Flashcards in Quiz 2 Vital signs Deck (69)
Pain Assessment (5th vital Sign)
Oxygen saturation via Pulse Oximetry
reflects the balance between heat the body produces and loses
is the measurement of heart rate and rhythm. Pulse corresponds to the bounding of blood flowing through various points in the circulatory system
is the body’s mechanism for exchanging oxygen and carbon dioxide between the atmosphere and the cells of the body, which is accomplished through breathing and recorded as the number of breaths per minute.
Blood pressure (BP)
reflects the force the blood exerts against the walls of the arteries during contraction (systole) and relaxation (diastole) of the heart
Guidelines for Measuring Vital Signs
-Ensure that equipment is functional and is appropriate for the size and age of the patient.
-Appropriately perform or delegate measurement.
-Be able to understand and interpret values.
-Know the patient’s usual range of vital signs.
-Determine the patient’s medical history, therapies, and prescribed medications.
-Control or minimize environmental factors that affect vital signs
-Use an organized, systematic approach when taking vital signs.
-Accurately document findings.
-Analyze the results of vital sign measurement.
Instruct the patient or family caregiver in vital sign assessment and the significance of findings.
Interpretation of Vital signs
Evaluate the reading (parameters)
Correlate w/ client’s medical history, therapies, prescribed medications, & symptoms
Consider environmental factors that may affect vital signs
When should vital signs be taken
Based on the provider’s (MD, DO, NP, PA) order set
Established minimum frequency
Acceptable temperature range
96.8° F to 100.4° F or 36° C to 38° C
Oral, rectal, axillary, tympanic membrane, temporal artery, esophageal, pulmonary artery, and urinary bladder
controls the physiological and behavioral mechanisms that regulate heat loss and heat production.assists in maintaining homeostatsis
CONTROLS HEAT LOSS
Controls heat production
Heat Loss Mechanism
sweating and vasodilation-widening or relaxation of blood vessel walls and inhibition of heat production. Redistributes blood to surface vessels to promote heat loss
Heat Conservation Mechanism
vasoconstriction- narrowing or tightening of blood vessel walls to reduce blood flow to the skin and extremities. Compensatory heat production is stimulated through voluntary muscle contraction and muscle shivering
Factors Affecting Body Temperature
Age(lower in older adults), exercise(up), hormonal levels,
Circadian rhythm(low 0100-0400, high 1800), environment, Temperature alterations, emotional stress, infection
Excessive heat production
Excessive heat loss
Minimal heat production
Minimal heat loss
Combination of these alterations
fever- important defense mechanism
-Pyrogens-such as bacteria and viruses elevate body temperature.
-Febrile/afebrile-Febrile means having fever; afebrile means not having fever
-Fever of unknown origin (FUO)-a fever with an undetermined cause
-occurs because the body is unable to keep pace with a heat production mechanism. This can occur because the hypothalamus is unable to keep the “set point.”
-Mild temperature elevations as high as 39° C (102.2° F) enhance the immune system of the body. But also increases oxygen demand and can stress the cardiac and respiratory systems.
. During a febrile episode, white blood cell production is stimulated.
elevated body temperature resulting from the body’s inability to promote heat loss or reduce heat production.
a hereditary condition of uncontrolled heat production that occurs when susceptible people receive certain anesthetic drugs.
body temperature of 40° C (104° F) or more] occurs from prolonged exposure to the sun or high environmental temperatures
Signs and symptoms of heatstroke
giddiness, confusion, delirium, excessive thirst, nausea, muscle cramps, visual disturbances, elevated body temperature, increased heart rate, and lower blood pressure.
occurs when profuse diaphoresis(perspiration) results in water and electrolyte loss
risks of fever in cardiac and respiratory patients
A prolonged fever weakens a patient by exhausting energy stores. Increased metabolism requires additional oxygen. If the body cannot meet the demand for additional oxygen, cellular hypoxia (inadequate oxygen) occurs. Myocardial hypoxia produces angina (chest pain). Cerebral hypoxia produces confusion. Interventions during a fever include oxygen therapy.
body temperature is constant and is continuously above 38° C (100.4° F) with little fluctuation
temperature returns to an acceptable value at least once in 24 hours
febrile episodes and periods of normothermia are often longer than 24 hours
occurs with exposure to cold. The core body temperature drops, and the body is unable to compensate
The patient suffers uncontrolled shivering, loss of memory, depression, poor judgment, becomes cyanotic