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
