Exam (elaborations)
Temperature, Pulse, Respirations (1).
Temperature, Pulse, Respirations (1).
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Temperature, Pulse, RespirationsVital Signs
-means of assessing vital or critical physiological functions
-variations reflect a state of health and/or functional ability of the body systems
-the importance of accurate assessments, interpretation, and documentation of vital signs cannot
be overemphasized
What are vital signs?
temperature, pulse, respiration, blood pressure, 02 Sat, Pain should be taken in this order
When to measure vital signs?
-on admission
-on regular, hospital schedule or as ordered (ex:q4hours)
-before and after procedures (ex:surgery)
-to identify problems
-to evaluate a patient's response to an intervention
-before, during, and after blood transfusions
-when pts condition changes
Example of post-op vital signs
-every 15 min x 4 sets then
-every 30 min x 2 sets then
-every 1 hr. x 2 sets then
-every 4 hours, if stable
Guidlines for assessment
-taken by nurse giving care
-equipment should be the appropriate size and in good condition
-know baseline VS and normal ranges for pt and age group
-know pt medical hx, surgeries ect
-minimize environmental factors
-organized in approach
-increase frequency as condition worsens
-compare readings to the whole picture and the pts usual range
-describe any abnormal readings
-communicate findings
Reporting Abnormal VS
WHEN—grossly abnormal, return to normal, noted change for that pt
WHY—indicates change in metabolism or physiological function within the body
WHO—student reports to instructor, then TL, RN, Dr (follow chain of command)
HOW—orally to appropriate person, then document on chart, in the computer
VS Accuracy
-Both measuring and recording
-vary according to pt illness/condition
-compare results with pts normal
-results are used to determine tx, meds, diagnostic work, ect
Vasodilation
widening of blood vessels
Convection
air movement, fan
Radiation
removing clothing or blankets
conduction
, ice pack, heating pad
evaporization
sweating (diaphoresis)
physiology of heat loss
-vasodilation
-convection
-radiation
-conduction
-evaporization
heat is produced by:
metabolism-food, BMR
increased muscle activity- exercise
vasoconstriction- narrowing of blood vessels, skin is pale and cool
external sources-environment, shivering, increased heat production 4-5x normal
Temperature range for adults
96.8-100.4
*no single temp is normal for all
average temperature for adults
98.6
average rectal temp
99.5
average ax temp
97.7
Neural and Vascular Temp control
-controlled by the hypothalamus
-establishes a comfortable "set point" for temp
thermoregulation
physiological and behavioral mechanisms regulate the balance between heat lost and heat
produced
temperature
the measurement of heat in the body
fever
the measurement of heat in the body that is above normal for the individual
Pyrexia
another term for fever
febrile
fever
hyperthermia
high body temperature (>100.4)
afebrile
without fever
hypothermia
low body temperature
mild hypothermia
93.2-96.8
moderate hypothermia
86-93.2
severe hypothermia
<86
Fever-a defense mechanism
-Indicator of disease in body.
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