Class 1 Vital Signs Flashcards
Elder speak
conveys a message of incompetence of the receiver and dominance of the speaker over the elder
-resistance to care in older adults with dementia (resistant, combative, aggressive)
-disrupts nursing care
-increases cost of care by 30%
Vital Signs
Temperature
Pulse
Respiration
Blood Pressure
Pain
Pulse Oximetry SpO2 and FIO2
When assess vital signs?
admission; institutional policy; change in patient’s condition; before & after surgical or invasive diagnostic procedures; before and/or after certain medications; before and/or after activity in certain cases
Baseline
Nursing Process
ADPIE
-assessment
-diagnosis or interpretation of assessment findings
-planning
-implementation
-evaluation
Independent Nursing Actions:
assessment of VS requires you to make judgements about the means of measurement, equipment, & frequency
Normal Ranges for VS for healthy adults
Oral temp: 35.8-37.5 C
Pulse rate: 60-100 beats per minute
Respirations: 12-20 breaths per minute
Blood pressure lower than 120/80
Temperature
difference in heat you generate and heat you lose (heat produced-heat loss)
Factors that affect temp:
-circadian rhythms (lower in am; higher in pm)
-age (woman are higher; elderly are lower)
-physical activity
-environmental temperature
Temperature physiology
Regulation by hypothalamus
-heat production:
-primary source is metabolism**
-hormones, muscle movements, & exercise increase metabolism
-heat loss:
-skin (primary source; mostly head)
-evaporation of sweat
-warming & humidifying inspired air
-eliminating urine & feces
Temperature Sites (Core)
internal body temp; temp at deep tissue
-rectal (no rectal if heart problems (vagus nerve –>decreased heart rate), low WBC neutropenic (can perforate lead to infection), low platelets)
-tympanic
-temporal artery
-pulmonary artery, bladder, esophagus
Temperature Sites (surface)
oral
axilla
skin surface chemical strips
you take the measurement of surface body temp to obtain a representative average temp of core body tissues
Thermometers
red is rectal
blue is oral & axilla
afebrile
without fever (temp)
febrile
fever
pyrexia
fever
Physical effects of Fever
decreased appetite
headache
hot skin
flushed face
thirst
muscle aches
fatigue
fever blisters
elderly may have periods of confusion/altered level of consciousness**
Interventions for patients with a fever
maximize heat loss:
-remove heavy blankets
-keep clothing & linens dry (otherwise chills/shivering causes increased metabolism)
-cool compresses
-ice packs
-cooling blanket
minimize heat production:
-limit physical activity
Pulse physiology
-the palpable bounding of the blood flow in a peripheral artery
-regulated by the cardiac sinoatrial node
-normal rate is 60-100 bpm
-count for 30 seconds X 2 or 15 seconds X 4
-lub/dub=a count of 1
-apical pulse take for 1 minute
characteristics of a peripheral pulse (3)
- rate
- rhythm (regular/irregular)
- Amplitude EPIC 4-point scale (how strong)
4+=bounding
3+=strong
2+=moderate
1+=weak
0=absent
Sites for detecting pulse
temporal (temple)
carotid (neck)
brachial (elbow)
radial (wrist)
femoral (groin)
popliteal (behind knee)
posterior tibial (inner above heel)
dorsalis pedis (top of food outer ankle)
Methods for Assessing a Pulse
-palpating peripheral arteries
-auscultating apical pulse with stethoscope
-5th intercostal space/mid-clavicular line=PMI
-doppler of peripheral arteries (if cannot find pulse)
Why don’t take pulse with thumb?
can hear your own pulse when using thumb
Tachycardia
over 100 bpm