Body temperature represents the balance between heat produced by metabolism, muscular activity, and other factors and heat lost through the skin, lungs, and body wastes. A stable temperature pattern promotes proper function of cells, tissues, and organs; a change in this pattern usually signals the onset of illness. Temperature can be measured with an electronic digital, chemical-dot, or tympanic thermometer. Oral temperature in adults normally ranges from 97° to 99.5°F (36.1° to 37.5°C); rectal temperature, the most accurate reading, is usually 1°F (0.6°C) higher; axillary temperature, the least accurate, reads 1° to 2°F (0.6° to 1.1°C) lower; and tympanic temperature reads 0.5° to 1° (0.3° to 0.6°) higher.1 Temperature normally fluctuates with rest and activity. Lowest readings typically occur between 4 and 5 a.m.; the highest readings occur between 4 and 8 p.m. Other factors also influence temperature, including gender, age, emotional conditions, and environment. Keep the following principles in mind: Women normally have higher temperatures than men, especially during ovulation. Normal temperature is highest in neonates and lowest in the elderly. Heightened emotions raise temperature; depressed emotions lower it. A hot external environment can raise temperature; a cold environment lowers it. If you use an electronic thermometer, make sure it’s been recharged. (See Types of thermometers, page 698.) Insert the probe into a disposable probe cover (as shown below).
Remove the thermometer from its protective dispenser case by grasping the handle end with your thumb and forefinger, moving the handle up and down to break the seal, and pulling the handle straight out. Keep the thermometer sealed until use.
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Rebecca Myatt Clinical Nurse Specialist, Guy’s and St Thomas’ NHS Foundation Trust, London, England |
Method | Normal Range |
---|---|
Oral | 35.8 – 37.3ºC |
Axillary | 34.8 – 36.3ºC |
Tympanic | 36.1 – 37.9ºC |
Rectal | 36.8 – 38.2ºC |
Pulse refers to the pressure wave that expands and recoils arteries when the left ventricle of the heart contracts. It is palpated at many points throughout the body. The most common locations to assess pulses as part of vital sign measurement include radial, brachial, carotid, and apical areas as indicated in Figure \(\PageIndex{8}\).
Pulse is measured in beats per minute. The normal adult pulse rate (heart rate) at rest is 60–100 beats per minute with different ranges according to age. See Table \(\PageIndex{2}\) for normal heart rate ranges by age. It is important to consider each patient situation when analyzing if their heart rate is within normal range. Begin by reviewing their documented baseline heart rate. Consider other factors if the pulse is elevated, such as the presence of pain or crying in an infant. It is best to document the assessment when a patient is resting and comfortable, but if this is not feasible, document the circumstances surrounding the assessment and reassess as needed.
Age Group | Heart Rate |
---|---|
Preterm | 120 – 180 |
Newborn (0 to 1 month) | 100 – 160 |
Infant (1 to 12 months) | 80 – 140 |
Toddler (1 to 3 years) | 80 – 130 |
Preschool (3 to 5 years) | 80 – 110 |
School Age (6 to 12 years) | 70 – 100 |
Adolescents (13 to 18 years) and Adults | 60 – 100 |
When assessing pulses, the characteristics of rhythm, rate, force, and equality are included in the documentation.
A normal pulse has a regular rhythm, meaning the frequency of the pulsation felt by your fingers is an even tempo with equal intervals between pulsations. For example, if you compare the palpation of pulses to listening to music, it follows a constant beat at the same tempo that does not speed up or slow down. Some cardiovascular conditions, such as atrial fibrillation, cause an irregular heart rhythm. If a pulse has an irregular rhythm, document if it is “regularly irregular” (e.g., three regular beats are followed by one missed and this pattern is repeated) or if it is “irregularly irregular” (e.g., there is no rhythm to the irregularity).
The pulse rate is counted with the first beat felt by your fingers as “One.” It is considered best practice to assess a patient’s pulse for a full 60 seconds, especially if there is an irregularity to the rhythm.
The pulse force is the strength of the pulsation felt on palpation. Pulse force can range from absent to bounding. The volume of blood, the heart’s functioning, and the arteries’ elastic properties affect a person’s pulse force. Pulse force is documented using a four-point scale:
- 3+: Full, bounding
- 2+: Normal/strong
- 1+: Weak, diminished, thready
- 0: Absent/nonpalpable
If a pulse is absent, a Doppler ultrasound device is typically used to verify perfusion of the limbs. The Doppler is a handheld device that allows the examiner to hear the whooshing sound of the pulse. This device is also commonly used when assessing peripheral pulses in the lower extremities, such as the dorsalis pedis pulse or the posterior tibial pulse. See the following hyperlink to a video demonstrating the use of a Doppler device.
Pulse equality refers to a comparison of the pulse forces on both sides of the body. For example, a nurse often palpates the radial pulse on a patient’s right and left wrists at the same time and compares if the pulse forces are equal. However, the carotid pulses should never be palpated at the same time because this can decrease blood flow to the brain. Pulse equality provides data about medical conditions such as peripheral vascular disease and arterial obstruction.
Use the pads of your first three fingers to gently palpate the radial pulse. The pads of the fingers are placed along the radius bone on the lateral side of the wrist (i.e., the thumb side). Fingertips are placed close to the flexor aspect of the wrist (i.e., where the wrist meets the hand and bends). See Figure \(\PageIndex{9}\) for correct placement of fingers in obtaining a radial pulse. Press down with your fingers until you can feel the pulsation, but not so forcefully that you are obliterating the wave of the force passing through the artery. Note that radial pulses are difficult to palpate on newborns and children under the age of five, so the brachial or apical pulses are typically obtained in this population.
The carotid pulse is typically palpated during medical emergencies because it is the last pulse to disappear when the heart is not pumping an adequate amount of blood.
Locate the carotid artery medial to the sternomastoid muscle, between the muscle and the trachea, in the middle third of the neck. With the pads of your three fingers, gently palpate one carotid artery at a time so as not to compromise blood flow to the brain. See Figure \(\PageIndex{10}\) for correct placement of fingers in a seated patient.
A brachial pulse is typically assessed in infants and children because it can be difficult to feel the radial pulse in these populations. If needed, a Doppler ultrasound device can be used to obtain the pulse.
The brachial pulse is located by feeling the bicep tendon in the area of the antecubital fossa. Move the pads of your three fingers medially from the tendon about 1 inch (2 cm) just above the antecubital fossa. It can be helpful to hyperextend the patient’s arm to accentuate the brachial pulse so that you can better feel it. You may need to move your fingers around slightly to locate the best place to accurately feel the pulse. You typically need to press fairly firmly to palpate the brachial pulse. See Figure \(\PageIndex{11}\) for correct placement of fingers along the brachial artery.
The apical pulse rate is considered the most accurate pulse and is indicated when obtaining assessments prior to administering cardiac medications. It is obtained by listening with a stethoscope over a specific position on the patient’s chest wall. Read more about listening to the apical pulse and other heart sounds in the “Cardiovascular Assessment” chapter.
Respiration refers to a person’s breathing and the movement of air into and out of the lungs. Inspiration refers to the process causing air to enter the lungs, and expiration refers to the process causing air to leave the lungs. A respiratory cycle (i.e., one breath while measuring respiratory rate) is one sequence of inspiration and expiration.
When obtaining a respiratory rate, the respirations are also assessed for quality, rhythm, and rate. The quality of a person’s breathing is normally relaxed and silent. However, loud breathing, nasal flaring, or the use of accessory muscles in the neck, chest, or intercostal spaces indicate respiratory distress. People experiencing respiratory distress also often move into a tripod position, meaning they are leaning forward and placing their arms or elbows on their knees or on a bedside table. If a patient is demonstrating new signs of respiratory distress as you are obtaining their vital signs, it is vital to immediately notify the health care provider or follow agency protocol.
Respirations normally have a regular rhythm in children and adults who are awake. A regular rhythm means that the frequency of the respiration follows an even tempo with equal intervals between each respiration. However, newborns and infants commonly exhibit an irregular respiratory rhythm.
Normal respiratory rates vary based on age. The normal resting respiratory rate for adults is 10–20 breaths per minute, whereas infants younger than one year old normally have a respiratory rate of 30–60 breaths per minute. See Table \(\PageIndex{3}\) for ranges of normal respiratory rates by age. It is also important to consider factors such as sleep cycle, presence of pain, and crying when assessing a patient’s respiratory rate.
Read more about assessing a patient’s respiratory status in the “Respiratory Assessment” chapter.
Age | Normal Range |
---|---|
Newborn to one month | 30 – 60 |
One month to one year | 26 – 60 |
1-10 years of age | 14 – 50 |
11-18 years of age | 12 – 22 |
Adult (ages 18 and older) | 10 – 20 |
A patient’s oxygenation status is routinely assessed using pulse oximetry, referred to as SpO2. SpO2 is an estimated oxygenation level based on the saturation of hemoglobin measured by a pulse oximeter. Because the majority of oxygen carried in the blood is attached to hemoglobin within the red blood cells, SpO2 estimates how much hemoglobin is “saturated” with oxygen. The target range of SpO2 for an adult is 94-98%. For patients with chronic respiratory conditions, such as chronic obstructive pulmonary disease (COPD), the target range for SpO2 is often lower at 88% to 92%. Although SpO2 is an efficient, noninvasive method to assess a patient’s oxygenation status, it is an estimate and not always accurate. For example, if a patient is severely anemic and has a decreased level of hemoglobin in the blood, the SpO2 reading is affected. Decreased peripheral circulation can also cause a misleading low SpO2 level.
A pulse oximeter includes a sensor that measures light absorption of hemoglobin. See Figure \(\PageIndex{12}\) for an image of a pulse oximeter. The sensor can be attached to the patient using a variety of devices. For intermittent measurement of oxygen saturation, a spring-loaded clip is attached to a patient’s finger or toe. However, this clip is too large for use on newborns and young children; therefore, for this population, the sensor is typically taped to a finger or toe. An earlobe clip is another alternative for patients who cannot tolerate the finger or toe clip or have a condition, such as vasoconstriction and poor peripheral perfusion, that could affect the results.
The target range of SpO2 for an adult is 94-98%. For patients with chronic respiratory conditions, such as chronic obstructive pulmonary disease (COPD), the target range for SpO2 is often lower at 88% to 92%.
Read more about pulse oximetry in the “Oxygen Therapy” chapter.
Nail polish or artificial nails can affect the absorption of light waves from the pulse oximeter and decrease the accuracy of the SpO2 measurement when using a probe clipped on the finger. An alternative sensor that does not use the finger should be used for these patients or the nail polish should be removed. If a patient’s hands or feet are cold, it is helpful to clip the sensor to the earlobe or tape it to the forehead.
Read information about how to accurately obtain blood pressure measurement in the “Blood Pressure” chapter.
After obtaining a patient’s vital signs, it is important to immediately analyze the results, recognize deviations from expected normal ranges, and report deviations appropriately. As a nursing student, it is vital to immediately notify your instructor and/or collaborating nurse caring for the patient of any vital sign measurement out of normal range.