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Temperature (T)
Pulse (P)
Respiration (R)
Blood pressure (BP)
Pain (often called the fifth vital sign)
Oxygen Saturation

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Upon admission to a healthcare setting
When certain medications are given
Before and after diagnostic and surgical procedures
Before and after certain nursing interventions
In emergency situations

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Definition: the heat of the body measured in degrees
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The difference between production of heat and loss of heat
Normal temperature: 97.0ºF (36.0ºC) to 99.5ºF
(37.5ºC)
Process: heat is generated by metabolic processes in the core tissues of the body, transferred to the skin surface by the circulating blood, and dissipated to the environment

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Core temperatures
› Tympanic and rectal
› Esophagus and pulmonary (invasive monitoring devices)
Surface body temperatures
› Oral (sublingual)
› Axillary

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Oral: impaired cognitive functioning, inability to close lips around thermometer, diseases of the oral cavity, and oral or nasal surgery
Rectal: newborns, small children, patients who have had rectal surgery, or have diarrhea or disease of the rectum, and certain heart conditions
Tympanic: earache, ear drainage, and scarred tympanic membrane

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Pulse rate
› Measured in beats per minute
Pulse quality (amplitude)
› The quality of the pulse in terms of its fullness
Pulse rhythm
› Pattern of the pulsations and the pauses between them
 Normally regular

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Palpating the peripheral arteries
Auscultating the apical pulse with a stethoscope
Using a portable Doppler ultrasound

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Temporal
Carotid
Brachial
Radial
Femoral
Popliteal
Posterior tibial
Dorsalis pedis

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Indications
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Patient is receiving medications that alter heart rate and rhythm
A peripheral pulse is difficult to assess accurately because it is irregular, feeble, or extremely rapid
Method
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Count the apical rate 1 full minute by listening with a stethoscope over the apex of the heart
Most reliable method for infants and small children; can be palpated with fingertips

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Rate
› Adults: 12 to 20 times per minute
› Infants and children breathe more rapidly
Depth
› Varies from shallow to deep
Rhythm
› Regular: each inhalation/exhalation and the pauses between occur at regular intervals

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Method
› Inspection (observing and listening)
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Listening with the stethoscope
Counting the number of breaths per minute
Considerations
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If respirations are very shallow and difficult to detect visually, observe sternal notch
Patients should be unaware of the respiratory assessment to prevent altered breathing patterns

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Exercise
Medications
Smoking
Chronic illness or conditions
Neurologic injury
Pain
Anxiety

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Retractions
Nasal flaring
Grunting
Orthopnea (breathing more easily in an upright position)
Tachypnea (rapid respirations)

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Ineffective Breathing Pattern
Impaired Gas Exchange
Risk for Activity Intolerance
Ineffective Airway Clearance
Excess Fluid Volume
Ineffective Tissue Perfusion

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Definition
› The force of the blood against arterial walls
Systolic pressure
› The highest point of pressure on arterial walls when the ventricles contract
Diastolic pressure
› The lowest pressure present on arterial walls during diastole (Taylor, 2007).

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Blood pressure is measured in millimeters of mercury (mm Hg)
Blood pressure is recorded as a fraction
› The numerator is the systolic pressure
› The denominator is the diastolic pressure
Pulse pressure
› The difference between the systolic and diastolic pressure

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Using a stethoscope and sphygmomanometer
Using a Doppler ultrasound
Estimating by palpation
Assessing with electronic or automated devices

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Use a cuff that is the correct size for the patient
Ensure correct limb placement
Use recommended deflation rate
Correctly interpret the sounds heard

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Age
Exercise
Position
Weight
Fluid balance
Smoking
Medications

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Purpose
› Measure the arterial oxyhemoglobin saturation of arterial blood
Method
› A sensor or probe, uses a beam of red and infrared light which travels through tissue and blood vessels
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The oximeter calculates the amount of light absorbed by arterial blood
Oxygen saturation is determined by the amount of each light absorbed

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Monitoring patients receiving oxygen therapy
Titrating oxygen therapy
Monitoring those at risk for hypoxia
Monitoring postoperative patients