Vital Signs (ch 24) Flashcards
When to assess vital signs
1) on admission
2) based on institutional policy& procedures
3) anytime theres a change in the patients condition
4) loss of consciousness
5) before and after surgical/invasive procedure
6) before & after activity that may incr risk (ex: ambulation after surgery
7) before admits tearing meds that affect cardiovascular and respiratory function
Temperature
Difference between the amount of heat produced by the body versus the amount of heat lost to the environment.
Physiology of body temperature
Heat production - primary source is metabolism. Influenced by hormones and exercise. Incr heat by shivering
Heat loss - primary site is skin. Evaporation of sweat through warming and humidifying of inspired air and through elimination of urine and feces.
Factors affecting body temperature
- Circadian Rhythms- temp lower in the morning
- Age and Gender- elderly lose thermoregulatory control. Infants and children adjust quickly. Women (hormones) experience more fluctuations.
- Environmental temp- hypo/hyperthermia without proper protection.
Hypothermia
Low body temp. < 96f (35.5c)
Hyperthermia
High body temperature
Afebrile
Without a fever. Normal body temp
Pyrexia
Fever
Febrile
Person with a fever. Signals infection
Causes:
-tissue injury, myocardial infarction, pulmonary emboli, cancer, trauma, surgery.
Difference between Fever and Hyperthermia
With hyperthermia the hypothalamic set point is not changed. Environmental factors (excessive heat) alter body temp and temp controlling mechanisms are ineffective.
Intermittent fever
Body temp alternates regularly between feverish and afebrile states.
Remittent fever
Body temp fluctuates several degrees above normal but does not reach normal between fluctuations.
Constant fever
Temp remains consistently elevated and fluctuates less than 2*C
Relapsing fever
Body temp returns to normal for at least a day, but then recurs
Crisis fever
Fever returns to normal suddenly
Lysis fever
Fever returns to normal gradually
Normal body Temps
Oral- 98.6 / 37 Rectal- 99.5 / 37.5 Axillary- 97.7 / 36.5 Tympanic- 99.5 / 37.5 Forehead- 94.0 / 34.4
Physical effects of fever
Loss of appetite, headache, hot and dry skin, flushed face, thirst, muscle aches, fatigue.
Increase respirations
Increase pulse rate
Elderly - confusion and delirium
At risk for fluid, electrolyte, acid-base imbalances
Methods for reducing fever
- Bacterial infection - antibiotics
- Antipyretics; aspirin, acetaminophen (reset thermoregulatory mechanism)
- Cool sponge baths, cool packs, &hypothermia
NIC Fever Interventions
Monitor temp frequently as appropriate
Monitor BP, pulse, respiration
Monitor intake and output
Monitor seizure activities
Admin antipyretic med
Admin IV fluids as appropriate
Apply ice bag covered with towel to axillary or
groin areaNOC Fever Treatment
Vital signs, hydration, thermoregulation
Risk Control: Hypothermia
Where are surface body temperatures measured at?
oral
axillary
and skin surface sites
Where are core body temperatures measured at?
tympanic or rectal
When is the temperature the hottest?
between 4-7 pm
Radiation
diffusion or dissemination of heat by electromagnetic waves
Convection
dissemination of heat by motion between areas of unequal density
Evaporation
conversion of a liquid to a vapor
Conduction
transfer of heat to another object during direct contact
Pulse
Throbbing sensation that can be palpated over a peripheral artery
bradycardia
pulse rate below 60 beats per minute
Tachycardia
pulse rate is 100-180 bpm
Factors contributing to tachycardia
- decrease in blood pressure
- elevated temperature
- any condition related to poor oxygenation
- exercise
- prolonged application of heat
- pain
- strong emotions
- some medication
dysrhythmia
irregular pattern of heartbeats
pulse deficit
difference between the radial and the apical pulse
Respiration
includes ventilation, diffusion, and perfusion
eupnea
normal breathing
tachypnea
increased respiratory rate
bradypnea
decrease in respiratory rate
apnea
periods during which there is no breathing
dyspnea
difficult or labored breathing
orthopnea
breathing easier sitting upright
blood pressure
force of the moving blood against the atrial walls
pulse pressure
difference between systolic and diastolic pressure
Hypertension
blood pressure that is above normal for a sustained period of time
Hypotension
below normal blood pressure
Orthostatic hypotension
drop in systolic blood pressure of a number greater than or equal to 20 mm Hg or diastolic pressure or a number greater than or equal to 10 mm Hg within three minutes of standing
