MODULE 4: VITAL SIGNS Flashcards
WHAT ARE THE VITAL SIGNS MEASURED
pulse, respirations, oxygen saturation, blood pressure
WHEN DO YOU MEASURE VITAL SIGNS
admission, during a community visit, changes in physical condition, reports of feeling funny or different, before during and after procedures, medication administration, and nursing interventions that may have an effect.
WHAT DO YOU NEED TO CONSIDER WHEN DOING VITAL SIGNS
- patient medical history, baseline values, interventions, and prescribed medications and the indications for them
- verify document, and communicate changes in vital signs
EXPLAIN THE PHYSIOLOGY OF BODY TEMPERATURE
posterior hypothalamus: produces heat
anterior hypothalamus: controls heat loss
WHAT ARE VASCULAR METHODS FOR CONTROLLING BODY TEMPERATURE
vasoconstriction, vasodilation, sweating
WHAT IS THE NORMAL/ACCEPTABLE BODY TEMPERATURE
36-38ºC
NAME 4 DIFFERENT WAYS TEMPERATURE CAN BE TAKEN
oral: is the most convenient and reliable, its normal range is 35.8-37.3ºC
tympanic: is 0.6ºC higher that OT, has the most variation but is also easily accessible
axillary: is 0.5º lower than OT, is non-invasive, it takes longer to do and is usually the least accurate.
rectal: is 0.5º higher than OT, is arguably the most reliable when OT isn’t available, however it is invasive and requires the patient to move
HOW IS HEAT PRODUCED IN ADULTS
base metabolic rate: heat produced by the body at rest
Shivering: involuntary response that increases temperature 4-5x than base metabolic rate
HOW IS HEAT PRODUCED IN INFANTS
non-shivering thermogenesis
EXPLAIN THE METHODS OF HEAT LOSS
RADIATION: transfer of heat without direct contact
CONDUCTION: transfer of heat with direct contact
CONVECTION: transfer of heat through air movement
EVAPORATION: transfer of heat when liquid is changed to gas
DIAPHORESIS: visible perspiration
WHAT FACTORS AFFECT BODY TEMPERATURE
age, exercise, circadian rhythm, hormones, stress, environments
HOW IS CORE BODY TEMPERATURE MEASURED
is is measured with a catheter in urinary sites, but can also be measures in the esophagus, pulmonary artery and nasopharynx
DEFINE HYPERTHERMIA, HYPOTHERMIA, HEAT STROKE, HEAT EXHAUSTION, MALIGNANT HYPERTHERMIA, AND FROSTBITE
Hyperthermia: elevated body temperature as a result of the body being unable to promote heat loss or heat reduction,
malignant hyperthermia is life threatening hyperthermia
Heat Stroke: prolonged exposure to heat can overwhelm the bodies heat loss mechanisms
Heat Exhaustion: Constant diaphoresis causing excessive electrolyte and heat loss
Hypothermia: heat loss during prolonged exposure to the cold, overwhelms bodies ability to produce heat
Frostbite: when body is exposed to subnormal temperatures causing ice crystals to form in the cells and cause a lack of circulation
DESCRIBE THE PHASES OF PYREXIA
- chill phase: patient feels chills or shivering
- plateau phase: patient begins to warm up, feeling warm and dry
- break: feeling very warm, vasodilation occurs and skin feels flushed to induce heat loss, this will eventually lead to the patient being afebrile
WHAT ARE SOME ASSESSMENTS FOR PATIENTS WITH A FEVER
- obtain temperature for all phases of febrile episode (chill, plateau, break)
- assess for contributing factors (dehydration, infection)
- measure all vital signs
- assess skin colour and temperature
- observe for diaphoresis and shivering
- assess comfort and well being
WHAT ARE SOME NURSING INTERVENTIONS FOR A FEVER
diagnostics (whats the cause of the fever)
minimize heat production (rest, limit activity)
maximize heat loss (remove coverings and keeping linen dry)
meet requirements for increased metabolic rate (oxygen, fluids, meals)
promote patient comfort (oral hygiene, health teaching as indicated)
WHAT IS THE NORMAL ADULT RANGE FOR PULSE
60-100 Beats per minute
WHAT DO WE ASSESS WHEN READING PULSE
Rate, rhythm, strength, and equality (same on both sides)
EXPLAIN THE CHARACTERISTICS OF PULSE (RATE, EQUALITY, RHYTHMS, STRENGTH)
rate: starts at one, is the first beat felt by fingers
rhythm: regular or irregular, even tempo
strength:
0- absent
1- diminished
2- normal
3- full pulse increase
4- bounding
equality: symmetrical pulses (may need to check in case of blood lots)
WHERE ARE PLACES THAT YOU CAN FEEL PULSE
radial pulse, brachial pulse, apical pulse, temporal pulse, femoral pulse, popliteal pulse, posterior tibial pulse, dorsi pedi pulse, carotid pulse.
WHAT FACTORS INFLUENCE HEART RATE
age, emotions, exercise, smoking, medication, temperature, pain, postural changes, hemorhage, pulmonary conditions,
DEFINE BRADYCARDIA, TACHYCARDIA, PULSE DEFICIT, AND DYSRHYTHMIA
Bradycardia lowered heart rate
Tachycardia: elevated heart rate
Pulse Deficit: fewer pulses then there are heartbeats
Dysrhythmia: abnormal heart rhythm
WHAT IS THE NORMAL ADULT RANGE FOR RESPIRATIONS
12-20 breaths per minute
WHAT FACTORS INFLUENCE RESPIRATIONS
Exercise
Acute Pain
Anxiety
Smoking
Body Position
Medications
Neurological Injury
Hemoglobin Function
WHAT DO WE ASSESS WHEN WE DO RESPIRATIONS
rate: starting at one cycle (1 inhale 1 exhale)
depth: deep, normal, shallow
rhythm: smooth, uninterrupted
DEFINE THE FOLLOWING: EUPNEA, BRADYPNEA, TACHYPNEA, HYPERPNEA, APNEA, DYSPNEA, HYPERVENTILATION AND HYPOVENTILATION
Eupnea: normal rate and depth of breathing
Bradypnea: regular but abnormally slow <12 breaths per minute
Tachypnea: regular but abnormally rapid >20 breaths per minute
Hyperpnea: is laboured increase depth and rate, is normal with exercise
Apnea: respirations cease for several seconds then resume
Dyspnea: shortness of breath
Hyperventilation: increased rate and depth
Hypoventilation: abnormally low rate and depth
WHAT IS THE NORMAL ADULT RANGE FOR OXYGEN SATURATION
95-100%
WHAT FATORS CAN EFFECT OXYGEN SATURATION
anemias, impaired gas exchange, ineffective tissue perfusion ineffective airway clearance
WHAT DOES OXYGEN SATURATION MEASURE
percentage of oxygen bound to hemoglobin
WHAT IS THE NORMAL ADULT RANGE FOR BLOOD PRESSURE
SYSTOLIC: 120-139
DIASTOLIC: 80-89
NORMAL: 120/80
UPPER LIMIT: 139/89
WHAT PHYSIOLOGICAL FACTORS AFFECT BP
CO, TPR, BV, viscosity, elasticity
WHAT ARE INVASIVE AND NON-INVASIVE WAYS OF MEASURING BP
catheter, and BP cuff
WHAT OTHER FACTORS AFFECT BP
age, stress, daily variation, medications, anxiety, weight, smoking
DEFINE HYPERTENSION, HYPOTENSION
hypertension: abnormally high BP, is not measured with just one valued and is diagnosed over time. its causes by thickening and los of elasticity in arteries.
hypotension: abnormally low blood pressure, is less than 90 mm/hg systolic.
need to be aware for what is normal for the patient. hypertension Canada recommends 3 measurements on the same arm, first is disregarded and the other 2 are averaged
