Vital Signs Flashcards
(63 cards)
Reflects the physiologic state which govern the body’s organs
The first thing done to the client/patient when in the hospital
VITAL SIGNS
Purposes
- Identify (1) __________
- Monitor (2) __________
- Evaluate (3) __________
- Basis for (4) __________
- Part of (5) __________ in any setting
(1) problems
(2) condition
(3) response/s to intervention/s
(4) clinical problem-solving
(5) care
Main vital signs
Temperature, pulse, RR, blood pressure
When to measure VS?
❖ On (1) _________ to a health care facility
❖When assessing the patient during (2) __________
❖In a hospital on a routine schedule according to a (3) __________
❖Before and after a (4) __________
❖Before, during, and after transfusion of (5) __________
(1) admission
(2) home visits
(3) physician’s or hospital’s standards of practice
(4) surgical procedure or invasive diagnostic procedure
(5) blood products
When to measure VS?
❖before, during, and after the administration of (1) __________ or applications of __________
❖when the patient’s (2) __________ changes
❖before and after (3) __________ that influence a VS
❖when the patient reports (4) __________
(1) medications / therapies
(2) general condition
(3) nursing interventions
(4) nonspecific symptoms of physical distress
TRUE OR FALSE:
GUIDELINES
1. KNOW THE CLIENT’S NORMAL/ USUAL RANGE/ LAST MEASUREMENT
- KNOW THE CLIENT’S MEDICAL HX, THERAPY & MEDICATION HE IS RECEIVING
- CONTROL ENVIRONMENTAL FACTORS THAT MAY INFLUENCE V/S VALUES
- MANNER OF APPROACH TO THE CLIENT MAY ALTER V/S
- MAKE CERTAIN THAT EQUIPMENT IS FUNCTIONAL & APPROPRIATE
- DECIDE FREQUENCY OF VITAL SIGNS ASSESSMENT
- USE AN ORGANIZED, SYSTEMATIC APPROACH TO MEASURE VITAL SIGNS
- VERIFY & COMMUNICATE SIGNIFICANT CHANGES
• Reflects balance between the heat produced and heat lost from the body
BODY TEMPERATURE
- Temperature of the deep tissues of the body
- Remains relatively constant within a range of 36 C– 37.4 C
- Relatively higher than surface temperature
- Measured in the tympanic or rectal sites
- Can also be measured through the esophagus, pulmonary artery or bladder via invasive devices
CORE TEMPERATURE
CORE TEMPERATURE
- Temperature of the (1) __________ of the body
- Remains relatively constant within a range of (2) __________
- Relatively (3) __________ than surface temperature
- Measured in the (4) __________ sites
- Can also be measured through the (5) __________ via invasive devices
(1) deep tissues
(2) 36 C– 37.4 C
(3) higher
(4) tympanic or rectal
(5) esophagus, pulmonary artery or bladder
- Temperature of the skin, subcutaneous tissue and fat
- Measured at oral and axillary sites
- Rises and falls in response to the environment
SURFACE TEMPERATURE
SURFACE TEMPERATURE
- Temperature of the (1) __________
- Measured at (2) __________ sites
- Rises and falls in response to the (3) __________
(1) skin, subcutaneous tissue and fat
(2) oral and axillary
(3) environment
REGULATION OF BODY TEMPERATURE
1. __________
2. __________
3. __________
- Neural and vascular control
- Maintaining heat production and heat loss
- Behavioral control
REGULATION OF BODY TEMPERATURE
> Increased temp.
- Hypothalamus
- Sweating and vasodilation
> Decreased temp.
- Hypothalamus
- Shivering and vasoconstriction
- Neural and Vascular Control
REGULATION OF BODY TEMPERATURE
>Heat Production
- BMR
- Muscle Activity
- Thyroxine Output
- Sympathetic Response
- Fever
> Heat Loss
- Radiation
- Evaporation
- Convection
- Conduction
- Maintaining Heat Production & Heat Loss
• Transfer of heat by means of waves
• Transfer of heat from one surface to another surface, without contact
RADIATION
• Process by which water is converted into steam / vapor
EVAPORATION
• Transfer / dispersion of heat away by air currents
CONVECTION
• Transfer of heat from one object to another during direct contact
CONDUCTION
- Adjustments initiated by an individual to maintain appropriate body temperature
- Behavioral Control
TRUE OR FALSE:
FACTORS AFFECTING TEMPERATURE
1. Environment
2. Diurnal variation / circadian rhythm
3. Exercise
4. Specific dynamic action of food
5. Hormonal activity
6. Sex
7. Age
8. Stress
9. Illness or injury
10.Medications
11. Sexual Orientation
FALSE
SEXUAL ORIENTATION IS NOT INCLUDED
Fahrenheit: 97.6 - 99.6
Celcius: 36.5 - 37.4
Oral Temperature
Fahrenheit: 98.6 - 100.6
Celcius: 37.0 - 38.1
Rectal Temperature
Fahrenheit: 96.6 - 98.6
Celcius: 36.0 - 37.0
Axillary Temperature
- Body temp. above usual range
- Related terminologies: pyrexia, fever, febrile vs afebrile
- Occurs when heat prod > heat loss
- Not harmful if stays below 39 C in adults; 40 C in children
- Can result from infection, but can also arise from heat exhaustion and heat stroke
- Hyperpyrexia– very high fever, occurs at 41 C
HYPERTHERMIA
