Vital Signs Flashcards
- Objective measurement of one’s overall health status
- Provides important information on the status of the patient
Vital Signs Taking
Vital signs consists of?
- Temperature
- Pulse
- Respiration
- Blood pressure
Often called the 5th sign
Pain
Makes the pain worse
Aggravating/exacerbating factors
Eases the pain
Palliating/remitting factors
Where pain is located?
Setting/location
When did the pain start?
Onset
How painful on a scale of 0 to 10?
Intensity
How does the pain feel?
Characteristics
How long do you experience pain?
Duration
Determine the severity, 3 scales commonly used are?
Visual analog, numeric rating, face pain scale
Describe the pain, how it started, pursue the seven features which are?
- Location/setting
- Quality
- Quantity/severity (intensity)
- Timing (when did it start)
- Setting in which it occurs
- Remitting or exacerbating factors
- Associated manifestations
Noninvasive measurement of arterial oxyhemoglobin saturation of arterial blood, detects the presence of deficient oxygen in the blood before visible signs develop
Pulse oximetry
Percentage of all hemoglobin binding sites occupied by oxygen
Oxygen saturation value
Factors in pulse oximetry?
- Amount of RBC and hemoglobin
- Circulation under the sensor is impaired
- Patient activity
- Acrylic nails and dark nail polish
- Moisture and oils on the skin
What are factors indicating the need for monitoring of oxygen saturation?
- Acute or chronic impaired respiratory functioning
- Recovery from any type of anesthesia
- Any trauma including surgery
- Ventilatory dependency
Receiving of supplementary oxygen
Best location for a pulse oximeter is based on the ________ and ________, usually the ________ is selected for adults
Client’s age and physical condition; finger
How to assess client’s overall condition including risk factors for development of hypoxemia and hemoglobin level?
- Vital signs, skin color and temperature, nail bed color, and tissue perfusion of extremities as baseline data
- Assess for adhesive allergy
- Assemble the necessary equipment: nail polish remover as needed, alcohol wipe, sheet or towel, pulse oximeter
- Check if the pulse oximeter is functioning normally
When to assess vital signs?
- Upon admission and before discharge of the client
- At the start of every shift
- Before, during, and after an invasive procedure
- Before and after an intervention,
therapy or treatment - Before and after medication administration
- Whenever a client’s condition changes
Balance between the
body heat produced by the body and the
heat lost from the body
Body Temperature
Assessing body temperature can be done through?
- Oral temperature
- Ear temperature
- Rectal temperature
- Axillary temperature
- Temporal artery temperature
Types of body temperature?
- Core temperature
- Surface temperature
- Temperature of the inner parts of the body
- Taken through oral, rectal, or tympanic
- More accurate than surface
Core temperature
It gives the most accurate core temperature
Rectal
Temperature of the superficial parts of the body
Surface temperature
With fever (pyrexia)
Febrile
Without fever (medicine is antipyretic drugs)
Afebrile
Temperature control center
Hypothalamus
- Controls heat loss.
- Nerve sensors send out signals that
initiate sweating, peripheral vasodilation
and inhibition of heat production
Anterior hypothalamus
- Controls heat production.
- Nerve sensors send out signals that
initiate shivering and vasoconstriction
and release epinephrine
Posterior hypothalamus
Factors that promote heat production
- Basal metabolic rate
- Muscle activity
- Thyroxine production
- Epinephrine, norepinephrine, and stress response
- Fever
Factors that promote heat loss
- Vaporization (evaporation)
- Radiation
- Conduction
- Convection
Factors affecting body temperature
- Age
- Diurnal variations
- Environment
- Exercise
- Hormones
- Stress
Which factor is affecting the body?
-Metabolic rate is higher in a younger
person and decreases in age.
-Infants and older adults are less able to
manage extreme environmental
temperature.
-Infants and children are not able to
shiver.
-Uses hats to hep in maintaining body
temperature.
-Older adults have less subcutaneous fats,
slower metabolism, slower motor.
Age
Which factor is affecting the body?
-Cyclical repetition of various
physiological forces throughout 24 hours
-Body temperature may increase or
decrease as much as 1.8 degrees
fahrenheit
-Highest temperature: 4-6pm
-Lowest temperature: 4-6am
Diurnal variations
Which factor is affecting the body?
-High environmental temperature and
high humidity
-Hypothermia, lack of clothing and
shelter and etc. (a cold environmental
temperature, greater heat loss)
Environment
Which factor is affecting the body?
- Thyroxine
- Epinephrine
- Catecholamine
Hormones
Functions as nuerotransmitters
Catecholamine
Types of thermometers
- Temporal Scanner
- Infrared sensors
- Tympanic Thermometer
- Electronic Thermometer
- Electronic Thermometer
- Skin strip Thermometer
Oral route is the ________ and ________; reflects rapid change in core temperature
Most accessible and convenient
Most accurate and reliable site for body temperature
Rectal
This route can be used for newborns and uncooperative clients, but it is not as accurate
Axillary
Approximately how long must be thermometer remain in place for axillary route?
Approximately 8 minutes
This route can be used for infants, unconscious, and dyspneic clients
Tympanic route
This route can be used for infants, unconscious, and dyspneic clients
Temporal artery
Route that is easily accessible for forehead or abdomen
Skin
Skin may only indicate ________
Surface temperature
Body temperature
is < 36 degrees Celsius
Hypothermia
Body temp < 28 degrees Celsius
Severe hypothermia
If ________ degrees Celsius, cardiac and
respiratory functions could cease, cells
could still be viable, but death could be
possible.
25
Temperature > 40.5
degrees Celsius
Hyperthermia
