CH2 Vital signs Flashcards
Vital signs contain: __________
Body temperature (T, Temp; degree Celsius, ˚C)
Pulse rate (P or PR; beats per min., bpm)
Respiration rate (R or RR; breaths per min, bpm)
Blood pressure (BP; milliliters mercury, mmHg)
Pulse oximetry (SaO2/ SpO2; percent, %)
Pain: 5th vital signs (Subjective data)
Time to perform vital signs assessment: ____________
- Doctor’s prescription (eg. Daily/ QD/ BD/ TDS/ QID/ Q4H),
- At least every 4 hours or even more frequent for patients when:
Elevated temperature >37.5˚C (Re-check temperature every 4 hours until fever subsided, and QD 72hrs no fever),
Changes in physical conditions (eg. Abnormal pulse rate/ respiratory rate too fast / too slow , abnormal blood pressure too high / too low),
Respiratory difficulty (airway & breathing problems),
Cardiac related discomfort - On admission
- Assess patients during home care visit or out-patient care setting visit
- Before, during and after any procedures/ operations/ nursing interventions, eg. Passive movements on bed, surgery, abdominal tapping成肚水 …
- Before, during and after the administration of medications or application of therapies that affect cardiovascular, respiratory, or temperature-control functions
- Client reports specific symptoms of physical distress
Frequency to monitor vital signs: 1 time per day = _______
Daily, QD
Frequency to monitor vital signs: 2 times per day = _______
BD
Frequency to monitor vital signs: 3 times per day = _______
TDS, TID
Frequency to monitor vital signs: 4 times per day = _______
QID
Frequency to monitor vital signs: every ? Hour(s) = _______
Q?H
QD = ?
1 time per day
BD = ?
2 times per day
TDS, TID = ?
3 times per day
QID = ?
4 times per day
Q?H = ____
Every ? Hour(s)
Factors of thermoregulation - heat production includes ______
- Basal metabolic rate (BMR): Rate of energy utilization to maintain essential activities, decrease with age
- Muscle activity, Eg. Exercise, shivering; increase the BMR and heat production
- Thyroxine output; Increase thyroxine output increases BMR
- Epinephrine, nonepinephrine, and sympathetic stimulation/ stress response; immediately increase BMR
- Fever
Factors of thermoregulation - heat loss includes ______
- Radiation
◦ Infrared rays
◦ Transfer heat from the surface of one object to the surface of another without contact between two
objects - Conduction
◦ Transfer heat from high temperature to low temperature by the contact of objects - Convection
◦ Dispersion of heat by air currents - Evaporation
◦ Continuous vaporization of moisture from respiratory tract, oral mucosa, and skin
List factors that you can change to reduce patient’s body temperature
Exercises (ask the patient to sit down for 15 minutes), Environment (turn on the air-conditioner or turn up the AC), Diseases, e.g. Infection -> fever (give antibiotic as prescribed for infectious disease) 打針比panadol effective
Factors affecting body temperature
-Age (basal metabolic rate)
-Diurnal variations (~1˚C morning to late afternoon)
-Hot/ cold drink (affects oral temperature)
-Exercises (increase metabolic rate)
-Hormones (e.g. Increase temperature during ovulation, thyroid disorders)
-Stress (due to hormonal changes)
-Environment (too hot/ too cold)
-Diseases, eg. Infection–> fever
Which body sites can measure core temperature?
Tympanic membrane, rectum, (temporal artery), (esophagus), (pulmonary artery), (urine bladder)
Which body sites can measure surface temperature?
Oral cavity, axilla, skin
Body temperature readings measured at tympanic is _____
37.5˚C (99.5˚F)
Body temperature readings measured at rectal is _____
37.5˚C (99.5˚F)
Body temperature readings measured at oral is _____
37.0˚C (98.6˚F)
Body temperature readings measured at axillary is _____
36.5˚C (97.7˚F)
Body temperature readings measured at forehead (skin) is _____
34.4˚C (94˚F)
How to measure tympanic temperature?
Straighten ear canal for measurement
◦ Adult: pull pinna upward & backward
◦ Child (< 3 years old): pull pinna downward & backward
State the advantages of taking tympanic temperature
Easily accessible site (available when the patient is sleeping), Provides accurate core reading because eardrum is close to
hypothalamus and sensitive to care temperature changes
State the limitation of taking tympanic temperature
Not used with patients who have had surgery of the ear or
tympanic membrane (should have no lesion)
Position for patient taking rectal temperature: ______
side-lying with one leg flexed
Procedures of taking rectal temperature: ________
Provide privacy
wear disposable gloves
Cover probe with disposable sheath
Lubricate & insert 1-1.5 inch into rectum; hold in place for 3 mins/ until “beep” sound
Remove disposable cover–> check the reading
(Never force insertion if resistance is felt)
State the limitation of taking rectal temperature
Requires lubrication
Procedures of taking oral temperature: ________
Use a disposable sheath to cover the thermometer before use
Put under tongue (at left or right posterior sublingual pocket)
Hold it (not talk) for > 3 mins / until “beep” sounds
State the limitation of taking oral temperature
Not used with infants; small children; or
confused, unconscious or uncooperative
patients
Procedures of taking axillary temperature: ________
Dry the axilla if it is moist
Cover probe with disposable sheath
Place the thermometer at the center of the axilla
Ask client/ you hold it in place > 3 mins
State the advantages of taking axillary temperature
Used with newborns and unconscious patients
State the limitation of taking skin temperature
Affected by environmental temperature
State the limitation of taking temporal artery temperature
Inaccurate with head covering or hair on
forehead
Affected by skin moisture such as diaphoresis
or sweating
Normal range of body temperature: _______
36˚C to 37.5˚C ( 96.8˚F to 99.5˚F)
Assessment for tympanic temperature measurement:
- Determine need to measure patient’s body temperature e.g.
◦ White blood cell count
◦ Expected or diagnosed infection
◦ Hypothermia or hyperthermia therapy
◦ Blood product infusion
// (◦ Open wounds or burns
◦ Immunosuppressive drug therapy
◦ Exposure to temperature extremes
◦ Postoperative status ) // - Assess any contraindication to temperature measurement (Ear injury/ recent ear surgery)
- Identify physician’s prescription if any
- Assess for factors that normally influence temperature
- Assess patient’s knowledge, understanding and ability to cooperate during the procedure
// (6. Assess signs and symptoms that accompany temperature alteration:
◦Hyperthermia: decreased skin turgor, dry mucous membranes, tachycardia, hypotension, decreased venous filling, concentrated urine
◦ Heatstroke: hot, dry skin, tachycardia, hypotension, excessive thirst, muscle cramps, visual disturbances, confusion or delirium
◦ Hypothermia: Pale skin, skin cool or cold to touch, bradycardia and dysrhythmias, uncontrollable shivering, reduced level of consciousness, shallow respirations ) //
// (7. Determine appropriate measurement and device for patient)
// (8. Determine previous baseline temperature and measurement site from patient’s record) //
Planning for tympanic temperature measurement:
Prepare equipment:
Tympanic thermometer
Disposable probe cover
Rubbish bag / kidney dish
Alcohol swabs
+/- disposable gloves for precaution
* Disinfect all equipment and check the function of the equipment before approaching patient
Prepare client:
Explain the procedure to patient to gain the cooperation
Tympanic temperature measurement:
Pull ear pinna ______ for an adult; Pull pinna ________ for children < __ years old
backward up, down and back, 3
Assist patient to comfortable position that provides easy access to temperature measurement site
◦ Sitting: head turned toward side, away from you
◦ Lying: measure the _____ ear
upper
For abnormal readings in tympanic temperature measurement,
◦ Repeat measurement in other ear; and/ or
◦ Repeat the measurement in same ear after __ minutes
2
Term to describe no fever:
Afebrile
Term to describe fever/hyperthermia:
febrile (37.6°C - 40.9°C)
Term to describe very high fever (> 41°C)
Hyperpyrexia
Stages of fever:
Onset (chill phase)
Stationary (fever phase)
Resolution (flush phase)
Signs & Symptoms in chill phase:
Increased pulse & respiratory rate
Shivering
Feeling cold
Pallor, cold skin
Pay attention to ________________ and give ______.when the patient is at chill phase of having fever
avoid taking a shower,
blanket
Signs & Symptoms in fever phase
Absence of chills
Skin that feels warm
Thirst/ mild dehydration
Malaise/ Fatigue/ weakness
Aches and pains (eg. Headache)
Loss of appetite
Drowsiness, restlessness or convulsions
Can the patient take a shower/bed bath in fever phase?
Yes
Signs & symptoms in resolution phase
Sweating
Decreased shivering
Nursing management/ interventions of client with fever:
- Continuous monitoring:
◦ Monitor temperature & vital signs regularly. Eg. Q4H
◦ ______________
◦ Monitor intake and output - Collaborative care:
◦ Work with doctor for investigation tests, eg. Collect specimens (mid-stream urine, sputum); septic
workup (mid-stream urine MSU for culture, sputum for culture, blood taking CBC, LRFT, clotting, blood
culture, chest X-ray)
◦ Administration of medications as prescribed, eg. Antipyretics (panadol), antibiotics
◦ Initiate intravenous infusion if indicated - Promote comfort for client with fever:
Sufficient hydration & nutrition
◦ __________
◦ Encourage oral intake
◦ Keep mucus membrane moist , lubricate dry lips
◦ _____________
Promote heat loss
◦ ____________________
◦ Promote sleep & rest
◦ Advise client to reduce activities
Assess skin color & temperature,
Encourage fluid intake if tolerated (2000-3000ml/ day),
Infusion IV fluid for promoting hydration if needed (for patient cannot drink),
Apply cold pad to client’s forehead, neck & armpits
Methods to reduce body temperature:
Reduce heat production:
Decrease physical activities
Treat the causes
Provide medications
Increase heat loss:
Decrease environmental temperature
Remove excessive clothes/ blankets
Decrease humidity
Cool drink
Cool compress
Cold pads
__________
Tepid sponging/ Tepid bath
Tepid sponging bath:
Lower body temperature for client with high fever, eg. 39’C or above
Wipe body with wet cloth or sponge using tepid water (lukewarm water ~____‘C)
Do NOT be applied during ____
Do NOT use _____ (prevent chilling)
Assess patient’s body temperature before & 15 mins. after the procedure
30-37 (not room temperature),
the chill stage,
cold water
Hypothermia:
Sustained reduction of core body temperature (< ___‘C)
35
Signs & symptoms of hypothermia:
◦ Decreased body temperature, pulse & respirations
◦ Severe shivering (initially)
◦ Feelings of cold & chills
◦ Pale, cool skin (cannot measure the SPO2)
◦ Hypotension
◦ Decreased urinary output
◦ Confusion
◦ Drowsiness–> coma
Methods to increase body temperature:
Increase temperature of environment
Decrease ventilation
Warm & dry clothes/ blankets/ socks
Cover scalp
Keep limbs close to body
Nursing management/ interventions of hypothermia:
1.1 Passive re-warming (mild hypothermia):
Remove cold/ wet clothes, dry body
Cover client’s head with cloth & wear socks
Provide blankets
1.2 Active re-warming (moderate to severe hypothermia):
Apply warm pads over central areas: _______
Provide warm blanket, eg. Space blanket, Bair hugger
Use warmer
**Check ________ for ALL heat application
- Monitor patient’s condition
◦ Assess vital signs hourly to Q4H
◦ Observe skin color & condition
◦ Assess sensation & movement of extremities
◦ Measure urine output hourly to Q4H if indicated (~__ml/hr)
neck, armpits & groins
,skin every 10 minutes for any redness & discomfort
30
Pulse:
A wave of blood created by contraction of heart muscles
Healthy person: Pulse rate (PR) = heart rate (HR)
Persons with some cardiovascular diseases (CVD)
◦ Heart may produce weak/ very weak pulse waves
◦ PR is not equal to HR
◦ That’s why measure the ____ rate
apical
Radial pulse
Position: radial artery over the radius
◦ On the ____, under your _____
Most commonly used to measure pulse rate in adults
wrist, thumb
Carotid pulse
Position: carotid artery
◦ Between ______, sides of the ____
Used during cardiac arrest/ shock in adults
To determine circulation to the brain
Do not press both carotid at the same time!
–> reflex drop in blood pressure or pulse rate
trachea & sternocleidomastoid muscle, neck
Apical pulse
Position: apex of the heart
◦ Older adults: sometimes further left with an enlarged heart
◦ Normal adult & child > 7 years old :
◦ Intersection of ______ line (Left MCL) , ____ intercostal space (ICS)
Detect differences with radial pulse
Auscultation using _____
For monitoring
◦ eg. Digoxin
left mid-clavicular, 5th,
stethoscope
Femoral pulse
Position : femoral artery
◦ Passes along the ____ ligament
Use in cases of cardiac arrest/ shock
Determine circulation to a leg
inguinal
Popliteal pulse
Position: popliteal artery
◦ _________
Determine circulation to the lower leg
Behind the knee
Temporal pulse
Position: temporal artery
◦ Over the temporal bone at side of ____
Use when other pulse is not accessible
the head
Posterior tibial pulse
Position: posterior tibial artery
◦ At medial surface of the ____; behind the medial malleolus
Determine circulation to the foot
ankle
Dorsalis pedis pulse
Position: dorsal pedis artery
◦ Over the space between _____ OR
◦ Space between second & third toes
Determine circulation to the foot
big & second toes
Pulse rate
◦ Normal range (adult) : _____
60-100 bpm
______: heart rate faster than normal (over 100 bpm)
______: heart rate of less than 60 bpm (confirm with apical rate instead of radial pulse)
Tachycardia, Bradycardia
Pulse rhythm: ____________
regular/ irregular (Dysrhythmia/ arrhythmia–> irregular heartbeat)
Pulse volume
◦ Strength of pulse
◦ From absent to bounding
Grade 0: No pulse
Grade 1+: A faint, but detectable pulse
Grade 2+: A slightly more diminished pulse than normal
Grade 3+: Normal pulse
Grade 4+: Bounding pulse
