II - Taking Vital Signs Flashcards
are body temperature, pulse, respiration, and blood pressure. Recently, many agencies have designated pain as a fifth vital sign.
The vital signs
Times to assess vital signs:
On admission to a health care agency to obtain baseline data
When a client has a change in health status or reports symptoms such as chest pain or feeling hot or faint
Before and after surgery or an invasive procedure
Before and/or after the administration of a medication that could affect the respiratory or cardiovascular systems; for example, before giving a digitalis preparation
Before and after any nursing intervention that could affect the vital signs (e.g., ambulating a client who has been on bed rest)
Purpose of taking vital signs
- To assess the health status of an individual
- To plan and implement nursing care
- To understand the effectiveness of the treatment
- To modify or change the mode of treatment
- Routine part of complete physical assessment
- To understand the present problem
The balance between the heat produced and heat lost from the body is measured in Celsius or Fahrenheit.
Body Temperature
The body continually produces heat as a by-product of ___.
metabolism
There are two kinds of body temperature:
Core temperature
Surface temperature
- This is the temperature of the deep tissues of the body, such as the abdominal cavity and pelvic cavity. It remains relatively constant.
Core temperature
The normal core body temperature is a range of temperature ___.
37C
- This is the temperature of the skin, the subcutaneous tissue, and fat. It rises and falls in response to the environment.
Surface temperature
Factors affecting the body’s heat production
Basal Metabolic Rate (BMR)
Muscle Activity
Thyroxine Output
Strong Emotions
Presence of disease/illness
Change in atmospheric temperature
It is the rate of energy utilization in the body required to maintain body essentials (breathing, digestion).
Basal Metabolic Rate (BMR)
Increases metabolic rate up to 2000 times and heat production can increase up to 50 times than normal.
Muscle Activity
Increased ___ output increases the rate of cellular metabolism throughout the body.
This effect is called ___, the stimulation of heat production in the body through increased cellular metabolism.
thyroxine
thermogenesis
Fight/Flight and stress hormones will be stimulated -> Increasing the rate of cellular metabolism
Strong Emotions
Increased levels of carbon dioxide and other greenhouse gases in the atmosphere -> Increased temperature of the earth’s atmosphere
Change in atmospheric temperature
Factors affecting the body’s heat loss
- Through the skin
- Through lungs
- Through kidneys
- Through bowel
- is the transfer of heat from the surface of another without contact between two objects.
Radiation
- is the transfer of thermal energy through direct contact.
Conduction
- is the transfer of heat energy in a gas or liquid by movement of currents like the heat of the stove while cooking, or the breeze.
Convection
- is the process of losing heat through the conversion of water to gas (sweat).
Evaporation
Factors affecting body temperature
Age
Diurnal variations
Exercise or Activity
Stress
Hormones
Environment
The point of highest body temperature is usually between ___
The lowest point is usually between ___
8 pm and midnight.
4 am and 6 am.
Sites for measuring body temperature and thermometers used
- Oral
- Rectal
- Axillary
- Tympanic membrane
- Skin/Temporal artery
- Peripheral
Ensure that the patient has not taken any hot or cold food or fluids or smoked in ___ minutes prior to the procedure
15 – 30
