometer. This id the maximum pressure exerted on the arterial walls when the left ventricle of the heart pushes blood into the aorta.
• Continue to gradually release air from the cuff. Note the last distinct loud sound heard on the stethoscope because it allows accurate measurement of the diastolic pressure.
• Diastolic pressure is that point which blood flows freely in the artery and is equivalent to the amount of pressure normally exerted on the walls of the arteries when the heart is at rest, or the minimum pressure which is constantly present on the arterial walls.
• Deflate the cuff rapidly and completely and remove from the arm becuase leaving the ciff inflated for a long period may cause discomfort to the patient.
• If using a digital BP apparatus: Turn the power on to start the unit.
• On the automatic models, the cuff will inflate by itself with a push of a button or On the manual models, you have to inflate the cuff, and to do this you squeeze the rubber bulb at a rapid rate.
• After the cuff inflates, the automatic device will slowly let air out.
• Look at the display screen to get your blood pressure reading, it will show your systolic and diastolic pressures and then a press the exhaust button to release all of the air from the cuff.
• If you need to repeat the measurement, wait 2 to 3 minutes before re-starting to allow the artery to rest.
• Cleaning cuff and device if multi-use device with hand hygiene can to prevent cross-contamination. To do this make sure you
• Record the BP reading on the jot down notebook which to document the procedure
• Oxygen Saturation

Oxygen Saturation

• This measures how much oxygen your blood is carrying as a percentage of the maximum it could carry using a device called pulse oximeter ( a small clamp-like device placed on a finger, earlobe, or toe).

• A pulse oximeter is a rapid tool to assess oxygenation accurately if signs and symptoms of hypoxemia may not be visible on physical examination.

• Indications: assessing how well a new lung medication is working, determine how well a pt needs breathing help, determine how will a ventilator can support and monitor oxygen levels during surgical procedures that requires sedation

• Determining is someone can tolerate increased physical activity helps monitor oxygen and is the reason why oxygen levels are taken

• Monitor the location of the probe for changes in skin conditions such as blisters or damage to the nail bed.

• If with patients with burns monitor probe to be replaced every 2 to 4 hours.

• Equipment needed: pulse oximeter, water-based wipes (optional), and jot down notebook and pen

• Clean the site where the probe of the pulse oximeter will be placed ensures accurate reading.

• Clean the site of finger, and remove the nail polish, if present and

• Place the pulse oximeter on the patient's finger, earlobe, or toe.

• In some cases, a small probe may be placed on the finger or forehead with a sticky adhesive

• Instruct your patient so that he may feel a small amount of pressure, but there is no pain or pinching.

• If used for a prolonged period monitor the site for the following risks :-If the probe falls off the earlobe, toe, or finger Skin irritation from adhesive on the probe

• Document the procedure on the jot down notebook

• Do after care.