Basta BHC ni Flashcards
- measures of various physiological status, in order to assess the most basic body function
- indicates that the person is alive
- can be observed, measured and monitored
- changes with age and medical condition
- useful in detecting or monitoring medical problems
Vital Signs
Measurements for the body’s basic function
a.Body temperature (Temp)
b.Pulse/heart Rate (PR/HR)
c.Respiration Rate (RR)
d.Blood Pressure (BP)
- the balance between the heat production due to chemical activities by the body and heat lost from the body through radiation, conduction, convection and vaporization
Body Temperature
When to assess Vital Signs?
Upon admission to any healthcare agency
Based on agency institutional policy and procedures
Any time there is changes in the patient’s condition
Before and after surgical or invasive diagnostic procedure
Before and after activity that may increase risk
Before and after administering medications that affect cardiovascular ore respiratory functioning
-the temperature of deep tissues of the body (ex: cranium, thorax, abdominal cavity)
true core temperature can only be measured by invasive means
CORE TEMPERATURE
What is the normal body temperature?
normal body temp : 36.2 to 37.2c
the temperature of the skin, the subcutaneous tissue and fat
rises and falls in response to environmental changes
average oral temp: 36.7 – 37c
Surface Temperature
Factors affecting Body’s Heat Production
Basal Metabolic Rate (BMR)
Muscle Activity
Epinephrine and symphathetic stimulation
Age
Gender
Diurnal variation
Exercise
A body temperature above the usual range
Gender Alterations in Body temperature: PYREXIA
usually referred as fever
Hyperthermia
A very high temperature, e.g. 41c (105 f) is called
Hyperpyrexia
temperature alternates at regular intervals between periods of fever and periods of normal temperatures.
Intermittent Fever
a wide range of temperature fluctuations occurs over the 2 hour period, all of which are above normal
Remittent Fever
short febrile periods of a few days are interspersed with periods of 1 or 2 days of normal temperature.
Relapsing Fever
body temperature fluctuates minimally but always remains elevated.
Constant Fever
increased heart rate and respiratory rate and depth.
Shivering due to increased skeletal muscle tension and contraction.
Cold skin due to vasoconstriction.
Cyanotic nail beds due to vasoconstriction.
Complain of feeling cold.
Gooseflesh appearance of the skin.
Rise in body temperature.
Clinical Signs of Fever: ONSET (Cold or Chill Stage)
Skin feels warm
increased pulse and respiratory rate.
increased thirst
mild to severe dehydration.
Cyanotic nail beds due to vasoconstriction.
Complain of feeling cold.
Gooseflesh appearance of the skin.
Rise in body temperature.
Clinical Signs of Fever: COURSE
Flushed and warm skin
Sweating
Decreased shivering
Possible dehydration
Clinical Signs of Fever: ABATEMENT
Treatment of Increasing Body temperature
Antypyretics (Paracetamol)
Cold sponge bath
Cold compress
Core body temperature below the lower limit of normal
The ability of hypothalamus to regulate temperature is greatly impaired when the body temperature falls below 34.5c ( 94 F), and death usually occurs when the temperature falls below 34c (93.2 F)
Alterations in Body temperature: HYPOTHERMIA
Physiologic Process of Hypothermia
excessive cold environment
inadequate heat production to counteract the heat loss
Clinical signs of Hypothermia
Decreased body temperature
Pale, cool, waxy skin
Hypotension
Lack of muscle coordination
Disorientation
Drowsiness may progress to coma
- considered reliable when thermometer is place posteriorly into the sublingual pocket
- tracks changes of core temp
- the most common way in checking temp.
Orally (common way) n: 37c – taken 3- 5mins
- measure by placing thermometer in the central position and adducting the arm close to the chest wall
- considered unreliable for estimating body temperature because there are no main blood vessels around this area
- most safest way in getting a patients body temp.
Axillary (safe way) n:36c +0.5c (10mins)
- most accurate method for measuring the core temperature
- should reduce 0,5c to actual reading
- the most accurate way in getting the body temp.
Rectal (accurate reading) 37c – 0.5c (2-3 mins)
Contraindications of Oral thermometer
the child is under 6 years old
unconscious patient
psychiatric patients
patient who cannot breath from his nose
mouth surgery or infection
patient on oxygen mask
Contraindications of Rectal thermometer
rectal surgery
rectal disorder (hemorrhoids, rectal fissure)
diarrhea
Types of Thermometer
Electronic /Digital
Glass/mercury
Tympanic
infrared
Alterations in thermoregulation
Heat exhaustion
Heat stroke
Hypothermia
Frostbite
- a wave of blood created by contraction of the left ventricle of the heart
- a measurement of a pressure pulsation created when the heart contracts and ejects blood into the aorta
Pulse
refers to the feel of the pulse, its rhythm and forcefulness
Pulse Quality
indirect measurement of cardiac output obtained by counting the number of apical or peripheral pulse waved over a pulse point
Pulse Rate
regularity of the heartbeat
Pulse Rhythm
the beats are evenly spread
Regular
the beats are not evenly spread
Irregular
irregular rhythm caused by early or late or missed heartbeat
Dysrhythmia (arrhythmia)
measurement of the strength or amplitude of force exerted by the ejected blood against the arterial wall with each contraction
Pulse Volume
less than normal rate
Bradycardia
more than normal rate
Tachycardia
Pulse Volume Scale
Scale Description
0 Absent Pulse
1 Weak and thread pulse
2 Normal Pulse
3 Bounding Pulse
Factors contributing to increase pulse rate
pain
fever
stress, exercise
bleeding
decrease in blood pressure
some medications (Adrenalin, aminophylline)
Factors contributing to slow pulse rate
rest
increasing age
people with thin body size
some medications
thyroid gland disturbances
- Accessible, used routinely and when radial is inaccessible
Temporal
Accessible, used routinely for infants and during shock or cardiac arrest when peripheral pulses are too weak to palpate,
- Used to assess cranial circulation
Carotid
used to auscultate heart sounds and assess apical field
Apical
- used in cardiac arrest for infants
- to assess lower arm circulation
- to auscultate the blood pressure
Brachial
- accessible, used routinely in adults to assess character of peripheral pulse
Radial
used to assess circulation to ulnar side of hand and to perform allen’s test
Ulnar
used to assess circulation to legs and during cardiac arrest
Femoral
used to assess circulation to the legs and blood pressure
Popliteal
Use to assess circulation of the feet
Posterior Tibial & Dorsalis
is indicator for clients whose peripheral pulse is irregular as well as for clients with known cardiovascular, pulmonary, and renal diseases.
It is commonly assessed prior to administering medications that effect heart rate.
The apical side is also used to assess the pulse for newborns, infants, and children up to 2-3 years old.
Apical Pulse Assessment
difference in the apical pulse and the radial pulse.
These should be taken at the same time, which will require that 2 people take the pulse.
One with a stethoscope and one at the wrist.
Count for 1 full minute. Then subtract the radial from the apical.
Pulse Deficit
movement of air in and out of the lungs
Pulmonary Ventilation (breathing)