Week four: assessment Flashcards
what is temperature?
the difference between heat produced by body metabolism and heat lost through skin
what are the expected values for temperature
- oral: 36.5-37.5/97.7-99.5
- axillary: 35.9-37.2/96.7-98.5
- tympanic: 36-37.5/98.2-100.5
temporal: 36.5-37.5/98.7-100.5
rectal: 37-37.5/98.7-100.5
when and how do you measure oral temperature
- wait 15-30 min after eating, drinking
- 2 min for smoking
- 5 min for gum
- for older children and adults who are alert and oriented
how and when do you test axillary temperature?
used in young children and infants, when oral isn’t an option and when immune system is impaired, hold in fold of arm tight
how and when do we measure tympanic temperature?
all patients with no ear infection or pain, lift the pinna up back and outward while inserting the probe into the ear canal angled towards the chin
how and when do we measure temporal temperature?
all patients especially those confused or unconscious, move thermometer slowly from forehead to past the ear crossing the temporal artery
how and when do we measure rectal temperature?
young children and confused or unconscious adults (only use when necessary) lubricate the probe and insert 2-3cm
what is hypo/hyperthermia?
hypo= <35 C hyper= >35C fever above 39.5
-requires immediate assessment and rapid cooling/warming measures
what are some considerations before taking temp?
- age (older is lower and children are higher)
- exercise
- hormone levels
- circadian rhythm
- stress
- environment
define the following terms:
- febrile: fever (above 37.5)
- pyrogen: something that increases temperature when entered into the blood
- antypyretic: medications that lower blood pressure
- diaphoresis (sweating heavily)
- rigors: cold sweats
- tachypnea: fast breathing +20/min
- bradypnea: slow breathing <12/min
- dyspnea: struggling to breathe
- apnea: not breathing for more than 10 seconds
how do you assess respiration?
- rate: less than ten or higher than 32 is bad
- rhythm: irregular
- depth: shallow or deep
- effort of respirations
- should be relaxed, smooth, effortless, and silent
what is inspiration and expiration
- inspiration: the intercostal muscles and diaphragm contract to expand the pleural cavity
- expiration: the intercostal muscles and diaphragm relax, decreasing space in the lungs
what are the expected values for respiration’s?
Newborn 30-40 Infant 20-40 Toddler 25-32 Child 20-26 Preteen 18-26 Teen 12-22 Adult 12-20 Elite athlete 10-20
what are some influencing factors of respiration’s?
- Age
- Exercise
- Pain
- Anxiety
- Smoking
- Body position
- Medications
- Neurological problems
- Medical conditions (COPD, asthma)
what is the objective data for respirations?
- measure cap fill by sqeeuzing the fingers - should fill in 1-2 seconds
- measure oxygen sat in arterial blood
- oxygen sat is a beam of light passing through tissue and measuring the amount of light absorbed by the hemoglobin that is carrying oxygen
