Quiz 2 Flashcards
(80 cards)
5 vital signs
temperature pulse respiration blood pressure pain (considered the 5th vital sign) (sometimes oxygen saturation is considered)
vital signs
- provides baseline assessment data of health status
- may be compared with later findings
- in the hospital, the physician may order minimum schedule for assessment but the nurse uses clinical judgement to determine if more frequent readings are needed
- nurses use vital sign data to implement prescribed treatment and notifies physician of significant changes
- taken in a step by step manner to ensure accuracy
- documentation is often done on a graphic chart to demonstrate trends
- taken on admission, before and after invasive or diagnostic procedures, with blood transfusions and medications, if condition changes or patient reports specific or nonspecific symptoms, when performing nursing interventions that may affect vital signs (ambulation following bed rest), and as ordered by the health care provider or agency policy
temperature
- body temperature =heat produced minus heat lost
- acceptable temperatures for humans:
- 96.8-100.4 degrees F (36-38 degrees C): Body functions best at this temperature
- average temp for elderly is 96.8 degrees C
- core temperature is in the deep tissues and remains stable
- surface temperature is of the skin and varies greatly depending on blood flow
- physiological and behavioral mechanisms affect temperature
- no single temperature is normal for everyone: Monitored to detect infection and response to treatment
thermoregulation
regulation of body temperature, done by balancing heat lost and heat produced
hypothalamus
- the body’s “thermostat”-responsible for controlling the body’s heat temperature.
- sends messages to blood vessels to help conserve heat by vasoconstriction or to release heat by vasodilation and sweating
- shivering is an involuntary response to create heat
- muscular activity increases heat production in the body
basal metabolic rate
- heat produced by the body at absolute rest, is affected by thyroid hormones that control metabolism
- men have higher BMR than women
heat loss
lost from the skin surface by radiation, conduction (contact), evaporation, convection (air movement), diaphoresis
factors that influence body temperature
- age- unstable in infants and children until puberty as control mechanisms are immature or may be impaired. Older adults are sensitive to extremes since their control mechanisms may deteriorate… especially cardiovascular vasoconstriction and vasodilation
- exercise- muscle activity increases metabolism
- hormone level- primarily affects women due to hormonal changes in cycle
- stress- physical and emotional stress changes physiology and increases temperature through hormone and nervous stimulation
- environment- cold or extreme heat may affect temperature
- temperature altercations- due to disease (example: fever from infection)
- circadian rhythm- varies over the 24 hour period with lowest temp 1am-4am, highest at 6pm. Tales 1 to 3 weeks to change with change of work and sleep pattern
types of thermometers
- glass (still may be used in homes)
- digital
- electronic (most often in health care agencies)
- tympanic
- disposable (eliminate cross contamination with heat sensing tape or inexpensive digital thermometers)
- chemical dot
- continuous measurement probe
- temporal arty scanner (detects temperature of cutaneous blood flow)
- Infrared Scanners
Core Body Temperature Sites
- rectal, tympanic, pulmonary, urinary bladder, esophagus
- deep inside of us
Surface Body Temperature Sites
- oral, skin, axillae
- affected by outside surface
Oral: Temperature Measurement
- accessible and comfortable
- affected by food, drinks or smoking
- not for infants or young children
- mercury thermometers are dangerous and slow (3minutes)
- electronic thermometers 20-50 seconds to display temp
Rectal: Temperature Measurement
- about 1 degree higher than oral
- used when cannot take oral temperature
- uncomfortable, requires lubrication
- not used with rectal problems, diarrhea, or bleeding problems
- mercury thermometers are dangers and slow
Axillary: Temperature Measurement
- about 1 degree lower than oral
- not as reliable
- noninvasive
- must be held in place for infants and children
- mercury thermometers are slow
Tympanic: Temperature Measurement
- can be accurate core temperature
- unaffected by fluids or food
- expensive and often unreliable due to techniques
- use with caution for infants or toddlers
- ear problems will distort temperature
Temporal: Temperature Measurement
- rapid, easy to access, comfortable, safe for all ages, including newborns
- must be used correctly with scanner flat on skin
- affected by skin moisture or hair
Fever (pyrexia, febrile episode)
- not harmful usually under 102.2 degrees F
- Pyrogens (bacteria, viruses) cause a rise in body temperature by triggering an immune response. This causes the hypothalamus to raise the set point temperature of the body
- important defense mechanism, works to enhance the immune system below 102
- Chills: body’s attempt to increase body temperature to attain new “set point” temperature set by hypothalamus affected by pyrogens. Client feels cold even though body temperature is rising
- Diaphoresis: sweating to release heat and decrease body temperature when fever is resolving. Afebrile- fever has “broke”
Chills
body’s attempt to increase body temperature to attain new “set point” temperature set by hypothalamus affected by pyrogens. Client feels cold even though body temperature is rising
Diaphoresis
sweating to release heat and decrease body temperature when fever is resolving. Afebrile- fever has “broke”
negative effects of fever
- dehydration
- increased cardiovascular workload
- increased oxygen needs due to increased metabolism
- weakness from depleting energy stores
treatment of fever
- antipyretics: drugs to reduce fever, including Tylenol and Motrin (increase heat loss)
- Oxygen
- Fluids
- Do not use ice packs or tepid sponge baths- will promote shivering
- caution with hypothermia blankets- shivering, and risk of injury to skin
Hyperthermia: Heat exhaustion
- excessive perspiration leads to fluid and electrolyte imbalances
- usually due to environmental conditions
- move client to cooler environment and replace fluids
- can lead to heatstroke if not treated
Hyperthermia: Heatstroke
- emergency situation caused by prolonged exposure to sun or heat
- hypothalamus malfunctions due to extreme temperatures, and does not cause sweating
- symptoms include cramps, confusion, visual disturbances, and hot, dry skin
- temperature of 105 degrees F can cause brain and tissue damage-brain is first organ affected
- treatment: cool client to increase heat loss and replace fluids by IV route
Hypothermia: prolonged exposure to cold
- danger point is at 95 degrees F when uncontrollable shivering occurs. Vital signs fail at 94 degrees F
- treatment: slowly increase the temperature with blankets, warming devices and warm fluids
- Hypothermia may be induced to decrease the body’s need for heat and oxygen