fundamentals of nursing

1. 1
Fundamental of Nursing
Vital Signs 1
Temperature & pulse
Dr; mosa alfageh

2. Learning objectives
 Define body temperature
 Identify the types of body temperature
 List the factors that influence the body temperature
 Describe appropriate nursing care for alterations in temperature.
 Identify nine sites used to assess the pulse and state the reasons for their use.
 List the characteristics that should be included when assessing pulses
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3. Vital Signs (v.s)
monitor the functions of the body
 Provide information about body function
Include:
 Temperature(T)
 Pulse(P)
 Respiration (RR)
 Blood pressure (BP)
Changes may be the first sign of disease
Many agencies such as 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

4. Vital Signs are measures of various physiological status, in order to assess the most
basic body functions. They indicate that a person is alive.
 Making a diagnosis
 Planning program of care, treatment and nursing care
 Follow the patient prognosis
 Reaction to treatment
Important of V.S
Vital signs are taken in the following:
1. On admission, when obtaining data base assessments
2. According to written medical orders
3. When a client is feeling unusual
4. Once per day when a client is stable or as agency policy
5. Before, during & after blood transfusion
6. At least every 4 hours when one or more vital signs is abnormal
7. Every 5 to 15 minutes when a client is unstable or at risk for rapid physiologic changes
8. Whenever a client’s condition appears to have changed
9. A second time, or more frequently, if there is significant difference from previous
measurement
10. Before administering medications that affect vital signs and after to monitor the drug’s
effect

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7. Temperature:
reflects the balance between the heat produced and the
heat lost from the body under control of the
hypothalamus.

8. 8

9. There are two kinds of body temperature:
 Core temperature
 Surface 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.
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.
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10.  Temperature Measurement
 The Fahrenheit scale (uses 32°F as water freezes and 212°F as the point at which
it boils)
 used in United States to measure and report body temperature.
 The centigrade scale (Celsius) (uses 0°C as water freezes temperature and 100°C
as point it boils). It is
 used more often
 Normal Body Temperature
 In normal, healthy adults, surface temperature generally ranges from 36.5°-
37.5°C. (Average 37 °C)
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Thermometer: is an instrument use to measured body
temperature

11.  Factors affecting body temperature
1. Age
2. Diurnal variations (circadian rhythms)
3. Exercise.
4. Hormones
5. Stress
6. Environment
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12. Age
Infants are greatly influenced by the temperature of the environment and must be
protected from extreme changes.
Children's temperatures vary more than those of adults do until puberty.
Many older people, particularly those over 75 years, are at risk of hypothermia . Older
adults are also particularly sensitive to extremes in the environmental temperature due to
decreased thermoregulatory controls.
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Factors affecting body temperature
Diurnal variations (circadian rhythms)
Body temperatures normally change throughout the day, varying as much as 1.0°C
between the early morning and the late afternoon.
The point of highest body temperature is usually reached between (4:00 pm and 6:00
pm), and the lowest point is reached during sleep between (4:00 am and 6:00 am)
Exercise. Hard work or strenuous exercise can increase body temperature to as high as
38.3°C to 40°C measured rectally.
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 above basal temperature.

13. 13
Factors affecting body temperature
 Stress.
Stimulation of the sympathetic nervous system can increase the production of
epinephrine and norepinephrine, thereby increasing metabolic activity and heat
production.
Nurses should anticipate that a highly stressed or anxious client could have an
elevated body temperature for that reason.
 Environment.
Extremes in environmental temperatures can affect a person’s temperature
regulatory systems.
If the temperature is assessed in a very warm room and the body temperature
cannot be modified by convection, conduction, or radiation, the temperature
will be elevated.
Similarly, if the client has been outside in cold weather without suitable clothing,
or if a medical condition prevents the client from controlling the temperature in
the environment (e.g., the client has altered mental status or cannot dress self),
the body temperature may be low.

14. Frequently used terms:
 Pyrexia or fever
 Febrile
 Hyperthermia
 Hypothermia
 Afebrile
Alterations in Body Temperature

15. Alterations in Body Temperature
The normal range for adults is considered to be between 36.5 °C and 37.5°C
There are two primary alterations in body temperature:
Pyrexia
Hypothermia
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 A body temperature above the usual range is called pyrexia, hyperthermia, or
fever.
 A very high temperature, e.g. 41Cº is called hyperpyrexia.
The client who has a fever is referred to as febrile; the one who does not is afebrile
Hypothermia: It is a body temperature below the lower limit of normal.
The hypothalamus that regulate temperature is greatly impaired, when the body
temperature falls below 34.5Cº , and death usually occurs when the temperature
falls below 34 Cº . And death usually occur when temp more than 42 Cº

16. Four common types of fevers are:
 Intermittent
 Remittent
 Relapsing
 Constant
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17.  During an intermittent fever, the body temperature alternates at regular
intervals between periods of fever and periods of normal or subnormal
temperatures. An example is with the disease malaria.
 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.
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Four common types of fevers are:
 Relapsing fever, short febrile periods of a few days are interspersed
with periods of 1 or 2 days of normal temperature.
 During a constant fever, the body temperature fluctuates
minimally but always remains above normal. This can occur
with typhoid fever.
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.

18. The signs and symptoms of fever:
 Loss of appetite.
 Headache.
 Hot.
 Dry skin.
 Flushed face.
 Thirst and general malaise.
 Young children or other people with high fevers may
experience periods of delirium or seizures.

19. Nursing Interventions for Client's with fever:
 Monitor vital signs
 Assess skin color and temperature
 Monitor WBC, HCT, and other laboratory reports for indications of infection or
dehydration
 Remove excess blanket when the client feels warm, but provide extra warmth when
the client feels chilled.
 Measure intake and output
 Provide adequate nutrition and fluid
 Reduce physical activity to limit heat production.
 Administer antipyretic as order
 Provide oral hygiene to keep mucous membranes moist
 Provide a sponge bath to increase heat loss
 Provide dry clothing and bed linens

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21. 21
Nursing Interventions for
Client's with hypothermia:
• Provide a warm environment
• Provide dry clothing
• Apply warm blankets
• Keep limbs close to body
• Cover the clients scalp with a cap
• Supply warm oral
• Apply warming pads

22. 
The most common sites of measuring
body temperature

23. 23

24. ORAL TEMPERATURE
• The area under the tongue is in
direct proximity to the sublingual
artery.
• Poor placement or premature
thermometer removal result in
inaccurate reading.
Contraindication ;
1. uncooperative
2. very young
3. unconscious, or Confused patients
4. shivering,
5. prone to seizures
6. mouth breathers
7. oral surgery
To ensure accuracy,
• delays oral temperature for 30 min after
chewing gum, smoking cigarette, or
eating hot/cold food or beverages.
• Leave in place 3 – 5 minutes with glass
thermometer

25. RECTAL TEMPERATURE
Contraindication
 Infant < 1 month of age
 Premature infants
 Following rectal surgery
 Severe diarrhea
 Bleeding tendency e.g
leukemia
 Imperforate anus
IMPORTANT POINTS
lateral or sim’s position
This site can be embarrassing and
emotionally traumatic for alert clients.
Stool in rectum, improper placement of
the thermometer, and premature removal
affect the accuracy
 The rectal temperature are usually (0.5)
higher than oral temperature
 Instruct client to take a deep breath insert
thermometer gently into anus infant 1.2 cm,
adult 3.5 cm
 Hold in pace for 2 minutes with glass
thermometer(DO Not take hand from
thermometer while rectal in progress)
 good method for persons with elevated temp
 Most reliable (accurate)
 Unconscious
 Lubricate thermometer

26. AXILLARY TEMPERATURE
AXILLARY temperature are
• Safe
• Non-invasive
• Least accurate
IMPORTANT POINTS
1. AXILLA MUST HAVE ADEQUATE TISSUE & BE
FREE OF PERSPIRATION Poor circulation, recent
bathing, or rubbing the axillary area dry with a
towel affects the accuracy of the axillary site
2. Not good method for persons with elevated temp
3. Axillary and temporal temperatures are usually 0.5
lower than oral temperatures
4. Used when cannot get oral or tympanic
5. Leave in place 7-11 minutes with glass thermometer
6. Leave electronic thermometer in place until signal is
heard
7. The axilla is often the preferred site for measuring
temperature in newborns because it is accessible and
safe

27. TYMPANIC TEMPERATURE
The tympanic
membrane
thermometer
recording are obtain
through 2 seconds or
less & should not be
used in people who
ear or scared
tympanic membrane

28. TYMPANIC TEMPERATURE
Indication
measurement by ear
 In children
 Accurate reading
 Fast method
Contraindications
 Blood or drainage in ear
canal
 Acute or chronic
inflammatory conditions of
the external canal
 Perforated tympanic canal

29.  Usually preferred method
 The normal tympanic temperature is usually
0.5c higher than an oral temperature
 Must direct probe toward TM (eardrum)
 Adults –pull pinna of ear up & back
 Children pull pinna of ear down & back
 Tympanic membrane has the closest
correlation to core temperature. because: the
tympanic membrane is just 1.4 inches (3.8
cm) from hypothalamus; blood from internal &
external carotid arteries, supply
hypothalamus & warms the tympanic
membrane. For these reasons,
 temperatures obtained at this site are
considered more reliable than oral and axillary
TYMPANIC TEMPERATURE
IMPORTANT POINTS

30. Temporal artery
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• A special thermometer is used to scan the
temporal artery temperature. While pressing
the scan button with your thumb . Place the
probe on a dry forehead and move slowly
across the width of forehead and temple
• Affected by skin moisture such
as diaphoresis or sweating

31. 31

32. Types of thermometers
 Class thermometer
 Electronic thermometer
 Tympanic membrane thermometer
 Disposable paper thermometer
 Temperature sensitive strips and chemical dot
 Digital thermometer
 Digital Lcd non contact infrared thermometer
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33. Oral thermometer
It has two parts Bulb & stem
Oral thermometer are with long
and slender Bulbs
Bulb containing mercury and stem
which can mercury rise
Rectal thermometer
It has two parts bulb and stem
Rectal thermometer are with
round bulbs
Bulb containing mercury and
stem which can mercury rise

34. • To shake the mercury down , grasp the thermometer by the upper end of the stem and
never hold it by the bulb. Shake it down by quick movement of wrist .
• Be careful not to let the thermometer fall or strike against anything
• The thermometer are never washed with hot water , because the heat expands the
mercury beyond the capacity of the stem and thermometer can break
• When storing the thermometers never store them in disinfectant solution. Rinse them in
clean water . Dry the bulb and stem put them in container
• For fear of breaking thermometers , never place the thermometer in mouth . Who can not
understand the instructions or who not able to hold the thermometer in place

35. GLASS
THERMOMETER
o CHECK THE THERMOMETER
FOR BREAKS AND CHIPS
o SHAKE DOWN THE
THERMOMETER SO THE
MERCURY IS BELOW THE LINES
AND NUMBERS
o PLACE A DISPOSABLE COVER
ON THE THERMOMETER
o PLACE THE THERMOMETER
UNDER THE PERSON’S TONGUE
o LEAVE THE THERMOMETER IN
PLACE FOR 3– 5 MINUTES
o IF THE PERSON HAS BEEN
EATING, DRINKING, OR
SMOKING, WAIT 30 MINUTES
BEFORE TAKING TEMPERATURE

36. • The thermometer consists of a battery powered control unit and
temperature sensitive probe connected to the control unit by a thin cord
• When in use , disposable sheath covers the probe to prevent
transmission of infection.
• Thermometer provide reading in less than 30 seconds
• It is safe , accurate and fast method for measuring temperature
• The reading is quickly displayed on the unit and is easy to read
• It can be used for oral , axillary or rectal temperature measurements
• It disadvantage it is high cost

37. o MEASURES THE TEMPERATURE IN THE TYMPANIC MEMBRANE (EARDRUM)
o FAST AND ACCURATE - 1 TO 3 SECONDS
INFANTS
 PULL THE EAR
DOWN AND BACK
ADULTS AND
CHILDREN OVER
ONE YEAR –
 PULL THE EAR
UPAND BACK

38. • Single use paper thermometers are thin strips of chemically
treated paper with raised dots that change color to reflect the
temperature usually in less than 1 minute
• This thermometer available in Celsius and Fahrenheit

40. USE A DISPOSABLE SHEATH
• It have a battery
• It can be used for oral, axillary temperature measurement
• It has probe , switch on/of button and reading parameter.
• When it will use for patient it should clean with cotton Or cover
with disposable sheath

42. 42
Sometimes a health professional staff need to convert
a Celsius reading to Fahrenheit, or vice versa
.

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44. 44
 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 and the
amount of blood that enters the arteries with each ventricular contraction.
 Compliance of the arteries is their ability to contract and expand. When a
person's arteries loss their distensibility as can happen in old age, greater
pressure is required to pump the blood into the arteries.
 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.
 SV: The amount of blood ejected with each cardiac contraction
 For example, 65mL x70 beats per minute = 4.55 L per minute. When an
adult is resting, the heart pumps about 5 liters of blood each minute.
 In a healthy person, the pulse reflects the heartbeat that is the pulse
rate is the same as the rate of the ventricular contractions of the heart.
However, in some types of cardiovascular disease, the heartbeat and
pulse rate can differ.

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 For example, a client's heart may produce very weak or small pulse
waves that are not detectable in a peripheral pulse far from the heart.
In these instances, the nurse should assess the heartbeat and the
peripheral pulse.
 A Peripheral pulse is a pulse located away from the heart, for example,
in the foot, wrist, or neck.
 Apical pulse, in contrast, is a central pulse, that it is located at the apex
of the heart.

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Pulse
 A wave of
blood flow
created by a
contraction
of the heart.
Name these pulses.
Click HERE to check answers.
A.
B.
D.
E.
F.
C. G.
H.

47. Chapter 9 47
Pulse Sites (Answers)
A. Temporal
B. Femoral
C. Popliteal
D. Posterior tibial
E. Carotid
F. Brachial
G. Radial
H. Dorsalis pedis
Back

48. 48
 Pulse sites most commonly used:
Brachial pulse –
found in the
antecubital space of
the arm (the bend of
the elbow) in adults.
Radial pulse –
located inside
the wrist, near
the thumb.
Apical pulse – auscultated
with a stethoscope on the
chest wall. The pulse is found
at the apex of the heart.

49. 49
Pulse Sites
Radial Readily accessible
Temporal When radial pulse is not accessible
Carotid During cardiac arrest/shock in adults
Determine circulation to the brain
Apical Infants and children up to 3 years of age
Discrepancies with radial pulse
Monitor some medications
Brachial Blood pressure
Cardiac arrest in infants
Femoral Cardiac arrest/shock
Circulation to a leg;
Popliteal Circulation to lower leg
Posterior tibial Circulation to the foot
Dorsalis pedis Circulation to the foot

51. NORMAL ADULT PULSE RATE IS – 60 TO 100 BEATS PER MIN.
TACHYCARDIA – HEART RATE OVER 100
BRADYCARDIA – HEART RATE BELOW 60
REPORT ABNORMAL HEART RATES TO THE NURSE
IMMEDIATELY

52. Assessment of Pulse
 Sites
 Use of stethoscope
 Character of pulse
 Nursing process and pulse determination

53. TECHNIQUE
 Feel over BONY area
 DO NOT use thumb
 Use 2-3 fingers
 DO NOT squeeze
 Count 30 seconds if regular
x 2
 Note Rate, Rhythm, Quality
 If irregular, count for 1 full
minute or take apical pulse
for 1 minute.

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 Characteristics of the Pulse
 Pulse Rate
 Assessed as beats per minute, or
for 30 seconds and MULTIPLY THE
NUMBER TIMES 2 to get the pulse
rate for 1 minute .
 We notes the rhythm (pattern) of the
heart beat – if the heart beat is irregular
we count the pulse foe a full minute
 Tachycardia – a pulse rate faster
than normal.
 Bradycardia – a pulse rate slower
than normal.

55. 55
Pulse (cont.)
 Characteristics of the Pulse
(cont.)
 Pulse Rhythm – the pattern of
the heartbeats.
 A client with an irregular
heartbeat (arrhythmia or
dysrhythmia) must be measured
a full minute to determine the
average rate.
 When documenting pulse
rhythm, record as regular or
irregular.
Click Pictures for
Sounds
Rhythm
Regular
Irregular

56. 56
Pulse (cont.)
 Characteristics of the Pulse (cont.)
 Pulse volume, or strength of the pulse, can be
measured with the following scale:
 0 – absent, unable to detect.
 1 – thready or weak, difficult to palpate, and
easily obliterated by light pressure from
fingertips.
 2 – strong or normal, easily found and
obliterated by strong pressure from fingertips.
 3 – bounding or full, difficult to obliterate with
fingertips.
 A thready or weak pulse may indicate decreased
circulation. A bounding pulse may indicate high
blood pressure.

57. 57
Pulse (cont.)
 Characteristics of the Pulse (cont.)
 Bilateral Presence – pulses should be
found within the same areas on both
sides of the body and have the same rate,
rhythm, and volume.

58.  Always clean the earpieces of
stethoscope with alcohol before and
after use
 Warm the diaphragm in your hand
before placing it on the person
 Hold the diaphragm in place over
the apical area
 Con not let the tubing strike against
anything with the stethoscope is
being used

59. o taken with a stethoscope
oCounted by placing the stethoscope over the heart
(apical area)
oCounted for one full minute
oThe heart beat normally sound like a LUB-DUB. Each
LUB-DUB is counted as one heartbeat
o DO NOT COUNT THE LUB AS ONE
HEARTBEAT AND THE DUB AS ANOTHER.
oThe apical pulse is taken on patients who have heart
disease , an irregular pulse rate , or taken medications
that can affect the heart

60. Requires 2 nurses
1 nurse counts apical heart rate
1 nurse counts radial pulse
BOTH count during the same 60 seconds
1 nurse acts as timekeeper for both nurses

61. PULSE DEFICIT
 Count apical-radial pulse
 The difference is the PULSE DEFICIT
 Apical pulse will always be the same or higher than
the radial pulse if both are counted correctly
 If the radial pulse is higher, one or both nurses
counted incorrectly

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Factors Affecting the Pulse
1. Age.
2. Gender
3. Exercise
4. Fever
5. Medication
6. Hypovolemia
7. Stress
8. Body position
9. pathology

63. 63
 Age.
Specific variations in pulse rates from birth to adulthood.as age increase , the pulse rate
gradually decreases overall
 Gender. After puberty, the average male's pulse rate is slightly lower
than the female’s.
 Exercise. The pulse rate normally increases with activity.

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Fever
 The pulse rate increases:
in response to the lowered blood pressure that results from peripheral vasodilatation
associated with elevated body temperature.
Medications
 Some medications decrease the pulse rate, and others increase it. For example,
cardiotonics (digitalis) decrease the heart rate, whereas epinephrine
increase it.
Hypovolemia.
Loss of blood from the vascular system normally increases pulse rate.
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.

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Position changes.
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 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.