Chapter 30: Vital Signs Flashcards
(147 cards)
What are the vital signs?
- Temperature
- Pulse
- Respiration
- Oxygen Saturation
- Blood Pressure
- Pain
Vital Signs measure the effectiveness of:
- The circulatory system
- The respiratory system
- The neural system
- The endocrine system
What causes vital signs to change?
- Temperature of environment
- Physical Exertion
- Effects of Illness
What are the guidelines to taking vital signs?
- The RN is always responsible for the measurement of VS. (nurse analyzes and interpret the significance)
- Ensure the equipment is functional and appropriate for the patient.
- Know the patient baseline if possible.
- Know your patient therapies. (Certain medications and therapies can alter VS)
- Know the frequency at which it is essential to take VS. (according to unit policy and patient condition)
- Communicate significant changes!
- Patient and family teaching.
Body Temperature
Heat Produced - Heat Lost = Body Temperature aka Thermoregulation
Temperature Range for Adults: Average Temperature Range
36° to 38° C (96.8° to 100.4° F)
Temperature Range for Adults: Average oral/tympanic
37° C (98.6° F)
Temperature Range for Adults: Average rectal
37.5° C (99.5° F)
Temperature Range of Adults: Axillary
36.5° C (97.7° F)
Core temperature
Temperature of the deep tissues
Sites of Temperature Measurement
- Axillary
- Rectal
- Oral
- Tympanic membrane (core)
- Temporal artery
- Esophageal (core)
- Pulmonary artery (core)
- Bladder (core)
Body temperature is controlled by the
Hypothalamus (between cerebral hemispheres)
Anterior Hypothalamus controls
Heat loss.
- vasodilation-increased blood flow to skin and extremities-cooling.
- sweating
- inhibition of heat production
Posterior hypothalamus controls
Heat production.
- vasoconstriction-reduced blood to skin and extremities.
- muscle contraction stimulates heat production through shivering
Heat produced by the body is a by-product of
Metabolism, which is the chemical reaction in all body cells. Food is the primary fuel source.
BMR
Basal Metabolic Rate
What is BMR?
Heat produced by body at absolute rest.
BMR is affected by what?
The thyroid hormone, Testosterone by promoting the breakdown of glucose and fat.
Voluntary movements
Such as exercise (muscle contraction/sweating) increases metabolic rate/heat production. Also, increases heart rate and O2 demand.
Shivering
- Involuntary body response that can increase heat production 4-5 times that of the normal.
- increases energy expenditure up to 400%.
In vulnerable populations, shivering ….
Seriously drains energy resources, resulting in further physiological deterioration.
the heat produced by shivering …
helps equalize body temperature and the shivering ceases.
Forms of Heat Loss
- Radiation
- Conduction
- Convection
- Evaporation
Radiation
Heat transfer from the surface of one object to another without direct contact.