Vital Signs Objectives Flashcards Preview

N110 Exam #1 > Vital Signs Objectives > Flashcards

Flashcards in Vital Signs Objectives Deck (55):
1

Regulation of Body Temperature

Hypothalamus controls heat production/loss

2

Heat Production

Shivering, non-shivering thermogenesis (infants), epinephrine (increases metabolism), vasoconstriction

3

Heat Loss

Vasodilation, sweating

4

Regulation of Pulse/Heart Rate

Sinoartrial node receives signals from the nervous system
Accelerator nerve: sympathetic NS, increases HR
Vagus nerve: parasympathetic NS, decreases HR

5

Regulation of Respiration

Chemoreceptors in the medulla oblongata/carotid/arterial arteries respond to changes in body (oxygen, CO2, pH) and stimulate respiration

6

Regulation of Blood Pressure

Cardiac Output and Systemic Vascular Resistance

7

Cardiac Output

Amount of blood ejected per minute; SV x HR= cardiac output

8

Systemic Vascular Resistance

Blood viscosity (thicker blood=more resistance= increased BP), arterial size (vasoconstriction= increased BP; vasodilation= lower BP), and elasticity

9

Factors that affect Temperature

(DEGEEC)
Developmental level: Babies lose 30% heat through head; older adults have lower temps bc less vasomotor control, slower metabolism, and loss of subcutaneous tissue
Environment
Gender: Women have higher temps bc hormones
Emotions: epinephrine ^ metabolism ^ temperature
Exercise
Circadian Rhythm: lower temps in morning, higher in afternoon/early evening, low again at night

10

Factors that affect Pulse/Heart Rate

(DDFFGEMSBP)
Developmental level: infants have rapid heart rate
Disease: heart disease, respiratory disease, etc.
Fear: fight or flight stimulates SNS and epinephrine
Fever: higher body temp
Gender: women have higher HR vs men
Exercise: in shape vs. out of shape people
Medications: cardiotonics and opioids
Stress
Blood loss: HR ^
Body positions

11

Factors that affect Respiration

(DESSMFPHDP)
Developmental level: infants RR is 40-60 bpm
Exercise: RR ^ to ^ oxygen and remove CO2
Smoking: ^ resting RR
Stress: ^ RR
Medications: stimulants inc. RR; depressants decrease RR
Fever: ^ HR= ^ RR
Pain: ^ RR, v depth
Hemoglobin: RR ^ to compensate for low oxygen getting to body from low hemoglobin
Disease: can ^ or v
Position: max RR when standing

12

Factors that affect Blood Pressure

(DGFLEBPSRODMD)
Developmental level: infants have ^ BP
Gender: men have higher BP vs women of same age
Family history
Lifestyle: sodium, smoking, +3 alcoholic drinks
Exercise: v BP over time; ^ BP initially when exercising
Body position: BP highest when standing, taking BP with arm unsupported, arm higher than heart, and legs crossed ^ BP
Pain: ^ BP; prolonged pain v BP
Stress: stimulates SNS= ^ BP
Race: African Americans have higher BP
Obesity: heart works harder so ^ BP
Disease: circulatory system
Medication: Pain meds v BP bc they depress the CNS and lower HR
Diurnal Variations: lowest BP when sleeping/waking, highest during the day, lower at night

13

Measuring temperature

Temporal, Rectal, Axillary, Oral, Tympanic, Skin (forehead)

14

Temporal

*MOST ACCURATE CORE TEMP*
+ Fast read, safe, no discomfort
- Requires special scanning thermometer, any coverings (hair, hat) can increase temp and give false read

15

Rectal

*MOST ACCURATE CORE TEMP IN CRISIS*
+ Used when clients cannot follow oral temp instructions
- Uncomfortable/embarrassing, can damage rectal mucosa, stool can alter read, requires special position from client

16

Contraindications of Rectal

-Clients who may be damaged by the method (infants [fragile mucosa]; adults with rectal disease etc)
-Not suggested for clients with cardiac problems as rectal temp can stimulate vagus nerve which slows HR
-Clients with hemorrhoids
-Immunosuppressed clients or with clotting disorders

17

Oral

+ Simple, safe, convenient for those who can follow directions
- Glass thermometers can break in mouth, food/drink can alter temp so wait 30 minutes after eat/drink, bradypnea may cause false elevated temperatures, slow read

18

Contraindications of Oral

-Clients who cannot follow directions (infants/small children, unconscious) or have injury to the mouth (oral surgery)

19

Axillary

+ Recommended for peds patients, good for routine checks, simple
- Cant read core temp, sweating can alter read, thermometer must be left in place for long time

20

Contraindications of Axillary

-Clients who sweat a lot
-Cannot accurately diagnose fever

21

Tympanic

+ Fast, can be used for uncooperative/unconscious clients
- Requires special positioning, can damage tympanic membrane, cerumen can alter read, L/R ear can give different reads, special thermometer required

22

Contraindications of Tympanic

-Clients who have had recent ear surgery
-Ear infection

23

Skin

+ Safe, simple, comfortable, inexpensive
- Skin temp is 28-48 degrees less than core

24

Contraindications of Skin

-Not to be used when accuracy is crucial (hypothermia or heatstroke etc.)
-Can be accurate however if obtained via infrared thermometer

25

Types of thermometers

Glass, Electronic, Infrared, Disposable Chemical

26

Glass

+ Easily cleaned, can be used in many spots (oral, rectal, axillary), inexpensive
- Can break and expose mercury, long time to get read, different people=different reads

27

Electronic

+ Quick, can measure oral, rectal, axillary
- Requires charging, routine checks for accuracy, expensive

28

Infrared

+ Quick, low error
- Requires charging, routine checks for accuracy, expensive

29

Disposable Chemical

+ Inexpensive, easy to use, recommended for peds patients, prevents spread of infection
- Cannot read core temp, skin must be dry

30

C --> F

Multiply by 9/5, then add 32

31

F --> C

Subtract 32, multiply by 5/9

32

Normal Adult Temperature

Oral= 98° F
Rectal= 98.6° F
Core= 97°-100.3° F

33

"Normal Temperature"

Older adults have slower metabolism (lower temp), pregnant women (higher temp)

34

Nursing Interventions for Pyrexia (fever)

Acetaminophen, cooling blankets, cold compress, monitor WBC/vitals, keep clients clothes and linens dry, measure intake/output, assess skin color and temp

35

Fever

Oral= higher than 100° F; Rectal= 101° F or higher
Foreign substance triggers phagocytosis--> phagocytes eat invader and release pyrogens--> pyrogens trigger prostaglandins--> prostaglandins raise body temp to new set point

36

Moderate Fever

up to 103° F

37

Hyperpyrexia

Temperature above 105.8° F

38

3 Phases of Fever

1. Initial phase (onset/febrile episode)
2. Second phase (course)
3. Third phase (defervescence/crisis)

39

Initial Phase (onset/febrile episode)

Temperature is rising; chilly, shivering, uncomfortable

40

Second Phase (course)

Temperature is at new set point; flushed, warm, dry; days-weeks

41

Third Phase (defervescence/crisis)

Temperature is returns to normal; diaphoresis; warm and flushed from vasodialation

42

Types of Fever

Intermittent
Remittent
Constant
Relapsing

43

Intermittent Fever

Temp fluctuates between fever and normal temp without meds

44

Remittent

Fluctuations in temp all above normal (98°F) in 24 hr period

45

Constant (Sustained)

Slight fluctuations all above normal

46

Relapsing (Recurrent)

Short periods of fever alternating with periods of normal temps, each lasting 1-2 days

47

Nursing Interventions for Hypothermia

slowly warm up, heating blanket, warm intravenous IV fluids, check temp hourly, assess HR/BP every 15 mins

48

Hypothermia

below 95° F

49

Early signs of Hypothermia

Shivering, cyanosis of lips and fingers, poor coordination; confusion, disorientation, mental impairment, slowed HR and respirations

50

Severe Hypothermia

Temperature lower than 82.4° F; unconsciousness, pulse/respirations are irregular and weak; death occurs at 70°-75° F

51

Signs/Symptoms of Pyrexia/Hyperthermia

1. ^ pulse/respirations
2. Shivering and chills
3. Diaphoresis
4. Elevated body temperature
5. Weakness

52

Normal Vital Signs

Temp: Oral 98° F; Rectal 98.6° F
Pulse: 60-100 bpm (beats per minute)
Respirations: 12-20 bpm (breaths per minute)
Blood Pressure: 100-119 mm Hg systolic/ 60-80 mm Hg diastolic

53

Prehypertension

120-139 mm Hg systolic/ 80-89 mm Hg diastolic

54

Blood Pressure Cuff Size

Width of the bladder should cover 2/3 of the length of the upper arm (adult)/entire upper arm (child)

55

BP Cuff Stipulations

Too small BP cuff= high reading
Too large BP cuff= low reading
Deflate too slow= high reading
Deflate too fast= underestimated sys/overestimated dia