vital signs :p Flashcards
refers to the patient’s blood pressure, temperature, respiration, and pulse
vital signs
when to take vital signs?
- upon admission and before discharge
- before, during, and after an invasive procedure
- before and after intervention or treatment
- before and after medication
- whenever the patient’s condition changes (level of consciousness)
part of the brain that is responsible for the regulation of heat in the body
hypothalamus
What does the core temperature indicate?
- 37C
- 38C
- 39C
- 42C
- 37C: normal
- 38C: oh no! sick!
- 39C: BEEDOOBEEDOO CALL THE AMBULANCE
- 42C: ur dead! that temp was so bad bruh
what are the 3 possible sites to take core temperature
rectum, tympanic membrane, oral cavity
where are the possible sites to take surface temperature
skin and axillae
what does the anterior hypothalamus do for temperature
controls heat loss
Nerve sensors send out signals that initiate sweating, peripheral vasodilation, and inhibition of heat production
what does the posterior hypothalamus do for temperature
controls heat production
Nerve sensors send out signals that initiate shivering, vasoconstriction (narrowing of blood vessels), and release of epinephrine
factors that promote heat production
basal metabolic rate, muscle activity, thyroxine production
factors that promote heat loss
conduction, radiation, convection, vaporization
factors that affect temperature
age, diurnal variations, environment, exercise, hormones, stress,
5 routes in taking temperature
- oral
- rectal
- axillary
- tympanic
- temporal
(mnemonic: old rabbits always take tea)
what is hypothermia
body temp is less than 36 C
what is severe hypothermia
body temp is less than 28
Shivering initially
Decreased, irregular pulse
Decreased respirations
Hypotension
Pale, cool skin
Oliguria - (Urine output, less than 30ml)
Reduced muscle coordination
Disorientation
Decreased level of consciousness
WOF: Coma
what do these signs indicate?
severe hypothermia
when temp is more than 40.5 C
hyperthermia
what is febrile
temperature is 37.8 orally, or 38.3 rectally
- fever
wave of blood created by contraction of the left ventricles of the heart. Regulated by the autonomic nervous system.
pulse
factors affecting pulse rate
- age
- Sex
- Exercise
- Fever
- Medications
- Stress and hormones
- Blood volume
- Position
Ensure that the client has not smoked or ingested hot or cold foods or liquids for 9 minutes before measurement and capable of sealing the lips around the thermometer
consider this before using which temperature route?
oral route
most accurate and reliable measurement of temperature
rectal route
safest and non-invasive; accessible route for temperature
- can be used for newborns and uncooperative clients
axillary route
the advantage of this route is that temperature is unaltered by eating, smoking, drinking, and oxygen administration
- can be used for inant, unconscious and dyspneic clients
the disadvantages is that it may be uncomfortable and earwax may result to inaccuracy
tympanic route
how to straighten the ear canal?
for adults: pull the pinna up and back
for children (3 yrs or younger): pull the pinna down and back
how to do a pulse assessment by auscultation?
Use the diaphragm of the stethoscope to out the apical pulse at Left 5th intercostal midclavicular for adult and Left 4th intercostal midclavicular for children
Movement of gases into in and out of the lungs, promoting an exchange of gases between the atmosphere and the capillary beds in the alveoli.
breathing
what type of breathing when External intercostal muscles and other accessory muscles, such as the sternocleidomastoid muscles move too much (exert too much effort)
coastal breathing
which type of breathing: the contraction and relaxation of the diaphragm only, and it is observed by the movement of the abdomen
diaphragmatic breathing
factors that increase respiratory rate:
- Exercise (Increases metabolism)
- Stress (Readies the body for flight or fight)
- Increased environmental temperature
- Lowered oxygen concentration at increased altitudes
factors that decrease respiratory rate:
- Decreased environmental temperature
- Certain medication (Eg. Narcotics)
- Increased intracranial pressure
how to assess respirations
- Count respiration with client in comfortable position. Place clients arm in relaxed position across abdomen or lower chest
- Discreetly observe the rise and fall of the chest
- Observe the character of respirations
what is Dyspnea
difficulty breathing
what is orthopnea
ability to breathe upright only
whats the difference between systolic and diastolic pressure
Systolic Pressure - Ventricular Contraction
Diastolic Pressure - Ventricular Relaxation
what is the pressure for hypertension
stage 1: 130/80
stage 2: >140/>90
an unpleasant and highly personal experience that maybe imperceptible to others while consuming all parts of the person’s life
pain
7 attributes of symptoms
- location
- quality (what does it feel like)
- quantity/ severity (ask with a scale of 1-10)
- timing (onset, duration, frequency)
- setting
- aggravating and relieving factors
- associated symptoms
cardinal techniques in physical examination
- inspection
- palpitation
- percussion
- auscultation
