TPR Temperature, Pulse and Respirations. Temperature Is the measurement of the balance between heat...
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![Page 1: TPR Temperature, Pulse and Respirations. Temperature Is the measurement of the balance between heat lost and heat produced by the body.](https://reader036.fdocuments.in/reader036/viewer/2022062313/56649cce5503460f9499a346/html5/thumbnails/1.jpg)
TPR
Temperature, Pulse and Respirations
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Temperature
• Is the measurement of the balance between heat lost and heat produced by the body
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Temperature
Can be measured by four basic routes• 1. Oral
– Mouth- leave in place for 3-5 minutes• 2. Rectal
– Rectum- leave in place for 3-5 minutes• 3. Axillary
– Axilla or groin- leave in place for 10 minutes• 4. Tympanic
– Eardrum-
• 5. Temporal– Across forehead-
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Types of Thermometers
• 1. Electronic/Digital• 2. Glass• 3. Thermoscan for Tympanic
measurement• 4.Temporal measurement
thermometers
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Normal temperature ranges
• Oral 97.6 F – 99.6 F – (36.5-37.5 C)
• Axillary or Groin 96.6 F – 98.6 F– ( 36- 37 C)– one degree Fahrenheit lower than Oral
• Rectal & Temporal 98.6 F – 100.6 F– (37-38.1 C)– one degree Fahrenheit higher than
Oral
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Normal Temperature Ranges
• Rectal & Temporal 98.6 F – 100.6 F– (37-38.1 C)– one degree Fahrenheit higher than Oral
• Aural or Tympanic– An ear (tympanic) temperature is 0.5°F
(0.3°C) to 1°F (0.6°C) higher than an oral temperature--- 98.1- 100.1 F
– ( 36.8- 37.8 C)
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Need to Know-Temperature Terms
• Hypothermia– Below 95F ( 35C)– Death at 93F (33.9)
• Fever– Elevated above 101 (38.3)
• Pyrexia= febrile= fever present
• Afebrile= normal temp or no fever present
• Hyperthermia– Temp exceeds 104 F (40C)– Convulsions & death at 106 F ( 41.1 C)
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Do not take oral temperatures on
• preschool children• patients with oxygen• delirious, confused, disoriented patients• comatose patients• patients with nasogastric tubes in place• patients who have had oral surgery• patients who are vomiting or nauseated
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Do not take rectal temperatures on
• infants or children unless a core temperature is needed
• patients who have had rectal surgery• combative patients
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Abnormal temperatures
• Fever, febrile, hyperthermia all indicate someone who has an elevated temperature (>100 Fahrenheit).
• High fever would include anything over 103 degrees Fahrenheit.
• Moderate fever would include anything 100 – 103 degrees Fahrenheit.
• Hypothermia (<96F)is subnormal temperature. This can be equally problematic for a person
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Need to Know Conversion Formulas
• Fahrenheit to Celsius–C=(F-32)/ 1.8
• Celsius to Fahrenheit–F=(C X 1.8) + 32
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Pulse
**Student will learn how to asses pulses **
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Assessing Temperatures
• With a partner• Take both an oral and axillary temperature
using a digital thermometer– Record each temperature reading in both
Fahrenheit and Celsius using the correct formula
• Take a tympanic temperature– Document your temperature
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Pulse
• Wave of blood produced and felt along the artery when the heart contracts and rests ( relaxes) BEATS
• Can feel at points where the artery is between finger tips and a bony area
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Need to Know Pulse Terms
• Rate – Number of bests/per minute
• Rhythm– Regularity of the pulse
• Volume– Refers to the strength of the pulse
• Apical pulse– Pulse take at the apex of the heart with
a stethoscope
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Pulse Points- NEED TO KNOW
1. Temporal --either side of forehead
2. Carotid- at neck- either side of trachea
3. Apical- at apex of heart
4. Brachial-inner aspect of antecubital space
5. Radial- inner aspect of the wrist
6. Femoral- inner aspect of the upper thigh where it meets trunk-- groin
7. Popliteal- behind the knee
8. Dorsal Pedis -at the top of the foot arch
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Pulse Point Diagram
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Measuring Pulses
• Measured by index, middle, and ring fingers over pulse point.
• Do not take with the thumb, since it has a pulse of its own.
• Count for 30 seconds and multiply by 2, or count for 60 seconds
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Pulse Ranges
• Normal = – Adults ----- 60 -100 beats/minute– Children 7 year & older --- 65-80 /minute– Children 1- 7 years--------- 80-110/ minute– Infants –birth – 1 year-------100-160/minute
• > than 100 = tachycardia• < than 60 = bradycardia
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Quality of Pulse
• Rhythm – regular or irregular• Strength – Bounding or thready
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What do you think????
• Jot down at least 5 factors that you think may contribute to
your pulse rate – accelerating –decelerating
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Circumstances affecting pulse rate
1. Body temperature
2. Emotions
3. Activity level
4. Health of heart
5. Medication
6. Sleep
7. Coma
8. Exercise
9. Shock states
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Assessing Pulses
• Pick a partner• Assess the following pulses for one full minute• Record – rate, rhythm, volume of the pulse
– Temporal – Carotid– Apical– Brachial– Radial– Popliteal– Dorsalis pedis
Repeat all pulses after your partner has done 25 jumping jacks
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Respirations
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Respirations
• Process of taking in O2 and expelling CO2
• one respiration consists of – One inspiration– One expiration
Please note the following when mearusing each and every respiration:
1. Rate
2. Character
3. Rhythm
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Respirations
• Each breath includes inspiration and expiration.
• Measure by observing chest rise and fall.
• Measured in breaths per minute.
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Respirations
• Rate– number of breaths/ minute
• Character– Depth and quality of respirations– Deep-shallow-difficult-stertorous-moist
• Rhythm– Regularity of respirations
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Need to Know Respiration Terms
• Dyspnea– Difficult or labored breathing
• Apnea– Absence of respirations
• Tachypnea– Rapid, shallow respirations-- < 25/minute
• Bradypnea – Slow respiratory rate- > 10/minute
• Orthopnea– Difficulty breathing in all positions except sitting or
standing
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Need to Know Terms
• Cheyne- stokes– Abnormal respirations in a dyspnea and
apnea pattern • Rales
– Noisy & bubbling • Wheezing
– Difficult breathing with high pitch whistling • Cyanosis
– Dusky, bluish discoloration of skin, lips, nail beds
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Ranges in Respirations
• Normal = adults12-24 breaths per minute– Children-16-30/ minute– Infants- 30-50/ minute
• > than 24 = tachypnea – if breathing in great depth then called hyperpnea
• < than 12 = bradypnea• Assess rate, character and rhythm
always!!!
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Quality of breathing
1. Depth
2. Clarity of breath sounds
3. Pain with breathing
4. Difficulty breathing – use of accessory muscles
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Assessing Respirations
• Assess the radial pulse rate of the patient for one minute
• After the pulse rate have been counted– leave your hand in the pulse position
• Count the number of respirations- chest rise and fall for one minute
• Each complete cycle is ONE respiration
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Pulse Oximetry
• Pulse oximetry is a procedure used to measure the oxygen level (or oxygen saturation) in the blood. It is considered to be a noninvasive, painless, general indicator of oxygen delivery to the peripheral tissues (such as the finger, earlobe, or nose).
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How it works…….
• Pulse oximetry technology uses the light absorptive characteristics of hemoglobin & the pulsating nature of blood flow in the arteries to aid in determining the oxygenation status in the body
• There is a color difference between arterial hemoglobin saturated with oxygen, which is bright red, and venous hemoglobin without oxygen, which is darker.
• with each heartbeat there is a slight increase in the volume of blood flowing through the arteries
• Pulse Oximetry measures the maximum amount of oxygen-rich hemoglobin pulsating through the blood vessels
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Normal / Abnormal Values
• Normal pulse oximeter readings range from 95 to 100 percent, under most circumstances
• Values under 90 percent are considered low– Hypoxemia
• describes a lower than normal level of oxygen in your blood.
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Pain Assessment
• Pain is subjective• Pain is also multidimensional, so the
clinician must consider multiple aspects (sensory, affective, cognitive) of the pain experience.
• the nature of the assessment varies with multiple factors so no single approach is appropriate for all patients or settings.
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Pain Assessment
• Onset & duration• Location• Quality-what does it feel like?• Intensity- give a numeric reading• Alleviating or exacerbating factors
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Common Assessment Tools
• Wong Baker Scale
• Numeric Scales