04 vital signs temp pulse

HEALTH
ASSESSMENT
VITAL SIGNS : TEMPERATURE AND PULSE
BY: JHONEE F. BALMEO.RN.

VITAL SIGNS
• VITAL SIGNS ARE MEASUREMENTS OF THE BODY'S MOST
BASIC FUNCTIONS. THE FOUR MAIN VITAL SIGNS ROUTINELY
MONITORED BY MEDICAL PROFESSIONALS AND HEALTH
CARE PROVIDERS INCLUDE THE FOLLOWING:
• TEMPERATURE
• PULSE
• RESPIRATION
• BLOOD PRESSURE

VITAL SIGNS
• VITAL SIGNS ARE USEFUL IN
DETECTING OR MONITORING
MEDICAL PROBLEMS. VITAL
SIGNS CAN BE MEASURED IN A
MEDICAL SETTING, AT HOME, AT
THE SITE OF A MEDICAL
EMERGENCY, OR ELSEWHERE.

VITAL SIGNS
• THE TRADITIONAL VITAL SIGNS ARE BODY TEMPERATURE,
PULSE, RESPIRATIONS, AND BLOOD PRESSURE. MANY
AGENCIES SUCH AS THE VETERANS ADMINISTRATION,
AMERICAN PAIN SOCIETY, AND THE JOINT COMMISSION
HAVE DESIGNATED PAIN AS A FIFTH VITAL SIGN, TO BE
ASSESSED AT THE SAME TIME AS EACH OF THE OTHER
FOUR.

VITAL SIGNS
• MONITORING A CLIENT’S VITAL
SIGNS SHOULD NOT BE AN
AUTOMATIC OR ROUTINE
PROCEDURE; IT SHOULD BE A
THOUGHTFUL, SCIENTIFIC
ASSESSMENT

VITAL SIGNS
• SOME AGENCIES HAVE
POLICIES ABOUT WHEN TO
TAKE CLIENTS’ VITAL SIGNS.
THE PRIMARY CARE PROVIDER
MAY SPECIFICALLY ORDER A
VITAL SIGN (E.G., “BLOOD
PRESSURE Q2H”).
Can we delegate the vital signs taking to

VITAL SIGNS
• UNDER THOSE CIRCUMSTANCES,
THE UAP MAY MEASURE,
RECORD, AND REPORT VITAL
SIGNS BUT REAL ASSESSMENT,
INTERPRETATION OF THE
MEASUREMENTS, RESTS WITH
THE REGISTERED NURSE.

BODY TEMPERATURE
• BODY TEMPERATURE REFLECTS THE
BALANCE BETWEEN THE HEAT
PRODUCED AND THE HEAT LOST
FROM THE BODY, AND IS MEASURED
IN HEAT UNITS CALLED DEGREES.
THERE ARE TWO KINDS OF BODY
TEMPERATURE: CORE TEMPERATURE
AND SURFACE TEMPERATURE.

BODY TEMPERATURE
• CORE TEMPERATURE IS THE
TEMPERATURE OF THE DEEP
TISSUES OF THE BODY, SUCH AS
THE ABDOMINAL CAVITY AND
PELVIC CAVITY. IT REMAINS
RELATIVELY CONSTANT.

BODY TEMPERATURE
• THE SURFACE TEMPERATURE IS THE
TEMPERATURE OF THE SKIN, THE
SUBCUTANEOUS TISSUE, AND FAT. IT, BY
CONTRAST, RISES AND FALLS IN RESPONSE
TO THE ENVIRONMENT.

BODY TEMPERATURE
• THE BODY CONTINUALLY
PRODUCES HEAT AS A BY-
PRODUCT OF METABOLISM. WHEN
THE AMOUNT OF HEAT PRODUCED
BY THE BODY EQUALS THE
AMOUNT OF HEAT LOST, THE
PERSON IS IN HEAT BALANCE

BODY TEMPERATURE
• A NUMBER OF FACTORS AFFECT THE BODY’S HEAT
PRODUCTION. THE MOST IMPORTANT ARE THESE FIVE:
• 1. BASAL METABOLIC RATE.
THE BASAL METABOLIC RATE (BMR) IS THE RATE OF ENERGY
UTILIZATION IN THE BODY REQUIRED TO MAINTAIN ESSENTIAL
ACTIVITIES SUCH AS BREATHING.

BODY TEMPERATURE
• 2. MUSCLE ACTIVITY.
MUSCLE ACTIVITY, INCLUDING SHIVERING, INCREASES THE
METABOLIC RATE.
• 3. THYROXINE OUTPUT.
INCREASED THYROXINE OUTPUT INCREASES THE RATE OF
CELLULAR METABOLISM THROUGHOUT THE BODY.

BODY TEMPERATURE
• 4. EPINEPHRINE, NOREPINEPHRINE, AND SYMPATHETIC STIMULATION /
STRESS RESPONSE.
THESE HORMONES IMMEDIATELY INCREASE THE RATE OF
CELLULAR METABOLISM IN MANY BODY TISSUES.
• 5. FEVER.
FEVER INCREASES THE CELLULAR METABOLIC RATE AND THUS
INCREASES THE BODY’S TEMPERATURE FURTHER.

BODY HEAT LOST
• HEAT IS LOST FROM THE BODY THROUGH
• RADIATION,
• CONDUCTION,
• CONVECTION, AND
• EVAPORATION

BODY HEAT LOST
• RADIATION IS THE TRANSFER OF
HEAT FROM THE SURFACE OF ONE
OBJECT TO THE SURFACE OF
ANOTHER WITHOUT CONTACT
BETWEEN THE TWO OBJECTS, MOSTLY
IN THE FORM OF INFRARED RAYS.

BODY HEAT LOST
• CONDUCTION IS THE TRANSFER OF HEAT FROM ONE
MOLECULE TO A MOLECULE OF LOWER TEMPERATURE.
CONDUCTIVE TRANSFER CANNOT TAKE PLACE WITHOUT
CONTACT BETWEEN THE MOLECULES AND NORMALLY
ACCOUNTS FOR MINIMAL HEAT LOSS EXCEPT, FOR
EXAMPLE, WHEN A BODY IS IMMERSED IN COLD WATER.

BODY HEAT LOST
• CONVECTION IS THE DISPERSION OF
HEAT BY AIR CURRENTS. THE BODY
USUALLY HAS A SMALL AMOUNT OF
WARM AIR ADJACENT TO IT. THIS WARM
AIR RISES AND IS REPLACED BY COOLER
AIR, SO PEOPLE ALWAYS LOSE A SMALL
AMOUNT OF HEAT THROUGH
CONVECTION.

BODY HEAT LOST
• EVAPORATION IS CONTINUOUS
VAPORIZATION OF MOISTURE
FROM THE RESPIRATORY
TRACT AND FROM THE
MUCOSA OF THE MOUTH AND
FROM THE SKIN.

REGULATION OF BODY TEMPERATURE
• THE SYSTEM THAT REGULATES BODY TEMPERATURE HAS
THREE MAIN PARTS: SENSORS IN THE PERIPHERY AND IN
THE CORE, AN INTEGRATOR IN THE HYPOTHALAMUS,
AND AN EFFECTOR SYSTEM THAT ADJUSTS THE
PRODUCTION AND LOSS OF HEAT.

• THE SKIN HAS MORE RECEPTORS FOR COLD THAN WARMTH.
THEREFORE, SKIN SENSORS DETECT COLD MORE EFFICIENTLY
THAN WARMTH.
• WHEN THE SKIN BECOMES CHILLED OVER THE ENTIRE BODY,
THREE PHYSIOLOGICAL PROCESSES TO INCREASE THE BODY
TEMPERATURE TAKE PLACE:
• 1. SHIVERING INCREASES HEAT PRODUCTION.
• 2. SWEATING IS INHIBITED TO DECREASE HEAT LOSS.
• 3. VASOCONSTRICTION DECREASES HEAT LOSS.

• THE HYPOTHALAMIC INTEGRATOR IS THE CENTER THAT
CONTROLS THE CORE TEMPERATURE. WHEN THE
INTEGRATOR DETECTS HEAT, IT SENDS OUT SIGNALS
INTENDED TO REDUCE THE TEMPERATURE, THAT IS, TO
DECREASE HEAT PRODUCTION AND INCREASE HEAT
LOSS.

• THE SIGNALS FROM THE COLD-SENSITIVE RECEPTORS OF THE
HYPOTHALAMUS INITIATE EFFECTORS, SUCH AS
VASOCONSTRICTION, SHIVERING, AND THE RELEASE OF
EPINEPHRINE, WHICH INCREASES CELLULAR METABOLISM AND
HENCE HEAT PRODUCTION.
• WHEN THE WARMTH-SENSITIVE RECEPTORS IN THE
HYPOTHALAMUS ARE STIMULATED, THE EFFECTOR SYSTEM
SENDS OUT SIGNALS THAT INITIATE SWEATING AND

FACTORS AFFECTING BODY TEMPERATURE
• NURSES SHOULD BE AWARE OF THE FACTORS THAT CAN
AFFECT A CLIENT’S BODY TEMPERATURE SO THAT THEY
CAN RECOGNIZE NORMAL TEMPERATURE VARIATIONS
AND UNDERSTAND THE SIGNIFICANCE OF BODY
TEMPERATURE MEASUREMENTS THAT DEVIATE FROM
NORMAL.

• 1. AGE.
THE INFANT IS GREATLY INFLUENCED BY THE
TEMPERATURE OF THE ENVIRONMENT AND MUST BE
PROTECTED FROM EXTREME CHANGES. CHILDREN’S
TEMPERATURES VARY MORE THAN THOSE OF ADULTS
UNTIL PUBERTY.

• 2. DIURNAL VARIATIONS(CIRCADIAN RHYTHMS).
BODY TEMPERATURES NORMALLY CHANGE THROUGHOUT
THE DAY, VARYING AS MUCH AS 1.0°C (1.8°F) BETWEEN
THE EARLY MORNING AND THE LATE AFTERNOON.
HIGHEST BODY TEMPERATURE: 4:00PM - 6:00PM
LOWEST POINT: 4:00 AM AND 6:00 AM

• 3. EXERCISE.
HARD WORK OR STRENUOUS EXERCISE CAN INCREASE
BODY TEMPERATURE TO AS HIGH AS 38.3°C TO 40°C
(101°F TO 104°F) MEASURED RECTALLY.

• 4. HORMONES.
WOMEN USUALLY EXPERIENCE MORE HORMONE
FLUCTUATIONS THAN MEN. IN WOMEN, PROGESTERONE
SECRETION AT THE TIME OF OVULATION RAISES BODY
TEMPERATURE BY ABOUT 0.3°C TO 0.6°C (0.5°F TO 1.0°F)
ABOVE BASAL TEMPERATURE.

• 5. STRESS.
STIMULATION OF THE SYMPATHETIC NERVOUS SYSTEM
CAN INCREASE THE PRODUCTION OF EPINEPHRINE AND
NOREPINEPHRINE, THEREBY INCREASING METABOLIC
ACTIVITY AND HEAT PRODUCTION. NURSES MAY
ANTICIPATE THAT A HIGHLY STRESSED OR ANXIOUS
CLIENT COULD HAVE AN ELEVATED BODY TEMPERATURE
FOR THAT REASON.

• 6. ENVIRONMENT.
EXTREMES IN ENVIRONMENTAL TEMPERATURES CAN
AFFECT A PERSON’S TEMPERATURE REGULATORY SYSTEMS.

ALTERATIONS IN BODY TEMPERATURE
• PYREXIA
A BODY TEMPERATURE ABOVE THE USUAL RANGE IS CALLED
PYREXIA, HYPERTHERMIA, OR (IN LAY TERMS) FEVER. A VERY
HIGH FEVER, SUCH AS 41°C (105.8°F), IS CALLED
HYPERPYREXIA.
THE CLIENT WHO HAS A FEVER IS REFERRED TO AS FEBRILE;
THE ONE WHO DOES NOT IS AFEBRILE.

TYPES OF FEVERS
• FOUR COMMON TYPES OF FEVERS ARE INTERMITTENT,
REMITTENT, RELAPSING, AND CONSTANT.
• DURING AN INTERMITTENT FEVER, THE BODY TEMPERATURE
ALTERNATES AT REGULAR INTERVALS BETWEEN PERIODS OF
FEVER AND PERIODS OF NORMAL OR SUBNORMAL
TEMPERATURES.

TYPES OF FEVERS
• DURING A REMITTENT FEVER SUCH AS WITH A COLD OR
INFLUENZA, A WIDE RANGE OF TEMPERATURE
FLUCTUATIONS (MORE THAN 2°C [3.6°F]) OCCURS OVER A
24-HOUR PERIOD, ALL OF WHICH ARE ABOVE NORMAL.

TYPES OF FEVERS
• IN A RELAPSING FEVER, SHORT FEBRILE PERIODS OF A
FEW DAYS ARE INTERSPERSED WITH PERIODS OF 1 OR 2
DAYS OF NORMAL TEMPERATURE.

TYPES OF FEVERS
• DURING A CONSTANT FEVER, THE BODY TEMPERATURE
FLUCTUATES MINIMALLY BUT ALWAYS REMAINS ABOVE
NORMAL. THIS CAN OCCUR WITH TYPHOID FEVER.

TYPES OF FEVERS
• A TEMPERATURE THAT RISES TO FEVER LEVEL RAPIDLY
FOLLOWING A NORMAL TEMPERATURE AND THEN RETURNS
TO NORMAL WITHIN A FEW HOURS IS CALLED A FEVER SPIKE.
• BACTERIAL BLOOD INFECTIONS OFTEN CAUSE FEVER SPIKES.

• IN SOME CONDITIONS, AN
ELEVATED TEMPERATURE IS NOT
A TRUE FEVER.
• TWO EXAMPLES ARE HEAT
EXHAUSTION AND HEAT STROKE

• HEAT EXHAUSTION IS A RESULT OF EXCESSIVE HEAT AND
DEHYDRATION. SIGNS OF HEAT EXHAUSTION INCLUDE
PALENESS, DIZZINESS, NAUSEA, VOMITING, FAINTING,
AND A MODERATELY INCREASED TEMPERATURE (38.3°C
TO 38.9°C [101°F TO 102°F]).

• HEAT STROKE IS GENERALLY HAVE BEEN EXERCISING IN
HOT WEATHER, HAVE WARM, FLUSHED SKIN, AND OFTEN
DO NOT SWEAT. THEY USUALLY HAVE A TEMPERATURE
OF 41.1°C (106°F) OR HIGHER, AND MAY BE DELIRIOUS,
UNCONSCIOUS, OR HAVING SEIZURES.

NURSING INTERVENTIONS FOR CLIENTS WITH
FEVER
• ■ MONITOR VITAL SIGNS.
• ■ ASSESS SKIN COLOR AND TEMPERATURE.
• ■ MONITOR WHITE BLOOD CELL COUNT, HEMATOCRIT VALUE, AND OTHER
PERTINENT LABORATORY
• ■ REMOVE EXCESS BLANKETS WHEN THE CLIENT FEELS WARM, BUT PROVIDE
EXTRA WARMTH WHEN THE CLIENT FEELS CHILLED.
• ■ PROVIDE ADEQUATE NUTRITION AND FLUIDS (E.G., 2,500–3,000 ML PER
DAY) TO MEET THE INCREASED METABOLIC DEMANDS AND PREVENT
DEHYDRATION.

FEVER
• ■ REDUCE PHYSICAL ACTIVITY TO LIMIT HEAT PRODUCTION
• ■ ADMINISTER ANTIPYRETICS (DRUGS THAT REDUCE THE LEVEL
OF FEVER) AS ORDERED.
• ■ PROVIDE ORAL HYGIENE TO KEEP THE MUCOUS MEMBRANES
MOIST.
• ■ PROVIDE A TEPID SPONGE BATH TO INCREASE HEAT LOSS
THROUGH CONDUCTION.
• ■ PROVIDE DRY CLOTHING AND BED LINENS.

HYPOTHERMIA
• HYPOTHERMIA IS A CORE BODY TEMPERATURE BELOW THE
LOWER LIMIT OF NORMAL.
• THE THREE PHYSIOLOGICAL MECHANISMS OF HYPOTHERMIA ARE
(a)EXCESSIVE HEAT LOSS,
(b)INADEQUATE HEAT PRODUCTION TO COUNTERACT HEAT LOSS,
AND
(c)IMPAIRED HYPOTHALAMIC THERMOREGULATION.

HYPOTHERMIA
• HYPOTHERMIA MAY BE INDUCED OR ACCIDENTAL.
• INDUCED HYPOTHERMIA IS THE DELIBERATE LOWERING OF THE
BODY TEMPERATURE TO DECREASE THE NEED FOR OXYGEN BY
THE BODY TISSUES SUCH AS DURING CERTAIN SURGERIES.
• ACCIDENTAL HYPOTHERMIA CAN OCCUR AS A RESULT OF (A)
EXPOSURE TO A COLD ENVIRONMENT, (B) IMMERSION IN COLD
WATER, AND (C) LACK OF ADEQUATE CLOTHING, SHELTER, OR
HEAT

HYPOTHERMIA
• ■ PROVIDE A WARM ENVIRONMENT.
• ■ PROVIDE DRY CLOTHING.
• ■ APPLY WARM BLANKETS.
• ■ KEEP LIMBS CLOSE TO BODY.
• ■ COVER THE CLIENT’S SCALP WITH A CAP OR TURBAN.
• ■ SUPPLY WARM ORAL OR INTRAVENOUS FLUIDS.
• ■ APPLY WARMING PADS.

ASSESSING BODY TEMPERATURE
• THE MOST COMMON SITES FOR
MEASURING BODY TEMPERATURE
ARE ORAL, RECTAL, AXILLARY,
TYMPANIC MEMBRANE, AND
SKIN/TEMPORAL ARTERY.

• FOR ORAL TEMPERATURES
WHEN USING A GLASS THERMOMETER, SHAKE THE THERMOMETER
DOWN TO 35°C (96°F) OR BELOW, INSERT IT UNDER THE TONGUE,
INSTRUCT THE PATIENT TO CLOSE BOTH LIPS, AND WAIT 3 TO 5
MINUTES.
NOTE THAT HOT OR COLD LIQUIDS, AND EVEN SMOKING, CAN ALTER
THE TEMPERATURE READING. IN THESE SITUATIONS, IT IS BEST TO
DELAY MEASURING THE TEMPERATURE FOR 10 TO 15 MINUTES (30MINS

• FOR A RECTAL TEMPERATURE
ASK THE PATIENT TO LIE ON ONE SIDE WITH THE HIP
FLEXED. SELECT A RECTAL THERMOMETER WITH A STUBBY
TIP, LUBRICATE IT, AND INSERT IT ABOUT 3 CM TO 4 CM
(1½ INCHES) INTO THE ANAL CANAL, IN A DIRECTION
POINTING TO THE UMBILICUS.

• TAKING THE TYMPANIC MEMBRANE
TEMPERATURE IS AN INCREASINGLY COMMON PRACTICE
AND IS QUICK, SAFE, AND RELIABLE IF PERFORMED
PROPERLY. MAKE SURE THE EXTERNAL AUDITORY CANAL
IS FREE OF CERUMEN, WHICH LOWERS TEMPERATURE
READINGS.

• THE AXILLA
IS OFTEN THE PREFERRED SITE FOR MEASURING
TEMPERATURE IN NEWBORNS BECAUSE IT IS ACCESSIBLE
AND SAFE. AXILLARY TEMPERATURES ARE LOWER THAN
RECTAL TEMPERATURES.

• THE TEMPERATURE MAY ALSO BE MEASURED ON THE
FOREHEAD USING A CHEMICAL THERMOMETER OR A
TEMPORAL ARTERY THERMOMETER. FOREHEAD
TEMPERATURE MEASUREMENTS ARE MOST USEFUL FOR
INFANTS AND CHILDREN WHERE A MORE INVASIVE
MEASUREMENT IS NOT NECESSARY.

TYPES OF THERMOMETERS
• TRADITIONALLY, BODY TEMPERATURES WERE MEASURED
USING MERCURY IN-GLASS THERMOMETERS. GLASS
THERMOMETERS CAN BE HAZARDOUS DUE TO EXPOSURE
TO MERCURY, WHICH IS TOXIC TO HUMANS, AND
BROKEN GLASS SHOULD THE THERMOMETER CRACK OR
BREAK

TYPES OF THERMOMETERS
• ELECTRONIC THERMOMETERS
CAN PROVIDE A READING IN
ONLY 2 TO
60SECONDS,DEPENDING ON THE
MODEL.

TYPES OF
THERMOMETERS
• CHEMICAL DISPOSABLE
THERMOMETERS ARE ALSO USED
TO MEASURE BODY
TEMPERATURES. CHEMICAL
THERMOMETERS HAVE LIQUID
CRYSTAL DOTS OR BARS THAT
CHANGE COLOR TO INDICATE
TEMPERATURE.

• TEMPERATURE-SENSITIVE TAPE MAY
ALSO BE USED TO OBTAIN A GENERAL
INDICATION OF BODY SURFACE
TEMPERATURE. IT DOES NOT INDICATE
THE CORE TEMPERATURE. THE TAPE
CONTAINS LIQUID CRYSTALS THAT
CHANGE COLOR ACCORDING TO
TEMPERATURE.

• INFRARED THERMOMETERS
SENSE BODY HEAT IN THE
FORM OF INFRARED
ENERGY GIVEN OFF BY A
HEAT SOURCE.

• TEMPORAL ARTERY THERMOMETERS
DETERMINE TEMPERATURE USING A
SCANNING INFRARED THERMOMETER
THAT COMPARES ARTERIAL
TEMPERATURE IN THE TEMPORAL
ARTERY OF THE FOREHEAD TO THE
TEMPERATURE IN THE ROOM

TEMPERATURE SCALES
• C = (FAHRENHEIT TEMPERATURE – 32) X 5/9
• F = (CELSIUS TEMPERATURE X 9/5) + 32

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• CONVERT 98.6°F TO CELSIUS TEMP
• 37.3°C TO FAHRENHEIT TEMP

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• KNOWN AS A NORMAL BODY TEMPERATURE
• A. AFEBRILE
• B. APYREXIA.
• C. HYPERPYREXIA
• D. PYREXIA

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• REPRESENTS THE BALANCE BETWEEN THE HEAT
PRODUCED BY THE BODY AND THE HEAT LOST
A. METABOLIC RATE
B. HOMEOSTASIS
C. CORE TEMPERATURE
• D. BODY TEMPERATURE

COMMON TERMINOLOGY
• APYREXIA A NORMAL BODY TEMPERATURE
• BODY TEMPERATURE REPRESENTS THE BALANCE BETWEEN THE
HEAT PRODUCED BY THE BODY
AND THE HEAT LOST
• CIRCADIAN RHYTHM SLEEP CYCLE (BODY TEMPERATURE IS
LOWER AT DIFFERENT TIMES OF THE
SLEEP CYCLE)
• CONDUCTION THE TRANSMISSION OF HEAT FROM ONE
OBJECT TO ANOTHER
• CONVECTION THE TRANSMISSION OF HEAT BY

COMMON TERMINOLOGY
• CORE TEMPERATURE THE TEMPERATURE OF THE DEEP
TISSUES AND ORGANS WITHIN THE
CRANIAL, THORACIC AND
ABDOMINAL CAVITIES
• EVAPORATION TO LOSE HEAT THROUGH
MOISTURE, I.E. SWEATING
• FRENULUM THE THIN MEMBRANE ANCHORING
THE TONGUE TO THE SOFT

COMMON TERMINOLOGY
• HEAT STROKE A POTENTIALLY SERIOUS CONDITION
PRODUCED BY PROLONGED EXPOSURE
TO EXCESSIVE TEMPERATURES, WHICH CAN
LEAD TO COMA AND DEATH
• HOMEOSTASIS MAINTENANCE OF A CONSTANT BUT
DYNAMIC INTERNAL ENVIRONMENT
• HYPERPYREXIA A VERY HIGH BODY TEMPERATURE

COMMON TERMINOLOGY
• HYPOTHERMIA A VERY LOW BODY TEMPERATURE
METABOLIC RATE THE SPEED AT WHICH THE BODY’S
INTERNAL MECHANISMS ARE
FUNCTIONING
• PYREXIA A HIGH BODY TEMPERATURE
• SURFACE TEMPERATURE TEMPERATURE OF THE SKIN
SURFACE)

PULSE
• THE PULSE IS A WAVE OF BLOOD CREATED
BY CONTRACTION OF THE LEFT VENTRICLE
OF THE HEART. GENERALLY, THE PULSE
WAVE REPRESENTS THE STROKE VOLUME
OUTPUT OR THE AMOUNT OF BLOOD THAT
ENTERS THE ARTERIES WITH EACH
VENTRICULAR CONTRACTION.

COMMON TERMINOLOGY
• CARDIAC OUTPUT IS THE VOLUME OF BLOOD PUMPED
INTO THE ARTERIES BY THE HEART AND EQUALS THE
RESULT OF THE STROKE VOLUME (SV) TIMES THE HEART
RATE (HR) PER MINUTE.
• FOR EXAMPLE, 65 ML X 70 BEATS PER MINUTE = 4.55 L /
MINUTE.

COMMON TERMINOLOGY
• A PERIPHERAL PULSE IS A PULSE LOCATED AWAY
FROM THE HEART, FOR EXAMPLE,
IN THE FOOT OR WRIST.
• THE APICAL PULSE IS A CENTRAL PULSE; THAT IS, IT IS
LOCATED AT THE APEX OF
THE HEART.
• IT IS ALSO REFERRED TO AS THE POINT OF MAXIMAL IMPULSE
(PMI).

FACTORS AFFECTING THE PULSE
• THE RATE OF THE PULSE IS EXPRESSED IN BEATS PER
MINUTE (BEATS/MIN).
• A PULSE RATE VARIES ACCORDING TO A NUMBER OF
FACTORS. THE NURSE SHOULD CONSIDER EACH OF THE
FOLLOWING FACTORS WHEN ASSESSING A CLIENT’S
PULSE:

• AGE.
AS AGE INCREASES, THE PULSE
RATE GRADUALLY DECREASES
OVERALL. FOR SPECIFIC
VARIATIONS IN PULSE RATES
FROM BIRTH TO ADULTHOOD.

• SEX.
AFTER PUBERTY, THE AVERAGE MALE’S PULSE RATE IS
SLIGHTLY LOWER THAN THE FEMALE’S.

• EXERCISE.
THE PULSE RATE NORMALLY INCREASES WITH ACTIVITY.
THE RATE OF INCREASE IN THE PROFESSIONAL ATHLETE IS
OFTEN LESS THAN IN THE AVERAGE PERSON .

• FEVER.
THE PULSE RATE INCREASES (A) IN RESPONSE TO THE
LOWERED BLOOD PRESSURE THAT RESULTS FROM
PERIPHERAL VASODILATION ASSOCIATED WITH ELEVATED
BODY TEMPERATURE AND (B) BECAUSE OF THE INCREASED
METABOLIC RATE.

• MEDICATIONS.
SOME MEDICATIONS DECREASE THE PULSE RATE, AND
OTHERS INCREASE IT. FOR EXAMPLE, CARDIOTONICS (E.G.,
DIGITALIS PREPARATIONS) DECREASE THE HEART RATE,
WHEREAS EPINEPHRINE INCREASES IT.

• HYPOVOLEMIA/DEHYDRATION.
LOSS OF BLOOD FROM THE VASCULAR SYSTEM INCREASES
PULSE RATE. IN ADULTS, THE LOSS OF CIRCULATING
VOLUME RESULTS IN AN ADJUSTMENT OF THE HEART RATE
TO INCREASE BLOOD PRESSURE AS THE BODY
COMPENSATES FOR THE LOST BLOOD VOLUME

• STRESS.
IN RESPONSE TO STRESS, SYMPATHETIC NERVOUS
STIMULATION INCREASES THE OVERALL ACTIVITY OF THE
HEART. STRESS INCREASES THE RATE AS WELL AS THE FORCE
OF THE HEARTBEAT. FEAR AND ANXIETY AS WELL AS THE
PERCEPTION OF SEVERE PAIN STIMULATE THE SYMPATHETIC
SYSTEM.

• POSITION.
WHEN A PERSON IS SITTING OR STANDING, BLOOD USUALLY
POOLS IN DEPENDENT VESSELS OF THE VENOUS SYSTEM.
POOLING RESULTS IN A TRANSIENT DECREASE IN THE VENOUS
BLOOD RETURN TO THE HEART AND A SUBSEQUENT
REDUCTION IN BLOOD PRESSURE AND INCREASE IN HEART
RATE.

• PATHOLOGY.
CERTAIN DISEASES SUCH AS SOME HEART CONDITIONS OR
THOSE THAT IMPAIR OXYGENATION CAN ALTER THE
RESTING PULSE RATE.

ASSESSING THE PULSE
A PULSE IS COMMONLY ASSESSED BY PALPATION (FEELING)
OR AUSCULTATION (HEARING). THE MIDDLE THREE
FINGERTIPS ARE USED FOR PALPATING ALL PULSE SITES
EXCEPT THE APEX OF THE HEART.
A STETHOSCOPE IS USED FOR ASSESSING APICAL PULSES.
A DOPPLER ULTRASOUND STETHOSCOPE IS USED FOR
PULSES THAT ARE DIFFICULT TO ASSESS.

ASSESSING THE PULSE
• THE NURSE SHOULD ALSO BE AWARE OF THE FOLLOWING:
• ■ ANY MEDICATION THAT COULD AFFECT THE HEART RATE.
• ■ WHETHER THE CLIENT HAS BEEN PHYSICALLY ACTIVE. IF SO,
WAIT 10 TO 15 MINUTES UNTIL THE CLIENT HAS RESTED AND
THE PULSE HAS SLOWED TO ITS USUAL RATE.
• ■ ANY BASELINE DATA ABOUT THE NORMAL HEART RATE FOR
THE CLIENT. FOR EXAMPLE, A PHYSICALLY FIT ATHLETE MAY
HAVE A RESTING HEART RATE BELOW 60 BEATS/MIN.

ASSESSING THE PULSE
• WHEN ASSESSING THE PULSE, THE NURSE COLLECTS THE
FOLLOWING DATA:
• THE RATE,
• RHYTHM,
• VOLUME,
• ARTERIAL WALL ELASTICITY, AND
• PRESENCE OR ABSENCE OF BILATERAL EQUALITY.

ASSESSING THE PULSE
• AN EXCESSIVELY FAST HEART RATE (E.G., OVER 100
BEATS/MIN IN AN ADULT) IS REFERRED TO AS
TACHYCARDIA.
• A HEART RATE IN AN ADULT OF LESS THAN 60
BEATS/MIN IS CALLED BRADYCARDIA.

ASSESSING THE PULSE
• THE PULSE RHYTHM IS THE PATTERN OF THE BEATS AND
THE INTERVALS BETWEEN THE BEATS. EQUAL TIME
ELAPSES BETWEEN BEATS OF A NORMAL PULSE. A PULSE
WITH AN IRREGULAR RHYTHM IS REFERRED TO AS A
DYSRHYTHMIA OR ARRHYTHMIA.

ASSESSING THE PULSE
• PULSE VOLUME, ALSO CALLED THE PULSE STRENGTH OR
AMPLITUDE, REFERS TO THE FORCE OF BLOOD WITH
EACH BEAT. USUALLY, THE PULSE VOLUME IS THE SAME
WITH EACH BEAT.

ASSESSING THE PULSE
• THE ELASTICITY OF THE ARTERIAL WALL REFLECTS ITS
EXPANSIBILITY OR ITS DEFORMITIES. A HEALTHY,
NORMAL ARTERY FEELS STRAIGHT, SMOOTH, SOFT, AND
PLIABLE.

ASSESSING THE PULSE
• WHEN ASSESSING A PERIPHERAL PULSE TO DETERMINE
THE ADEQUACY OF BLOOD FLOW TO A PARTICULAR
AREA OF THE BODY (PERFUSION), THE NURSE SHOULD
ALSO ASSESS THE CORRESPONDING PULSE ON THE
OTHER SIDE OF THE BODY

How to check your pulse
As the heart forces blood through the arteries, you feel the beats by firmly pressing
on the arteries, which are located close to the surface of the skin at certain points of
the body.
The pulse can be found on the side of the neck, on the inside of the elbow, or at the
wrist.
For most people, it is easiest to take the pulse at the wrist. If you use the lower neck,
be sure not to press too hard, and never press on the pulses on both sides of the
lower neck at the same time to prevent blocking blood flow to the brain. When taking
your pulse:

 Using the first and second fingertips, press
firmly but gently on the arteries until you feel
a pulse.
 Begin counting the pulse when the clock's
second hand is on the 12.
 Count your pulse for 60 seconds
 When counting, do not watch the clock
continuously, but concentrate on the beats of
the pulse.
 If unsure about your results, ask another
person to count for you.

?
• THE CLIENT’S TEMPERATURE AT 8:00 AM USING AN ORAL ELECTRONIC
THERMOMETER IS 36.1°C (97.2°F). IF THE RESPIRATION, PULSE, AND
BLOOD PRESSURE WERE WITHIN NORMAL RANGE, WHAT WOULD THE
NURSE DO NEXT ?
• 1. WAIT 15 MINUTES AND RETAKE IT.
• 2. CHECK WHAT THE CLIENT’S TEMPERATURE WAS THE LAST TIME IT
WAS TAKEN..
• 3. RETAKE IT USING A DIFFERENT THERMOMETER.
• 4. CHART THE TEMPERATURE; IT IS NORMAL.

?
• WHICH CLIENT MEETS THE CRITERIA FOR SELECTION OF THE APICAL SITE
FOR ASSESSMENT OF THE PULSE RATHER THAN A RADIAL PULSE?
• 1. A CLIENT WHO IS IN SHOCK 2
• . THE PULSE CHANGES WITH BODY POSITION CHANGES
• 3. A CLIENT WITH AN ARRHYTHMIA.
• 4. IT IS LESS THAN 24 HOURS SINCE A CLIENT’S SURGICAL OPERATION

?
• AN 85-YEAR-OLD CLIENT HAS HAD A STROKE RESULTING IN
RIGHT-SIDED FACIAL DROOPING, DIFFICULTY SWALLOWING, AND
THE INABILITY TO MOVE SELF OR MAINTAIN POSITION UNAIDED.
THE NURSE DETERMINES THAT WHICH SITES ARE APPROPRIATE FOR
TAKING THE TEMPERATURE? SELECT ALL THAT APPLY.
• 1. ORAL 2. RECTAL 3. AXILLARY. 4. TYMPANIC. 5.
TEMPORAL ARTERY.

REFERENCES
• AUDREY BERMAN . . . [ET AL.]. – 9TH ED. (2012)
KOZIER & ERB’S FUNDAMENTALS OF NURSING
CONCEPTS, PROCESS, AND PRACTICE.
• BICKLEY, LYNN S. -11TH ED. (2013) BATES’ GUIDE
TO PHYSICAL EXAMINATION AND HISTORY-
TAKING.

04 vital signs temp pulse

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