Vital signs
-Vital signs are key in obtaining physiologic data on
patients.
-They are used to monitor physiological functioning
of body systems.
-Useful in assessing for condition changes in
patients as well as determining the effectiveness of
interventions.
6 vital signs
-Temperature
-Pulse
-Respirations
-Blood pressure
,-Pulse oximetry
-Pain
Temperature
-Measurable heat of the body.
-97.6-99.5 F
-Can be measured in multiple ways- measurement
type (oral, rectal, axillary, and temporal) will be
based on patient status.
-Rectal temperature is rarely used in adults- never if
rectal/anal surgery, diarrhea, or tissue trauma is
present.
-***Increased temperature when infections are
present (fever) is associated with a mild increase in
heart rate and blood pressure r/t increased metabolic
demand in the body***
Pain
-Multiple ways to assess pain; pain scale (1-10 rating
by the pt) is the most common.
-If your patient is unable to articulate pain, use
alternate scale such as the Wong-Baker faces scale.
-Vital signs are NOT a reliable measure of pain!
-Pain is subjective- it is what the patient says it is.
Asepsis (know the signs and symptoms of infection):
-Fever
-Redness
-Heat
-Purulent drainage (is from wounds)
, -Odor (if from wounds)
-Malaise
-Anorexia
Asepsis (older adult considerations)
-WBCs are increased with infection- this is part of
the body's immune response to fight infection.
-As we age, we have decreased number of WBCs-
this makes it harder to fight infections and easier for
them to become more serious.
-Age is always one of the highest risks for infection.
Additional risks for asepsis:
-Heredity
-Poor nutrition
-Chronic disease
-Medical disease
-Medical therapies and medications
-Stress
High risk for HAI's (healthcare- associated
infections):
-Age
-Central lines
-IVs
-Indwelling urinary catheters (Foley)
Interventions to prevent infection:
-Wash hands
-Nutrition
-Stress reduction
-Sleep
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