Ch. 29 Vital Signs Flashcards
6 types vital signs
Temperature Pulse Respirations Blood pressure Oxygen saturation Pain
Vital signs monitor what?
functions taking place in the body
What gives the healthcare provider the baseline data of a clients healthcare status?
Vital signs
Vital signs measure the effectiveness of what body functions?
Circulatory
Respiratory
Neural
Endocrine
T/F
Vital signs are a nursing intervention
True
T/F
Vital signs cannot be done without a physicians order
False
Shivering does what?
Increases heat production
Sweating is also known as
Diaphoresis
Sweating is inhibited to do what?
Decrease heat loss
Vasoconstriction does what?
Decreases heat loss
Vasoconstriction
Narrowing of the blood vessels resulting from contraction of the muscular walls of the vessels
WAYS HEAT LEAVES THE BODY
Radiation
Transfer of heat from surface of one object to another without contact
Ex. Infrared rays
WAYS HEAT LEAVES THE BODY
Conduction
Applying an ice pack to decrease edema
WAYS HEAT LEAVES THE BODY
Convection
A fan blowing air on patient who is perspiring
WAYS HEAT LEAVES THE BODY
Evaporation
Perspiration
WAYS HEAT LEAVES THE BODY
Insensible water loss
Breathing
Have an immature thermoregulatory system, influenced by environment
Infants
At risk for hypothermia (loss of subcutaneous fat; reduced thermoregulatory efficiency)
Elderly
Circadian rhythm
Temp varies throughout the day, temp is highest at about 6pm; lowest at 1am-4am
TF
hormones can increase temp
True
Ex. Estrogen
TF
Stress can increase temp
True
TF
Disease or trauma to the hypothalamus can effect body temp
True
Pyrexia
Fever
100.4+
Hyperrexia
Very high temp
Above 105.8F
Febrile
Fever
100.4+
Afebrile
No fever
Intermittent (fever)
Temp alternates between periods of fever and normal/subnormal temp
Remittent (fever)
Wide range of temp fluctuation
Ex. Cold or flu
Relapsing (fever)
Short febrile periods with 1 or 2 days of normal temp
Sustained (fever)
Temp remains constant
Fever spikes
Temp rises to fever level rapidly and then returns to normal within a few hours
Eg. bacterial blood infections
8 Clinical manifestations of fever
Shivering Lethargy Convulsions Pale, cold skin Goose bump look to flesh Flushed face Increased heart rate Increased respiratory rate
Hypothermia
Core body temp below 95F
Causes of hypothermia
Immersion in water
Lack of heat to body
Lack of appropriate cover/shelter
Impaired hypothalamic thermoregulation
Frostbite
Skin and underlying tissues are damaged by freezing cold
Usually hands, feet, nose, ears
temp check in Sublingual area under the tongue
Oral
Temp taken in the ear
Tympanic
Temp taken in anal canal
Rectal
Temp taken in armpit
Auxiliary
Temp taken on forehead
Skin/temporal/artery
How far do you insert probe when taking rectal temp in adult?
1 1/2”
Tympanic temp reading in child ages 3+
Pull pinna up and back
Tympanic temp reading in child under 3 y.o.
Pull pinna down and back
Pulse
Palpable blinding of blood flow in a peripheral artery; indicator of circulatory status
Peripheral pulses
Located away from the heart
Apical pulse
At apex of heart; use stethoscope. Pulse recorded as BPM
Carotid pulse site
Neck
Brachial pulse site
Forearm
Radial pulse side
Wrist (lateral)
Ulnar pulse site
Wrist (medial)
Femoral pulse site
groin
Popliteal pulse site
Back of knee
Posterior tibial pulse site
Ankle
Dorsalis pedis pulse site
Foot
What is the normal respiration range
12-20 per minute
Perfect blood pressure reading
120/80
Top number in blood pressure reading
Systolic
Bottom number in blood pressure reading
Diastolic
What is the normal pulse range?
60-100 BPM
