Vital Signs Flashcards
Body Temperature is controlled by the …
Hypothalamus
What factors affect pulse rate?
Age- decreases w age Sex - higher in females Exercise - increased during Food - ingestion slightly increases Stress - increases Fever - increase ~ 10 bpm Disease - either Blood loss - can increase nominally Position change - increases w sitting/standing Medications - either
What are the phases of fever?
Initial/febrile/onset - T is rising, Pt feels chilly, uncomfortable and may shiver
Second/course - T reaches max, Pt feels warm, dry, may last days or weeks
Third/defervescence/crises/breaking - T returns to normal, Pt feels warm, flushed due to vasodilation, diaphoresis(sweating)
What is the normal range for respiration rates in adults?
12-20 rpm
What are some interventions for fever/hyperthermia
Help determine causality Monitor T and other VS every 2hr Observe for clinical signs Administer prescribed antibiotics Provide oral/IV fluids Provide cooling blankets, baths, ice packs, fans, minimal bedcovers Provide nutritional support Provide special mouth care - lip lube Keep linens and clothing dry Provide emergency measures
If a patients Vs are abnormal how often should their VS be checked?
5-15 min
When would you diagnose Ineffective thermoregulation?
T fluctuates above and below normal (intermittent fever)
What is the normal range for an oral core temp in adults?
36 - 38 C
How does stress affect body temp?
Stress stimulates the sympathetic nervous system which causes increased production of epinephrine and norepinephrine. These hormones increase metabolic rates which then increase temp.
At what frequency should you check VS for a patient in the clinic?
Each visit
How does the circadian rhythm affect temp
Temperatures can fluctuate 1-2C over 24hrs.
Temps usually lowest in the early morning and highest in the lease afternoon or early evening.
Severe hypothermia exists when…
Core T falls below 28C
At what frequency should you check VS for a patient in the hospital?
Every 4-8 hours
How is heat exchanged with the environment?
Radiation - heat loss through EM waves
Convection - transfer of heat through air or water currents
Evaporation - heat lost through water-vapor conversion (insensible loss - affected by humidity)
Conduction - heat transfer through direct contact
What is the ideal average for an oral or tympanic temp in adults?
37 C
When would you diagnose hyperthermia?
T is above normal
Pt c/o fatigue, feels warm, is flushed, has an increased heart rate
How do hormones affect body temp?
Women’s body temp can fluctuate 1degree with menstruation and menopause can cause temperature fluctuations.
High T up to 102.2F or 39C enhance immune response by…
Kill/inhibit growth of microorganisms
Enhance phagocytosis
Cause breakdown of lysosomes and self-destruction of virally infected cells
Cause the release of interferon to protect cells against viruses
What is the ideal average for a Axillary temp in adults?
36.5C
What is the range for a prehypertensive blood pressure in adults?
120-130 systolic
80-89 diastolic
What is the range for normal pulse rate in adults?
60-100 bpm
Avg 70-80 bpm
What are some common occasions for assessing vital signs?
On admission
Admission to general practitioner or clinic
Before, during or after surgery or special procedures
Monitoring affects of meds
Whenever the condition of the patient changes
What are some patient centered goals for hypothermia?
oral T >37C
No clinical signs of hypothermia
Pulse and RR within normal range
Hypothermia is diagnosed when
A Pt body T is below normal
