Chapter 30: Vital Signs Flashcards
List times when a patients vital signs are normally assessed:
A) On admission to a healthcare agency, to establish baselines
B) Part of a physical assessment
C) During an inpatient stay, as routine monitoring
Most frequent and routine measurements obtained by health care providers:
Temperature
Pulse
Blood pressure
Respiratory rate
Oxygen saturation
Average temperature range:
96.8-100.4 degrees F
Average oral/tympanic temperature
98.6 F
Average rectal temperature:
99.5 F
Average axillary temperature
97.7 F
Average pulse:
60 to 100 beats/min, deep and regular
Average adult respiration
12 to 20 breaths/min, deep and regular
Average blood pressure
Systolic <120
Diastolic <80
Average pulse pressure:
30-50 mm HG
Average core temperature for elderly
95-97 F as a result of decreased immunity
Lowest temperature is at ____ while highest temperature is at ____
Lowest: 6 am
Highest: 4 pm
Which part of brain controls body temperature?
Hypothalamus
Senses minor changes in body temperature
Anterior hypothalamus controls
heat loss
Posterior hypothalamus controls
heat production
When metabolism decreases,
less heat is produced.
Heat production occurs during
rest, voluntary movements, involuntary shivering and non shivering thermogenesis
7 factors that can cause an individual’s body temperature to change:
Age
- Newborn’s temp unstable baseline temp drops with age, infants and elderly more susceptible to environmental temp extremes
Exercise
-Increases body temperature
Hormonal fluctuations
-Women’s temp higher at ovulation
Circadian rhythms
- lowest temp: 6 am, highest 4pm
Stress
- levels of extreme temps affect core body temp
Environment
Smoking
-causes vasoconstriction that can decrease temp of skin
Factors influencing vital signs (9)
Infection
renal disease
Respiratory disease
Cardiovascular disease
Physical Environment
Emotional state of patient
Medications
Food and fluid intake
Activity level and tolerance
Pain SOCRATES meaning:
Site
Where is pain located?
Onset
When did pain start? gradual or sudden?
Character
Quality of pain? Stabbing, burning, aching in nature?
Radiation
Does pain radiate anywhere?
Associations
signs and symptoms associated with pain
Time Course
Any pattern to pain?
Exacerbating/relieving factors
What makes it worse or help it?
Severity
0-10 scale
Patterns of fever (SIRR)
Sustained: constant body temp that has little fluctuation
Intermittent: Fever spikes interspersed with usual temp levels. (Temp returns to acceptable value at least once in 24 hours)
Remittent: fever spikes and falls without a return to acceptable temperature levels
Relapsing: periods of febrile episodes and periods with acceptable temperature values (febrile episodes often longer than 24 hours)
Hyperthermia:
elevated body temperature related to the inability of the body to promote heat loss or reduce heat production
Malignant hyperthermia
hereditary condition of uncontrolled heat production that occurs when susceptible people receive certain anesthetic drugs
5 types of thermometers
Electric thermometer (oral/anus/axillary)
temporal artery thermometer (forehead of child typically)
tympanic thermometer (Ear)
disposable paper thermometers
temperature sensitive strips
5 sites commonly used to measure body temperature
Oral (most common)
-under tongue
Axillary
-frequently used for healthy newborns
Tympanic
Temporal
Rectal
Examples of nursing diagnoses for patients with body temperature alterations include (5)
Risk for imbalanced body temperature
hyperthermia
hypothermia
ineffective thermoregulation
risk for hypothermia
Pulse is the
palpable bounding of blood flow in a peripheral artery
Infant heart rate
120-160 beats/min