Ch. 17 Measuring vital signs Flashcards
______ _______ are a means of assessing vital or critical physiological functions. one of the most frequent assessments and variations reflect a person’s state of health and/or functional ability of the body systems
vital signs
Includes temp, pulse, respirations, BP, SA02, Pain
Even though vital signs are performed on a regular basis what is the frequency determined by?
physician order and/or nursing judgment
facility standards (hospital is typically every 4-8 hours)
How often also depends on the pt’s condition and the events taking place (Common occasions include: admission, beginning of shift, visit to clinic/office, before-during-after surgery or procedures, after administration of drugs, when conditions change.)
A patient is relying on carbon dioxide instead of oxygen. This is known as?
chronic obstructive pulmonary disease (COPD)
if you give the pt. O2 leave it at 2-4 liters or they will have respiratory problems/wont be able to breathe
what is the only exception for not having a prescribed order?
Oxygen because you do not want the pt. to die while trying to find a doctor. BUT get a doctor order asap!
If a pt. needs more than 8 liters of oxygen what do you do?
change the mask or consult with a doctor
what are facility standards for monitoring?
Hospital: every 4-8 hours
Home health: each visit
Clinic: each visit
Skilled nursing facility: weekly to monthly
Your pt. just came from the OR, how often should you monitor them?
every 15 min for the 1st hour then if the pt. is stable you can monitor less frequently
______ is the degree of heat maintained by the body. Heat produced minus heat lost.
Temperature
Can be affected by
environment - hot shower = hot skin
sex-women temp changes due to hormones
exercise - you exercise to increase temp to burn calories
emotions and stress - triggers sympathetic, releases epi and norepi
circadian rhythm - temp fluctuates 1-2 degrees F over 24 hours.
What are the symptoms of fever?
Chills Sweating Headache Body/muscle aches Weakness Fatigue
The doctor orders a _________ __________ that states “if this happens, do this!” Example: “if pain is more than 5, give more norco”
Standing order
There can be multiple standing orders if the first standing order does not work
What is the core temperature?
97-100.8 degrees Fahrenheit/ 36.1-38.2 degrees Celsius.
Typically 1-2/0.6-1.2 degrees higher than skin temperature
___________ temperature is lower than core temperature and uses the oral and axillary method.
Surface (review table 17.3)
Changes in temperature can occur in four ways:
List them
Conduction
Convection
Radiation
Evaporation
____________ is transfer of heat from a warm to a cool surface by direct contact. Example: If a patient lies on a cold examination table, the heat from the skin will leave the patient and go onto the cold table.
Conduction
__________ is transfer of heat through currents of air or water.
Example: . Putting a febrile pt into a cool tub or using a fan to reduce fever.
Convection
________ is the loss of heat through electromagnetic waves emitting from surfaces that are warmer than the surrounding air.
Example: The reason a room gets warm once it is crowded; our body heat leaves us to go to the cool air.
Radiation
During _________ water is converted to vapor and lost from the skin (perspiration) or the mucous membranes (through the breath)
Note: “insensible loss” – water loss by evaporation
Evaporation
Also known as fever, ________ results in abnormally high temp in response to pyrogens (bacteria). More than 100 degrees Fahrenheit or 37.8 degrees Celsius.
Pyrexia
Antigen enters–>Phagocytes attack antigen–>pyrogens are stimulated–>induce prostaglandins–>reset hypothalamic thermostat to change temperature of body.
Some fevers are good – killing invaders!
_______ induces secretion of substances (prostaglandins) that reset the hypothalamic thermostat at a higher temp
Pyrogens
What is the difference between intermittent and remittent fever? Both are within a 24-hour period, but….
If the temperature returns to normal at any point in a 24-hour period, it is considered intermittent. Remittent also endure fluctuations, but ALL fluctuations remain above normal temperature.
Remittent - Ebola
Intermittent - Flu
Remittent fever and constant fever both fluctuate. What is the difference?
Constant has a lower degree of fluctuation, less than one degree.
Remittent tends to be greater than three degrees in fluctuation.
Constant - infection/immunocompromised
Why should we avoid treating a fever below 102?
THe body uses the heat to kill or inhibit the growth of microbes; enhances phagocytosis; causes breakdown of lysosomes (self destruction of infected cells); releases interferons (which interfere with viral infection).
What is the term for meds that reduce fevers?
antipyretics
IN hospitals tympanic is used most of the time to check temp. What are the benefits and the downside?
super fast, can be used on anyone. Downside, ear wax can affect reading, needs careful positioning to be accurate.
Signs of fever?
– sweating, shivering, elevated BP/Pulse
True or False: Pregnant women have higher baseline body temp
True
What is the common range for core temp?
CORE: 97-100.8
T or F: Typically core temperature is 1°F to 2°F (0.6°C to 1.2°C) higher than skin temperature.
True
The route of ________ temperature taking is most accurate for core; least preferred by pt.; contraindicated for cardiac conditions and newborns who can be injured due to fragile rectal mucosa.
rectal
Upside and downside to using Oral and Axillary to check temp:
Oral- upside:Safe, convenient, comfortable; downside: eating/drinking can throw off reading
Axillary- upside: safe, easy to use, good for children and unconscious adult; recommended over rectal. Downside-not good for heavy perspirer, least accurate, not reflective of core.
What part of the body controls thermoregulation?
hypothalamus
Hypothalamus controls thermoregulation!
HOT? Then, Vasodilationblood to surface, skin sweats=cooler body temp.
COLD? Then, vasoconstrictionshunts blood away from surface and into core of body. Shivering+Epinephrine=increased metabolism (p.319)
Metabolism-uses energy&generates heat
________ is a fever >105.8°F (41.0°C) and it can cause seizures; very dangerous and requires intervention.
Hyperpyrexia
105.8 temperaure and above damages cells, esp brain and can cause confusion stupor or coma. At 109 a person dies.
________ is when the Core temperature below normal (
Hypothermia
Monitor for dysrhythmias
Sometimes dr deliberately puts body into hypothermic state to decrease the need for oxygen in body tissues (during cardiac and neurological surgery)
As a fever runs its course, it has three different phases:
- Initial phase - febrile episode/onset
- Second phase - course
- Third phase - defervescence or crisis
Describe each phase
Initial - Febrile episode
Onset of the fever…
Body temp is rising (sudden or gradual)
Pt feels chilly, uncomfortable & may shiver
Second – Course
Reaches maxixum temperature aka “set point”
Remains constant
Feels warm & dry, flushed; may last a few days-few weeks
Third - Defervescence or crisis
Definition of defervescence - the abatement of a fever as indicated by a decrease in bodily temperature.
Feels warm & flushed DUE to vasodilation
Diaphoresis (sweating to an unusual degree as a symptom of a disease) assists with heat loss by evaporation
“fever is breaking” & temp returns to normal
When a person gets a fever, the hypothalamus regulates the temperature. HOwever, when ________ occurs, the body cannot promote heat loss fast enough to balance and heat exhaustion or heat stroke can occur.
Hyperthermia
p.322
heat exhaustion is up to 103, after 103 its heat stroke
________ fever comes in short periods of fever alternating with periods of normal temp; lasting 1-2 days
relapsing
TB pt would have this
The nurse would monitor the body temperature most closely/frequently in the care of
a. The client with an infection b. The client who is an infant c. The client who has experienced heat stroke d. The client with a head injury
All of the clients depicted would need to have their temperatures monitored closely. However, a client with a head injury may have damage to the hypothalamus and therefore loss of global thermoregulation. The temperature of this client would need to be monitored more frequently.
To convert from fahrenheit to celsius…
(Temperature in F) - 32 X (5/9)=
102 f - 32 x (5/9) = 39
What sites are used to take temp in clinic setting:
From temperature lowest to highest reading: axillae, oral, tympanic, rectal, temportal artery.
The _____ is the rhythmic expansion of an artery produced when a bolus of blood is forced into it by contraction of the heart. The “wave” that begins when the left ventricle contracts and ends when the ventricle relaxes.
pulse
Each contraction forces blood into the already-filled aorta, causing increased pressure within the arterial system. The pulse that we feel is the peak of the wave when the artery expands. You cannot feel the pulse during a trough (low point).
What can you use if you cannot feel a pulse to find the pulse?
A doppler
Normal pulses are higher in newborns and decrease over the lifespan. A newborn’s pulse is on average 130. A toddler’s pulse is around 110. From 6-10, it is in the 90’s.
What is the rate for teens - adults over 70?
Pulse rate - Measured in beats per minute (bpm)
Normal range for healthy adults = 60–100 bpm
Average = 70–80 bpm
