perfusion and vital signs Flashcards
vitals signs
indicators of health status- effectiveness of circulatory, respiratory, neural and endocrine systems
name vital signs
temp, pulse, respiration, bp, oxygen saturation, (pain)
temp can be affected by
age, exercise, hormone level, circadian rythm, environment, temp alterations
radial pulse measurement includes
rate, rhythm, and quality; 30 sec if reg, 1 min if irregular
apical pulse
rate and rhythm, always 1 min
respiration affected by
exercise, smoking, pain, anxiety, meds, body position, neurological injury, hemoglobin fn
bp affected by
age, stress, ethnicity, gender, daily variations, meds, activity, weight, smoking
hypertension - physiological changes
thickening of walls, less elastic; family hx, risk factors
hypotension -physiology and effects
dilation of arteries, loss of blood volume, dec blood flow to organs; systolic < 90mm Hg
normal temp range
36-38 C (96.8-100.4 F)
average oral / tympanic temp for adult
37 C (98.6F)
average rectal temp
37.5 C (99.5F)
average axillary temp
36.5 C (97.7F)
average pulse - adult
60-100 beats/ min
average respirations adult
12-20 breaths/ min
average pulse pressure adult
30-50 mm Hg
pulse pressure
difference between systolic and diastolic pressure, normally 30-40 mm Hg
newborn body temp
35.5-37.5 C (95.9-99.5F)
progesterone levels effect on temp
decreased levels during menstrual fluctuations cause baseline temp to decrease few tenths of a degree
when body temps is too low, the hypothalamus initiates
vasoconstriction - blood flow to the skin is decreased to preserve heat
physical and emotional stress - effect on body temp
increased - via hormonal and neural stimulation
fever is usually not harmful if stays below
39 C (102.2F)
fever
alteration in the hypothalamic set point
pyrogens
bacteria and viruses that elevated body temp; act as antigens stimulating an immune response
patterns of fever
sustained, intermittent, remittent, relapsing
sustained fever
continued temp above 38C (100.4F), little fluctuation
intermittent fever
fever spikes interspersed with normal temp (temp normal at least once in 24 hr)
remittent fever
fever spikes and falls without return to normal temp
relapsing fever
periods of febrile and afebrile episodes; febrile and normothermia episodes often longer than 24 hr
hypothermia classification
mild, moderate, severe
mild hypothermia
34-36 C(93.2-96.8)
moderate hypothermia
30-34 C (86- 93.2F)
severe hypothermia
> 30 C (86F)
body metabolism increases during fever by
10% for every degree C
hyperthermia
body temp exceeds set point; inability of the body to promote heat loss or inhibit heat production
malignant hyperthermia
due to certain anesthetic drugs; hereditary condition of uncontrolled heat production
heat stroke
body temp of 40C or more (104F); heat depresses hypothalamic function; high mortality
symptoms of heat stroke
delirium, thirst, muscle cramps, nausea, visual disturbance, incontinence, inc HR, low BP
MOST important sign of heat stroke
hot, dry skin- no sweat due to electrolyte loss and hypothalamic malfunction
progression of heat stroke
unconscious, fixed nonreactive pupils; permanent neurological damage
heat exhaustion
diaphoresis results in electrolyte and water loss
hypothermia
heat loss due to prolonged exposure to cold overwhelms ability to produce heat; can be intentionally induced during surgical procedures
accidental hypothermia
develops gradually, can go unnoticed for hours; when temp drops below 35C / 95F uncontrollable shivers, memory loss, depression, poor judgment
if body temp falls below 34.4 C (94F)
HR, resp, and BP fall; cyanotic skin, dysrhythmias, loss of consciousness, unresponsive to pain
severe hypothermia symptoms
similar to death - lack of response to stimuli, extremely slow resp and pulse
frostbite
ice crystals form inside the cell; permanent circulatory and tissue damage; area becomes white, waxy and firm to touch; sensation loss
areas susceptible to frostbite
earlobes, tips of nose, fingers ad toes
frostbite tx
gradual warming, analgesia, protect tissues
compare oral, rectal and axillary temp
rectal usually .5C (.9F) higher than oral, axillary .5C lower than oral
convert C to F
F = 9/5C +32 C= (F-32) x 5/9
advantage of oral temp
easily accessible,comfortable, shows rapid change in core temp; provides accurate surface temp reading; reliable for intubated patients
oral temp limitations
delay if patients smoked, ate cold/ hot, or receiving oxygen by mask / cannula; not for patients with oral surgery, hx of epilepsy, shaking chills; risk of fluid exosure
don’t use oral temp with
infants, small children, confused, unconscious or uncooperative
tympanic temp benefits
if patient has tachypnea - does not disturb breathing; provides accurate core temp - close to hypothalamus; sensitive to core temp changes; rapid measurement (2-5s), unaffected by oral intake, smoking
tympanic temp used with newborns why?
reduce infant handling and heat loss
tympanic temp disadvantages
more variability than other core temp devices, requires removing hearing aid; disposable cover available in only 1 size; otis media and cerumen distorts reading; not accurate for core temp changes before / after exercise; affected by fans, incubators; incorrect handling of device = errors
rectal temp benefit
more reliable if can’t get oral temp
rectal temp disadvantages
lags behind during rapid core temp changes; requires lubrication, not usually for newborns
axillary temp often used for
newborns and unconscious patients
axillary temp limitations
underestimates core temp; time consuming, needs continuous positioning by nurse; requires exposure to thorax - heat loss (esp newborns); affected by environment including time to place thermometer
axillary temp not recommended for fever detection in
infants and young children
skin temp benefit
noninvasive, safe, continuous reading; used in neonates
skin temp limitations
lags behind during core temp changes - esp hyperthermia; sweat affects adherence, affected by environmental temp; can have allergy
temporal artery benefit
rapid, used in premature infants, newborns, children; reflects rapid change in core temp change; sensor cover not required
temporal temp affected by
sweat, moisture, hair on forehead
