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Name the vital signs - -temperature
-pulse
-Respirations
-Blood Pressure
-Pulse Oximetry
-Pain
Why are vital signs important? - Indicator of overall health
-provides baseline data
-show changes in patients "normal"
-Show response to psychological stress and medical and nursing treatments
What should you look for when taking vital signs? - trends for that individual
What is the role as a nurse when assessing vital signs? - -decide frequency
-develop a systematic approach
-know patients normals
-be aware of elements that influence vital signs
If vital signs are abnormal what should you do? - retake, record, report
What does the body temperature reflect? - a balance/imbalance between heat produced
and heat lost
What is body temperature regulated by? - hypothalamus
Describe the core - body temperature relatively constant/surface
-this varies
What is the average oral temp? f and c - 98.6 f
,37 c
What is the range for body temperature in adults? - 96.8-100.4 (36-38c)
If temperature is above the range what is this called? - Febrile
What is the trend for elderly patients body temperature? - usually below normal range
Name all influencing factors for body temp? - age
exercise
hormones
circadian rhythm
stress
environment
hot/cold liquids
smoking
How might exercise affect body temperature? - temp may go up
Describe the trends of the circadian rhythms and body temperature? - in the morning
this rhythm may be lower and higher in the evening. It depends on the activity of the patients
on a normal basis.
As far as body temperature goes how might you help a patent with dementia? - You
should help them stay warm or cooler to keep their body temperature stable
In a female how might hormones affect body temperature? - During ovulation
progesterone is released so they will be warmer than usual.
How will stress influence body temperature? - stress will influence hormones and they
will influence body temp.
What is another name for fever? - Pyrexia
Describe a set point - set point is used to describe a baseline for a individuals body
temperature
-everyone has a different set point
Word for no fever - afebrile
,Signs/ symptoms of fever - chills
malaise- feeling unwell
increase in body metabolism
Hypothermia - abnormally low body temperature
Hyperthermia - Abnormally high body temperature
An increase in body metabolism may cause the needs: - -increase in nutritional needs
-increase in oxygen needs
-possible dehydration
What nursing measures should be taken for a patient with a fever? - -minimize heat
production
-maximize heat loss
-Promote pt. comfort
-satisfy requirement for increased metabolic rate
-monitor pulse and respirations
How can you minimize heat production for a pt. with fever? - allow pt. to rest
How can you maximize heat loss for a pt. laying in bed with a fever? - decrease covers on
body
How can you promote pt. comfort with a fever? - keep clothing, linen dry
-oral hygiene measures
How can you satisfy the requirements for an increased metabolic rate? - replace fluids
balance nutrition
oxygen prn
What do you want to do as far a monitoring a pulse and respiration of a pt. with a fever? -
keep it down because it will go up as the fever goes up
Name all the assessment sites for taking a temperature and where they are ? - oral-
mouth 3 min at least
, tympanic- ear
rectal
axillary
skin
temporal
What site for body temperature has the best core? - rectal
When would oral temp be inappropriate? - on a baby
someone with oral surgery
what things should you do/get before taking a temp? - hand hygiene
2 identifiers
appropriate thermometer
What does the pulse reflect? - reflects functioning cardiovascular system
The pulse is a indirect measure of what? - cardiac output
Normal range for pulse in adult? - 60-100 beats/min
What is bradycardia? - slow pulse
below 60
what is tachycardia - fast pulse (heart rate)
above 100
What is dysrhythmia
what is arrhythmia - -regular
irregular
if a person has a beta blocker what would that do to their pulse (heart rate) - -make the
heart rate low
/What do you assess for when checking pulse. - -rate
-rhythm