TPR and Peripheral Pulses

PN 1 Nursing Skill Labs

Equipment

glass thermometer - consider mercury spills

electronic thermometer tympanic thermometer others - patch, tape, single use watch paper and pen for recording

Sites and Methods Oral wait 15 – 30 min after hot or cold drink

smoking or chewing gum do not use oral site if

• unconscious

• seizure prone

• irrational

• child - very young

• O2 by mask

• recent oral surgery

if using glass thermometer, shake down and wipe down!!

place in sublingual pocket and close lips must wait 3 minutes when using glass

thermometer; others alarm or indicate when ready

always indicate the site used in your documentation

Rectal (not used for newborns!!) shake down and wipe glass thermometer

and insert 1 1/2 inches (adults) after lubricating well!!! (check depth depending on age/size) - hold 2-3 mins

hold thermometer in place to ensure accurate reading

considered most accurate reflection of core temp

Axilla if using glass thermometer, shake, wipe

and hold for 10 mins make sure axilla is dry place tip of thermometer in center of

axilla and place arm close to body considered as accurate as oral or rectal

when done correctly

Tympanic pull pina up and back (for adults) most common site currently used uses infrared sensers does not actually touch the typmanic

membrane

Factors affecting Pulse Rate & Rhythm

Tachycardia pulse of 100 - 180 bpm may be caused by pain, emotions,

exercise, prolonged heat, decreased blood pressure, pyrexia, reduced O2 in blood, some medications

Bradycardia pulse below 60 bpm pulse is generally slower at rest may be related to thin body size, gender

( males slower than females), increased age and some medications

this is often considered normal for people in great physical shape!!

Equipment Stethoscope, doppler, cardiac monitor cleanse earpieces with alcohol swab warm before use point ear pieces toward nose ensure bell is “on” bell – low freq. Heart & BP diaphragm – hi freq. Resp & bowel

sounds watch with second hand

Sites and methods never use your thumb to palpate a pulse use the pads of three middle fingers count for 1 full minute exception - if peripheral pulse irregular or

abnormal for that patient repeat at apical site and count for 1 full minute

Pulse deficit = difference between apical and radial pulse

Radial

• ease of access, circulation of hand

• make sure arm is resting comfortably Carotid

• most easily palpable if blood pressure is low (only palpate one side at a time)

Apical

• audible with stethoscope

• measured at 5th intercostal space, slightly left of pts. midclavicular line

Brachial - used in infants Femoral - often used in cardiac arrests Popliteal - peripheral circulation Posterior tibial (tibial) and Dorsalis pedis

(pedal) - assesses peripheral circulation always document location of pulse

assessment

Pulse Points

Respirations one respiratory cycle = from beginning of

one inspiration to beginning of the next inspiration

important that patient not be aware you are counting his/her respirations

normal ratio is 1 breath to 4 heartbeats count for 1 full minute document rate and depth

Factors affecting RespirationIncreases rate if in pain in BMR exercise sympathetic

stimulation smoking require more oxygen pyrexia

Decreases depth if in pain pathologies sedatives and

analgesics parasympathetic relaxation increased ICP

Terms related to Respiration

tachypnea - rapid > 24 per min bradypnea - slow < 10 per min apnea - periods of no breathing

- brain damage in 4-6 mins orthopnea - breathing easier in

upright position dyspnea - labored or difficult

breathing

hyperventilation - increased rate and depth

hypoventilation - decreased rate and depth

Cheyne-Stokes - deep rapid breathing followed by periods of apnea