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Vital Signs
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What measures are included in assessing Vital Signs?
Temperature
Pulse
Respirations
Blood Pressure
Pain
O2 Saturation
What is the frequency of monitoring vital signs in the
Hospital?
Every 4-8 hrs
What is the frequency of monitoring vital signs in the
Home Health Setting
?
Each Visit
What is the frequency of monitoring vital signs in the
Clinic
?
Each Visit
What is the frequency of monitoring vital signs in the
Skilled Nursing Facilities (SNF)?
Weekly to Monthly
The frequency of monitoring vital signs is determined by what 3 things?
Physician's Order &/or Nursing Judgement
Client's Condition
Facility Standards
When do you measure Vital Signs?
On admission to the
Hospital
Before, during and after a
surgery or a procedure
After a
medication administration
When there is a
change
in a client's condition
Before, during and after a
blood transfusion
What should you do to be ready to measure Vital Signs? (3 things)
-Be organized in approach
-Be aware of needed equipment
-Know the baseline vital signs for the client and the normal ranges for the population
(The patient needs to be confident in you)
When should you report Abnormal Vital Signs?
Immediately
Who should you report Abnormal Vital Signs to?
The Student to the
Instructor
then to the
RN
then to the
Charge RN
then to the
MD
When should you report Abnormal Vital Signs?
When Abnormal
When they Return to Normal or Change
How should you report Abnormal Vital Signs?
1st - Verbally to appropriate person
2nd - Document VS in patient's records
Define Temperature.
The degree of heat maintained by the body
What is the equation for body temperature?
heat produced - heat loss
The body's Internal Temp. is known as the ______ Temp.
Core
What is the Normal Range for the body's
Core Temp
.?
96.2 - 100.4 F
36.2 - 38 C
Is the body's Surface Temp. higher or lower than its Core Temp.?
LOWER
What 2 methods are mainly used to measure the body's
Surface Temp.?
Oral & Auxillary (arm pit)
What 2 methods are mainly used to measure the body's
Core Temp.?
Rectal & Tempanic (ear)
What is the body's Average
Surface Temp.
Range?
98 - 98.6 F
36.7 - 37 C
What is the body's thermostat? Its
Thermoregulation
?
The
Hypo
thalamus
Does the amount of temperature increase equate to the degree of illness?
No
What is more important than the increase in temp.?
patterns and continuousness
Heat Production
can be
a result of what 5 things?
Metabolism
(BMR - thyroid hormones)
Skeletal Muscles
(break down of fats)
Nonshivering Thernogenesis
(infants)
Shivering
(tells hypothalamus to help)
Vasoconstriction
Heat Loss
can be a result of what 4 things?
Radiation
(tranfer of heat w/o contact) 50 % of Heat Loss
Convection
(transfer of heat through air/water)
Conduction
(transfer w/ contact) 15 - 20 % of Heat Loss
Evaporation
(transfer occurs when water is convrted to vapor)
What type of
Heat Loss
is perspiration (sweating)?
Evaporation
What type of
Heat Loss
occurs when patient lays on a cold x-ray table?
Conduction
Where is most of the body's heat lost?
on the skin
What factors affect your body's temperature?
Age, Hormones, Exercise, Circadium Rhythm (sleep cylce), Stress & Emotions, Environment
Body Temp. is _______ in the morning and _______ in the afternoon
lowest, highest
Why do infants wear hats?
b/c they lose
30 %
of their body's temp. through their head
Febrile
means ______
Elevated temperature
Afebrile
means ______
w/o Elevated temperature
Pyrexia
means _______. It is a response to _______ or _______ or _______.
Fever. Bacterial or Viral infections or Tissue Injury
What is the body's temp. when it has Pyrexia?
Greater than 100.4 F (38 C)
What is the body's temp. when it has Hyperpyrexia?
Greater than 105.8 F
Is a fever always a bad thing? Why/Why Not?
No - Up to 102.2 F can be beneficial b/c it:
- enhances immune responce
- kills/inhibits many microorganisms
- enhances phagocytosis
- causes breakdown of lysosomes
- virally infected cells self destroy
- releases interferons (protects cells from viruses)
What cell damage can a high temperature cause in the brain?
Agitation
Confusion
Stupor
Coma
Vascular Collapse
Death
Heat Exhaustion is:
profuse diaphoresis (sweating) leading to water & electrolyte loss
Malignant Hyperthermia is a repsonse to _____
Anesthesia
A Heatsrtoke is:
A Medical Emergency
Hot & Dry skin
no sweating
What are the levels of Hypothermia?
Mild = Less than 96.8
Moderate = 96.7 - 82.4
Severe = Less then 82.4
What are the causes of Hypothermia?
cold weather
cold water
lack of shelter/clothing
surgery (coldness can save cells)
What tyoe of thermometer would you use on a patient in isolation?
Disposable thermometer
An Axillary temp. is _____ than an Oral temp.
1 degree cooler
A Rectal temp. is ______ than an Oral Temp.
1 degree warmer
What should you do before you administer a rectal thermometer?
Make sure it is marked RED (Rectal)
Lube it 1-2"
**Stop if you feel resistance**
Author
awnoles
ID
40879
Card Set
Vital Signs
Description
Temperature
Updated
2010-10-09T21:01:11Z
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