Vital Signs - Nrsg Fun Ch 17 Flashcards
What is the normal rang for a rectal core temp in adults?
97.2 - 101.4 F (35.7 - 38.6 C)
What is the ideal average for an oral or tympanic temp in adults?
98.6 F or 36.7-37 C
What is the ideal average for a rectal temp in adults?
99.5 F or 37.5 C
What is the ideal average for a Axillary temp in adults?
97.7F or 36.5C
What is the normal range foe pulse rate in adults?
60-100 bpm
What is the average for pulse rate in adults?
80 bpm
What is the normal range for respiration rates in adults?
12-20 rpm
What is the average for blood pressure in adults?
100-120 systolic
60-80 diastolic
What is the range for a prehypertensive blood pressure in adults?
120-130 systolic
80-89 diastolic
What is the the average for normal blood pressure in adults?
New recommendations say 110/70
Old norm was 120/80
What are the main vital signs?
Temp, pulse rate, respirations, blood pressure, pain
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
At what frequency should you check VS for a patient in the hospital?
Every 4-8 hours
At what frequency should you check VS for a patient in a home health setting?
Each visit
At what frequency should you check VS for a patient in the clinic?
Each visit
At what frequency should you check VS for a patient in skilled nursing facilities/convalescence?
Weekly to monthly
If a patients Vs are abnormal how often should their VS be checked?
5-15 min
Which readings are considered core temps and which are surface temps?
Core - rectal and tympanic
Surface - oral and axillary
Body Temperature is controlled by the …
Hypothalamus
Body temperature is decreased by what physiological processes?
Vasodilation
Sweating
Inhibition of heat production
Body temperature is increased by what physiological processes?
To produce heat
Shivering
Release of epinephrine to increase metabolism
To reduce heat loss
Vasoconstriction
Piloerection - hairs standing on end
How is heat produced in the body?
Metabolism
Sketch muscle (catabolism of fats and carbs)
Nonshivering thermogenesis - metabolism of brown fat in infants only
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
How does developmental level affect body temp?
Infants and the elderly ca not regulate their body temp as efficiently.
Infants lose ~ 30% heat through head which is proportionately larger
Elderly have slower metabolic rates, decreased vasomotor control and loss of subcutaneous tissue.
How do hormones affect body temp?
Women’s body temp can fluctuate 1F with menstruation and menopause can cause temperature fluctuations.
How does exercise affect body temp?
Exercise increases metabolism which causes increased body temps
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.
How does the circadian rhythm affect temp
Temperatures can fluctuate 1-2F over 24hrs.
Temps usually lowest in the early morning and highest in the lease afternoon or early evening.
What is the conversion from F to C?
(F-32) x 5/9 = C
What is the conversion from C to F
(C x 9/5) + 32 = F
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 are the types of fever?
Intermittent - T alts between fever, normal and below-normal
Remittent - wide fluctuations all above normal
Constant/sustained
Relapsing fever - short periods of fever alt w periods of normal, each lasts 1 - 2 days
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
When would you diagnose hyperthermia?
T is above normal
Pt c/o fatigue, feels warm, is flushed, has an increased heart rate
When would you diagnose Ineffective thermoregulation?
T fluctuates above and below normal (intermittent fever)
When would you diagnose Risk for Imbalanced body temperature?
When T of Pt is normal, but Pt is at risk for failure of T regulation (e.g. Infants/frail elderly)
What are the standardized outcomes for Hyperthermia and Ineffective thermoregulation
Thermoregulation, thermoregulation: Newborn, and VS
What are the outcomes for risk for imbalanced body temperature
Adherence behavior, compliance behavior, risk control, risk detection
What are some examples of Pt centered individual goals
Oral temp
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
Hypothermia exists when …
Core T drops below normal
Severe hypothermia exists when…
Core T falls below 82.4F or 28C
Hypothermia is diagnosed when
A Pt body T is below normal
What are some patient centered goals for hypothermia?
oral T >98.6F or 37C
No clinical signs of hypothermia
Pulse and RR within normal range
What are some interventions for hypothermia?
Provide warm, dry clothing and warm drinks
Use warmed IV fluids, heating pads, blankets or baths
Rewarm Pt gradually
Monitor VS frequently
Observe for s/s of hypothermia
What is the range for normal pulse rate in adults?
60-100 bpm
Avg 70-80 bpm
Stroke volume is ….
The volume of blood forced out of the heart in a single contraction of the left ventricle (avg 70mL)
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 is the normal range for an oral core temp in adults?
96.2 - 100.4 F (35.7 - 38 C)
