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BODY TEMPERATURE ² is the balance between
the heat produced by the body and the heat lost from the
body
K 2 Kinds:
1. Core temperature-
temperature- is the temperature of the deep
tissues of the body such as the cranium, thorax,
abdominal cavity, and pelvic cavity
2. Surface temperature-
temperature- rises and falls in response
to the environment

K Age Variations:
AGE AVERAGE TEMPERATURE
newborn to ----- 36.1 ² 37.7 C
1 year 97.0 ² 100.0 F
2-4 years ----- 37.2 C
98.9 F
6 years to ----- 37.0 C
adult 98.6 F
elderly (over ----- 36.0 C
70 years) 96.8 F
K Factors affecting the body·s heat production

1. Basal metabolic rate (BMR) ² the rate of energy

utilization in the body required to maintain
essential activities such as breathing. Metabolic
rate decreases with age. In general, the younger
the person, the higher the BMR.
2. Muscular activities including shivering, increases
the metabolic rate.
3. Thyroxine output ² increased thyroxine output
increases the rate of cellular metabolism
throughout the body. This effect is called
chemical thermogenesis.
4. Epinephrine, norepinephrine, and sympathetic
stimulation ² these hormones immediately
increase the rate of cellular metabolism in many
body tissues, thereby increasing cell metabolism.
5. Fever ² increases the cellular metabolic rate and
thus increases the body·s temperature further.
K •eat is lost from the body through:

1. Radiation ² transfer of heat from the surface of

one object to the surface of another without the
contact between the two objects, mostly in the
form of infrared rays.
2. Conduction ² transfer of heat from one molecule
to another
3. Convection ² dispersion of heat by air currents.
4. Vaporization ² continuous evaporation of moisture
from the respiratory tract and from the mucosa of
the mouth and from the skin ( insensible heat loss
loss--
continuous and unnoticed water loss).

K Factors affecting body temperature:

1. Age
2. Diurnal variations (circadian rhythms)
3. Exercise
4. •ormones
5. Stress
6. Environment
K Alterations in body temperature:
o Pyrexia/•yperthermia/Fever ² a body temperature above
the normal range
o •yperpyrexia ² a very high fever
o Febrile ² referred to a client who has a fever
o Afebrile ² referred to a client who has no fever

K 4 Common types of fever:

o Intermittent ² the body temperature alternates at regular
intervals between periods of fever and periods of normal
or subnormal temperatures.
o Remittent ² a wide range of temperature fluctuations
occurs over the 24 ²hour period, all of which are above
normal.
o Relapsing fever ² short febrile periods of a few days are
interspersed with period of 1 or 2 days of normal
temperature.
o Constant fever ² the body temperature fluctuates
minimally but always remains above normal.
K Clinical signs of hypothermia
1. Decreased body temperature
2. Severe shivering (initially), feelings of cold and chills
3. Pale, cool, waxy skin
4. •ypotension
5. Decreased urinary output
6. Lack of muscle coordination
7. Disorientation
8. Drowsiness progressing to coma

K Clinical signs of fever

Onset (cold or chill stage)
1. Increased heart rate
2. Increased respiratory rate and depth
3. Shivering due to increased skeletal muscle tension and
contractions
4. Pallid, cold skin due to vasoconstriction
5. Complaints of feeling cold
6. Cyanotic nail beds due to vasoconstriction
7. ´Goosefleshµ appearance of the skin due to contraction of
the arrectores pilorum muscles
8. Cessation of sweating
9. Rise in body temperature
Course
1. Absence of chills
2. Skin that feels warm
3. Feelings of neither hot or cold
4. Increased pulse and respiratory rates
5. Increased thirst
6. Mild to severe dehydration
7. Simple drowsiness, restlessness, or delirium and
convulsions due to irritations of the nerve cells
8. •erpetic lesions of the mouth
9. Loss of appetite (if the fever is prolonged)
10. Malaise, weakness, and aching muscle due to protein
catabolism

Defervescence (fever abatement)

1. Skin that appears flushed and feels warm
2. Sweating
3. Decreased shivering
4. Possible dehydration
K Types of thermometers:
A. Mercury--in-
Mercury in-glass thermometers
1. Long slender tip
2. Short rounded tip
3. Pear--shaped tip
Pear
4. Color coded
B. Disposable thermometers
C. Electronic thermometers-
thermometers- consists of a battery-
battery-operated
portable electronic unit, a probe that the nurse attaches to
the unit, and a probe cover, which is usually disposable
D. Chemical disposable thermometer-
thermometer- comes in a plastic case
E. Temperature--sensitive tape
Temperature
F. Infrared thermometers

K Temperature scales:
1. Celsius = ( Fahrenheit temperature ² 32) x 5/9
2. Fahrenheit = ( Celsius temperature x 9/5) + 32
 Advantages and disadvantages of four sites for body temperature
measurement
Sites Advantages Disadvantages
1. Oral -Most accessible and - Mercury-in-
Mercury- in-glass thermometers can break if
convenient bitten, therefore, they are contraindicated for
children under 6years and clients who are
confused or who have convulsive disorders
- Inaccurate if client has just eaten very hot or
cold food or fluid or smoked
- Inaccurate if client breathes through the mouth,
therefore contraindicated for clients who have
nasal surgery
- Could injure the mouth following oral surgery

2. Axillary -Safe and most non-

non- -The thermometer must be left in place a long
invasive time to obtain an accurate measurement

3. Tympanic -Readily accessible; -Equipment is expensive. Can be uncomfortable

membrane reflects the core and involves risk of injuring the membrane if the
temperature probe is inserted too far.
4. Rectal -Most reliable -Inconvenient and more unpleasant for
measurement clients; difficult for client who cannot turn
to the side.
- Could injure the rectum following rectal
surgery
-Placement of the thermometer at
different sites within the rectum yields
different temperatures, yet placement at
the same time each time is difficult
- A rectal thermometer does not respond
to changes in arterial temperatures as
quickly as an oral thermometer, a fact that
ay be potentially dangerous for febrile
clients, because misleading information
may be acquired
- Presence of stool may interfere with
thermometer placement. If the stool is
soft, the thermometer may be embedded
in stool rather than against the wall of the
rectum. If the stool is impacted, the depth
of the thermometer insertion may be
insufficient.
- In newborns and infants, insertion of the
rectal thermometers has resulted in
ulceration and rectal perforations.
Tympanic thermometer / Digital
thermometer
Mercury glass thermometer

Mercury bulb
 Infrared
thermometer
Different types of glass
thermometers
Different types of digital / battery-
battery-operated thermometers
Tympanic thermometer
Digital thermometers
Temperature - sensitive tape
PULSE ² is a wave of blood created by contraction
of the left ventricle of the heart. It can be palpated
(felt with the fingers) at sites where an artery passes
alongside or over a bone, by placing slight pressure on
the artery.

Ú Stroke volume output ² the amount of blood that enters

the arteries with each ventricular contractions.
Ú Compliance of the arteries ² the ability of the arteries
to contract and expand.
Ú Cardiac output ² the volume of blood pumped into the
arteries by the heart. It is the result of the stroke
volume (SV) x the heart rate (•R) per minute.
Ú Peripheral pulse ² located in the periphery of the body
(ex. foot, hand, neck).
Ú Apical pulse ² central pulse; located at the apex of the
heart.
Ú Factors affecting pulse rate:
1. Age ² generally, as the age increases, pulse rate
gradually decreases.
2. Sex ² after puberty, the average male·s pulse rate
is slightly lower than the female·s.
3. Exercise ² pulse rate normally increases with
activity. The rate of increase in the professional
athlete is often less than the average person
because of greater cardiac size, strength, and
efficiency.
4. Fever - pulse rate increases in response to the
lowered blood pressure that results from
peripheral vasodilation associated with elevated
body temperature, because of the increased
metabolic rate.
5. Medications ² some medicines decreases, and
others increases. Ex« digitalis - decreases,
epinephrine - increases
6. •emorrhage ² loss of blood from the vascular system
normally increases pulse rate. It results in a temporary
adjustment of the heart rate as the body compensates
for the lost blood volume.
 7. Stress ² in response to stress, sympathetic stimulation
increases the overall activity of the heart. It increases
the rate as well as the force of the heart beat. Ex.. Fear
and anxiety
8. Position changes ² when a person assumes a sitting or
standing position, blood usually pools in dependent
vessels of the venous system. Pooling results in
transient decrease in the venous blood return to the
heart and a subsequent reduction of blood pressure and
increase in heart rate

Ú Pulse sites:
1. Temporal ² where the temporal artery passes over the
temporal bone of the head. The site is superior (above)
and lateral to (away from the midline of) the eye
2. Carotid ² at the side of the neck below the lobe of the
ear, where the carotid artery runs between the trachea
and the sternocleidomastoid muscle
3. Brachial ² at the inner aspect of the biceps muscle of
the arm or medially in the antecubital space
4. Femoral ² where the femoral artery passes through the
inguinal ligament
5. Apical ² located at the apex of the heart

ADULT ² located on the left side of the heart, no more than

8cm (3inches) to the left of the sternum (breastbone)
and under the 4th, 5th, or 6th intercostal spaces (area
between the ribs)
7-9 YEARS OLD ² located between the 4th and
FOR A C•ILD 7-
5th intercostal spaces
BEFORE 4 YEARS OF AGE ² at the left of MCL (midclavicular
line)
BETWEEN 4-4-6 YEARS ² at the MCL

6. Radial ² where the radial artery runs along the radial

bone, on the thumbside of the aspect of the wrist
7. Popliteal ² where the popliteal artery passes behind the
knee. This point is difficult to find but it can be palpated
if the client flexes the knee slightly
8. Posterior tibial - on the medial surface of the ankle
where the posterior tibial artery passes the medial
malleolus
9. Pedal (dorsalis pedis) ² where the dorsalis pedis artery
passes over the bone of the foot. This artery can be
palpated by the dorsum (upper surface) of the foot on
an imaginary line drawn from the middle of the ankle to
the space between the big and second toes
Assessing apical-
apical-radial pulse by 2-
2-nurse technique
Popliteal pulse site
Ú Ways to assess the pulse:
1. By palpation-
palpation- using the middle 3 fingers for palpating all
pulses except the apical pulse
2. By using stethoscope-
stethoscope- for assessing apical pulse and
fetal heart tone (F•T)
3. By Doppler UTZ stethoscope (DUS)-
(DUS)- for pulses that are
difficult to assess. DUS headset has earpieces similar
to standard stethoscope but it has a long cord attached
to a volume-
volume-controlled audio unit and an UTZ
transducer (battery operated)
4. By using cardiac monitoring machine-
machine- indicating the
rate on the screen or readout graph (chestleads are
attached on different sites of the body)
Ú When assessing the pulse, the nurse collects the
following data: rate
rate,, rhythm
rhythm,, volume
volume,, arterial wall
elasticity and presence or absence of bilateral
equality.
Ú Tachycardia ² referred to an excessively fast heart
rate (ex. Over 100 beats per minute in adult)
Ú Bradycardia ² referred to an excessively slow heart
rate (ex. Less than 60 beats per minute in adult)
Ú Pulse rhythm ² pattern of the beats and the interval
between the beats
Ú Dysrhythmia/arrhythmia ² a pulse with irregular rhythm
Ú Pulse volume ² also called as pulse strength or
amplitude, refers to the force of blood with each beat
Ú Elasticity of the arterial wall ² reflects its
expandability or its deformities

Ú Apical ² Radial pulse = may need to be assessed for

clients with certain cardiovascular disorders.
Normally, they are identical. An apical pulse rate
greater than the radial pulse rate can indicate that the
thrust of the blood from the heart is too feeble for the
wave to be felt at the peripheral pulse site, or it can
indicate that vascular disease is preventing impulses
from being transmitted. Any discrepancy should be
reported promptly. There is no instance that radial
pulse is greater than the apical pulse. Apical-
Apical-radial
pulse can be taken by 2 nurses or 1 nurse but the 2- 2-
nurse technique may be more accurate.
Stethoscope ² an instrument use to listen to the sounds
produced by the heart, lungs, and other body organs.
Use to take apical pulse and blood pressure.
Ú •eartbeat normally sounds like lub-
lub-dub. Each lub
lub--dub
is counted as 1 beat.

Ú Parts of a stethoscope:
1. Earpieces
2. Binaurals
3. Rubber or plastic tubing
4. Bell
5. diaphragm
Colored stethoscope
Stethoscopes
Binaurals

BP app kit
Stethoscope with animal
cover
 Variations of pulse rate at rest/min by age

Age Average Range

Newborn 125 70-190
70-
1 year 120 80--160
80
2 years 110 80--130
80
4 years 100 80--120
80
6 years 100 75--115
75
8-10years 90 70--110
70
12 years Male--85
Male 65--105
65
Female--90
Female 70--110
70
14 years Male--80
Male 60--100
60
Female--85
Female 65--105
65
16 years Male--75
Male 55--95
55
Female--80
Female 60--100
60
18 years and Male--70
Male 50--90
50
above Female--75
Female 55--95
55
Ú Respiration - the act of breathing; it includes the
intake of oxygen and the output of carbon dioxide.

External respiration ² refers to the interchange of

oxygen and carbon dioxide between the alveoli of the
lungs and the pulmonary blood.
Internal respiration ² takes place throughout the body;
the interchange of same gases between the circulating
blood and the cells of the body tissues.
Inhalation/Inspiration ² refers to the intake of air into
the lungs.
Exhalation/Expiration ² refers to the breathing out or
the movement of gases from the lungs to the
atmosphere.
Ventilation ² another word that is used to refer to the
movement of air in and out of the lungs.
Ú 2 types of breathing that nurses observe:
1. Costal (thoracic) breathing ² involves the external
intercostal muscle and other accessory muscles such
as the sternocleidomastoid muscle.
2. Diaphragmatic (abdominal) breathing ² involves the
contraction and relaxation of the diaphragm, observed
by the movement of the abdomen, which occurs as a
result of the diaphragm·s contraction and downward
movement.

Breathing Patterns:
Ú Rate
1. Eupnea ² normal respiration that is quiet, rhythmic, and
effortless
2. Tachypnea ² rapid respiration marked by quick, shallow
breaths
3. Bradypnea ² abnormally slow breathing
4. Apnea ² cessation of breathing
Ú Volume
1. •yperventilation ² an increase in the amount of air in
the lungs, characterized by prolonged and deep breaths;
may be associated with anxiety
 2. •ypoventilation ² a reduction in the amount of air in the lungs;
characterized by shallow respirations
Ú Rhythm
1. Cheyne-stroke breathing ² rhythmic waxing and waning of
Cheyne-
respirations, from very deep to very shallow breathing and
temporary apnea; often with associated with cardiac failure,
increased intracranial pressure, or brain damage
Ú Ease of effort
1. Dyspnea ² difficult and labored breathing during which the
individual has a persistent, unsatisfied need for air and feel
distressed
2. Orthopnea ² ability to breath only in upright sitting or standing
positions

Breath Sounds:
Ú Audible without amplification
1. Stridor ² a shrill, harsh sound heard during inspiration with
laryngeal obstruction
2. Stertor ² snoring or sonorous respiration, usually due to a
partial obstruction of the upper airway
3. Wheeze ² continuous highhigh--pitched musical squeak or whistling
sound occurring on expiration and sometimes on inspiration
when air moves through a narrowed or partially obstructed
airway
 4. Bubbling ² gurgling sound heard as air passes through
most secretions in the respiratory tract
Ú Audible by stethoscope
1. Crackles ² (formerly called rales) dry or wet crackling
sounds simulated by rolling a lock of air near the ear.
Generally heard on inspiration as air moves through
accumulated moist secretions. Fine-
Fine-to
to--medium crackles
occur when air passes through moisture in small air
passages and alveoli. Medium-
Medium-toto--coarse crackles occur
when air passes through moisture in bronchioles,
bronchi, and the trachea.
2. Gurgles ² (formerly called rhonchi) coarse, dry, wheezy
or whistling sound more audible during expiration as
the air moves through tenacious mucus or narrowed
bronchi
3. Pleural friction rub ² coarse, leathery, or grating sound
produced by the rubbing together of inflamed pleura
Ú Chest movements
1. Intercostal retraction ² indrawing between the ribs
2. Substernal retraction ² indrawing beneath the
breastbone
3. Suprasternal retraction ² indrawing above the clavicle
 4. Tracheal tug ² indrawing and downward pull of the
trachea during inspiration
5. Flail chest ² the ballooning out of the chest wall through
injured rib spaces; results in paradoxical breathing,
during which the chest wall balloons on expiration but
is depressed or sucked inward on inspiration
Ú Secretions and coughing
1. •emoptysis - the presence of blood in the sputum
2. Productive cough ² a cough accompanied by
expectorated secretions
3. Nonproductive cough ² a dry, harsh cough without
secretions

Major Factors Influencing Respiratory Rate

1. Exercise (increases metabolism) ² increase RR
2. Stress (readies the body for ´fight or flightµ) ² increase
RR
3. Environment (increase temperature) ² increase RR
4. Increased altitude (lower oxygen concentration) ²
increase RR
5. Certain medications (ex. narcotics, analgesic) ²
decrease RR
 VARIATIONS IN RESPIRATION BY AGE

Age Respiratory Rate/Minute

Average Range

Newborn 15 30--80
30

1 year 30 20--40
20

2 years 25 20--30
20

8 years 20 15--25
15

16 years 18 15--20
15

Adult 16 12--20
12
 BLOOD PRESSURE
Arterial blood pressure ² is a measure of the pressure
exerted by the blood as it flows through the arteries.
It is measured in millimeters of mercury (mm•g) and
recorded as a fraction. It is controlled by:
1. The force of hear contractions (resistance)
2. The amount of blood pump with each heartbeat
(volume)
3. •ow easily the blood flow through the blood vessels
(viscosity)

2 Blood Pressure measurements as the blood moves in

waves:
Ú Systolic pressure ² the pressure of the blood as a result
of contraction of the ventricles, that is, the pressure of
the height of the blood wave
Ú Diastolic pressure ² the pressure when the ventricles
are at rest; it is the lower pressure
Ú Pulse Pressure ² the difference between the systolic
and diastolic pressure
Ú Cardiac output ² volume of the blood pumped into
the arteries by the heart
Ú •ypertension ² persistent measurement above the
normal systolic and diastolic pressure (over 140/90)
Ú •ypotension ² abnormally low blood pressure below
100 mm•g systolic

Factors Affecting Blood Pressure

1. Age ² BP increases as person grows older. It is
lowest in infancy and childhood and highest in
adulthood. BP continuous to increase with aging.
2. Gender ² women usually have lower BP than men. BP
rises in women after menopause.
3. Blood volume ² (the amount of blood in the system)
severe bleeding lowers blood volume, therefore BP
lowers. Rapid administration of IV fluids increases
the blood volume, therefore the BP rises.
4. Stress ² includes anxiety, fear, and emotions. •R and
BP increases as part of the body·s response to
stress.
5. Pain ² generally increases BP. •owever, severe pain
can cause shock. BP is seriously low in the state of
shock.
6. Exercise ² increases •R and BP; so BP should not be
measured right after exercise.
7. Weight ² BP is higher in overweight persons. BP
lowers with weight loss.
8. Race ² black persons generally have higher BP than
white persons do.
9. Diet ² a high-
high-sodium diet increases the amount of
water in the body. Extra fluid volume increases BP.
10. Medications ² drugs can be given to raise or lower
BP. Other drugs have side effects of high or low BP.
11. Position ² BP is lower when lying down and higher in
standing position. Sudden changes in position can
cause sudden changes in BP (orthostatic
hypotension). A person who stands suddenly may
have sudden drop in BP. Dizziness and fainting can
occur.
12. Alcohol ² excessive alcohol intake can raise BP.
13. Smoking ² increases BP. Nicotine in cigarettes
causes blood vessels to narrow. The heart must
work harder to pump blood through narrowed
vessels.
14. Diurnal variations ² BP s usually lowest early in the
morning, when the metabolic rate is lowest; then
rises throughout the day and peaks in the late
afternoon or early evening.
15. Disease process ² any condition affecting the
cardiac output, blood viscosity, and/or compliance of
the arteries has a direct effect on the BP.

BP equipment:
1. Sphygmomanometers
Ú Aneroid
Ú Mercury
Ú Electronic / Digital
2. BP cuff
Ú Cuff
Ú Bulb
Ú Valve
Ú Tube to sphygmomanometer
Ú bladder
 Aneroid
sphygmomano
meter
Digital / Electronic BP app
 Aneroid
sphygmomanometer
 Mercurial
sphygmomanometer
 Cuff

Different
bladder sizes
Arm blood pressure
Thigh blood
pressure
Doppler probe on the dorsalis
pedis
Ú KOROTKOFF·S SOUND ² ( named after Dr. Nikolai
Korotkoff, a Russian Physician,1905) the five phases
in the series of sounds heard when taking the blood
pressure by using a stethoscope.
1. P•ASE 1 ² The period initiated by the first faint, clear
tapping sounds. These sounds become rapidly more
intense. To ensure that they are not extraneous sounds,
the nurse should identify at least two consecutive
tapping sounds.
2. P•ASE 2 ² the period during which the sounds have a
swishing quality.
3. P•ASE 3 ² the period during which the sounds are
crisper and more intense.
4. P•ASE 4 ² the period during which the sounds become
muffled and have a soft, blowing quality.
5. P•ASE 5 ² the point where the sounds disappear.
VARIATIONS IN BLOOD PRESSURE BY AGE

Age Mean BP (mm•g)

Newborn 78/42
1 year 96/65
2 years 100/63
4 years 97/64
6 years 98/65
8 years 106/70
10 years 110/72
12 years 116/74
14 years 120/76
16 years 123/76
18 years 126/79
Adult 120/80
Elderly (over 70 years) 120/80
 SELECTED SOURCES OF ERROR IN BLOOD PRESSURE
ASSESSMENT
Ú Too narrow bladder cuff ² erroneously high
Ú Too wide bladder cuff ² erroneously low
Ú Arm unsupported ² erroneously high
Ú Insufficient rest before the assessment ² erroneously high
Ú Repeating assessment too quickly ² erroneously high
systolic or low diastolic readings
Ú Cuff wrapped too loosely or unevenly ²erroneously high
Ú Deflating cuff too quickly ² erroneously slow systolic and
high diastolic readings
Ú Deflating cuff too slowly ² erroneously high diastolic reading
Ú Failure to use the same arm consistently ² inconsistent
measurements
Ú Arm above level of the heart ² erroneously low
Ú Assessing immediately after a meal or while client smokes
or has pain ² erroneously high
Ú Failure to identify auscultatory gap ² erroneously low
systolic pressure and erroneously low diastolic pressure
 GUIDELINES FOR MEASURING BLOOD PRESSURE

1. Let the person rest for 10-

10-20 minutes before
measuring BP.
2. Do not take BP on an arm with an IV infusion, a cast,
or a dialysis access site. F a person has had breast
surgery, BP is not taken on that side. Also avoid
taking BP on an injured arm.
3. Measure BP with the person sitting or lying.
Sometimes the doctor orders measurement of BP in
the standing position.
4. Apply the cuff on the bare upper arm. Clothing can
affect the measurement. Do not apply the cuff over
clothing.
5. Make sure the cuff is snug. Loose cuff can cause
inaccurate readings.
6. Place the diaphragm of the stethoscope firmly over
the artery. The entire diaphragm must be in contact
with the skin.
7. Make sure the room is quiet. Talking, TV, radio, and
sounds from the hallway can affect an accurate
reading.
8. •ave the sphygmomanometer clearly visible.
9. Locate the radial artery, and then inflate the cuff.
When you no longer feel the pulse, inflate the cuff
another 30mm•g. This prevent cuff inflation to an
unnecessarily high pressure which is painful to the
person. (You can deflate the cuff at this time and
note the point where you feel a pulse. Wait
30seconds and inflate the cuff 30mm•g above the
point.
10. Measure the systolic and diastolic pressure. Expect
to hear the 1st BP sound at the point where you felt
the radial pulse. The 1st sound is the systolic
pressure. The point where the sound disappears is
the diastolic pressure.
11. Take the BP again if you are not sure of an accurate
measurement. Wait 30-30-60seconds before repeating
the measurement.
12. Notify the nurse in charge if you cannot hear the BP.