Key Highlights from VS lecture Flashcards
Rectal temperature is accurate, but contraindicated for pts with:
- pts undergoing rectal surgery
- immunosuppressed
- clotting disorder
- have diarrhea / disease of rectum
- have significant hemorrhoids
How is the tympanic temperature checked in adults and children under the age of 3?
UP and back - adUlts
Down and back - chilDren
If the pt has taken cold or hot fluids the nurse should wait _______ minutes to ensure accurate temperature
30 min
When are the times to assess vital signs?
- On admission to facility to obtain baseline data
- Change in health status or reports s/s of chest pain or feeling hot or faint
- After an invasive procedure and before and after surgery
- Before and after the admin of meds that affect respiratory / cardiovascular systems
- Before and after any nursing intervention that could affect VS like walking after being on bed rest
What are the four types of heat loss?
- Radiation
- Conduction
- Convection
- Evaporation
What is radiation heat loss?
The transfer of heat from the surface of one object to the surface of another without contact between two objects. (Emission of heat through electromagnetic waves. As electromagnetic waves contact other molecules, it increases that molecules energy; therefore making it hotter.)
What is conduction?
Transfer of heat from one molecule to a molecule of lower temperature (The touching of two objects)
What is convection?
Fluid movement (only deals with liquids or gases)
What is eVAPORation?
The continuous vaporization of moisture from the respiratory tract and from the mucosa of the mouth and from the skin(Where liquids change into gases)
Why are the elderly (those over the age of 75) at risk for HYPOthermia (temp below 36 C or 96.8 F)?
- Inadequate diet
- Loss of sub Q fat
- Lack of activity
- reduced thermoregulatory
When do you get a low body temp and when do you get a peak body temp?
low body temp readings are in the morning
peak body temp readings are from 1600 - 1800
What are the 3 phases of a fever?
Phase 1: Onset
Phase 2: Course (Plateau phase) = malaise, weakness, aching muscles
Phase 3: Defervescence = dehydration, sweating, breaking the fever
What is the body temperature during a HYPERpyrectic fever?
41 C or 105.8 F (can cause cellular or brain damage)
What is cardiac output?
Volume of blood pumped into the arteries by the heart. Stroke volume (SV) times the heart rate (HR) per minute
When assessing the pulse, the nurse collects the following?
Rate
Rhythm
Volume
Where are the pulse sites on the body?
- Temporal
- Carotid
- Apical
- Popliteal
- Brachial
- Radial
- Femoral
- Posterior tibial
- Dorsalis pedis
What is the normal range for respirations?
12 - 20 breaths per min {sleeping BPM can be lower}
What part of the brain regulates breathing?
Medulla oblongota and Pons
What is pulse pressure?
The difference between the systolic and diastolic blood pressure
What is Hypertension stage 1 BP?
130 - 139 (systolic)
80 - 90 (diastolic)
What is Hypertension stage 2 BP?
Greater than 140 (systolic)
Greater than 90 (diastolic)
What is a Hypertensive crisis BP?
Higher than 180 (systolic)
Higher than 120 (diastolic)
What primary ethnic group has high BP?
African Americans
What is orthostatic hypotension?
BP falls as the pt assumes an upright position
What is the difference between the apical and radial pulse called?
Pulse deficit
Where can the pulse oximeter sensor be placed?
Toes
Finger
Nose
Earlobe
Forehead
Around the hand or foot of neonate
How much of a drop in mmHg systolic and diastolic and an increase in pulse indicates orthostatic hypotension?
A drop in blood pressure of 20 mmHg systolic or 10 mmHg diastolic or an increase in pulse of 20 beats/min indicates orthostatic hypotension
