Chapter 12
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| 🇬🇧 | 🇬🇧 |
| When measuring vital signs what can happen? | A change in one has the potential to alter the others |
| When measuring vital signs what can happen? | A change in one has the potential to alter the others |
| When measuring vital signs what can happen? | A change in one has the potential to alter the others |
| Ausculate | Listen for sounds within the body to evaluate the condidion |
| What should be included in an overall assessment for all patients? | Cultural assessment |
| What are the guidelines for obtaining vital signs? | Measuring them correctly, understanding & interpreting the values, communicating findings appropriately, beginning interventions as needed |
| High temperature | Body can be fighting off infection |
| High B/P | Patient can be prone to having a stroke |
| What is the 5th vital sign? | Pain or comfort level |
| What do you need to be aware of for patients' vital signs? | The normal range |
| 2 types of body temperature | Core temp & surface temp |
| Core temp | Deep tissue of the body; remains relatively constant |
| Surface temp | Temperature of the skin |
| When taking a patient's temp what do you need to remember to always do? | Always note where you took it |
| Hypertension | High blood pressure |
| Fever | A body defense mechanism |
| What happens when the body temp is elevated? | Helps destroy invading bacteria |
| Radial Pulse Rate | Is obtained at the radial artery thumb |
| What pulse rate will you check the LOC? | Thumb (Radial Pulse) |
| Remittent | Fluctuates, does not return to normal until feeling better |
| Intermittent | Rise/falls to normal everyday ex: normal in the morning & spikes in the after noon |
| Apical pulse | Actual beating of heart |
| Lub-Dub | One cardiac cycle |
| If pulse differs by more than 2 then what exist? | Pulse deficit exists |
| Internal resperation | Gas exchange on tissue level |
| Paracentesis | Fluid out of the lungs |
| What is considered as a silent killer? | Hypertension |
| Apnea | Stopped breathing |
| What do you need to report while doing vital signs? | Abnormalities |
| How frequently are vital signs measured? | Depend on the nurse's judgment of the need |
| Neonate Heart Rate | 120-160 per minute |
| Neonate Resp. Rate | 36-60 per minute |
| Neonate B/P | Systolic 20-60 |
| Infant Heart Rate | 125-135 |
| Infant Resp. Rate | 40-46 |
| Infant B/P | Systolic 70-80 |
| Toddler Heart Rate | 90-120 |
| Toddler Resp. Rate | 20-30 |
| Toddler B/P | Systolic 80-100 |
| School Age Heart Rate | 65-105 |
| School Age B/P | Systolic 90-100 Diastolic 60-64 |
| Adolescent Heart Rate | 65-100 |
| Adolescent Resp Rate | 16-22 |
| Adolescent B/P | Systolic 100-120 Diastolic 70-80 |
| Adult Heart Rate | 60-100 |
| Adult Resp. Rate | 12-20 |
| Adult B/P | Systolic 100-120 Diastolic 70-80 |
| Older Adult Heart Rate | 60-100 |
| Older Adult B/P | Systolic 130-140 Diastolic 90-95 |
| Temperature | A relative measure of sensible heat or cold of 98.6 which is considered normal |
| Normal oral temp | 98.6 |
| When the patient reports nonspecific symptoms of physical distress (feeling funny or different) | Take vital signs |
| Normal body temperature for oral | 98.6,37.0 |
| Normal body temperature for rectal | 99.6,37.5 |
| Normal body temperature for axillary | 97.6,36.4 |
| Where is the hypothalamus located? | In the brain and forms the floor & part of the lateral wall of the third ventricle |
| Often varies a great deal in response to the environment | Surface temperature |
| Pyrexia, febrile & hyperthermia | Used to describe the condition of having above-normal body temperature |
| Temperatures exceeding 105 | Have the potential to damage normal body cells |
| What are fever classified as? | Constant, intermittent, & remittent |
| Constant fever | Remains elevated consistently and fluctuates very little |
| Hypothermia | Body temperature is abnormally low |
| When the body temp falls below 93.2 | Death is a risk |
| Hypothyroidism | Produce a subnormal temperature |
| Factors that affect body temperature | Age, exercise, hormonal influences, diurnal (daily) variations, stress, environment, ingestion of food & hot & cold liquids, & smoking |
| What are some signs & symptoms of elevated body temp? | Anorexia, disorientation, elevated pulse/respirations, warm skin, headache, irritability,thirst |
| Tympanic | Temperature by scanning the tympanic (eardrum) membrane |
| What are the instructions for tympanic probe positioning? | Gently tug ear pinna upward and back for an adult, down and back for a child |
| Stethoscope | An instrument that is placed against the patient's chest or back to hear heart & lung sounds |
| Cultate | Listen for sounds within the body to evaluate the condition of heart, lungs, pleura, intestines, or other organs or to detect fetal heart tones |
| Oral temp | Most accessible site; comfortable for patient; necessitates no position change |
| Rectal temp | Argued to be more reliable when oral temperature cannot be obtained |
| Axilla temp | Safe method because noninvasive |
| Tympanic Temperature | Noninvasive, accurate, safe; provides core reading |
| Temporal artery temp | Provides core temperature; rapid, noninvasive method; tolerated well by children; lessens need to handle newborns, which aids in preventing heat loss |
| Pulse | A rhythmic beating or vibrating movement |
| What does pulse signify? | The regular recurrent expansion and contraction of an artery produced by the waves of pressure that are caused by the ejection of blood from the left ventricle of the heart as it contracts |
| Tachycardia | Pulse is faster than 100 beats per minute |
| Bradycardia | Pulse slower than 60 beats per minute |
| Hypovolemia | An abnormally low circulating blood volume |
| What may cause tachycardia? | Shock, hemorrhaging, exercise, fever, medication, or substance abuse, and acute pain |
| What may cause bradycardia? | Unrelieved severe pain; stimulates the parasympathetic nervous system, which slows the heart rate |
| Dysrhythmia | Any disturbance or abnormality in a normal rhythmic pattern, specifically, irregularity in the normal rhythm of the heart |
| Imperceptible | A pulse you are unable to feel at all |
| What do you do when taking the pulse? | Note the rate, the rhythm, and the volume or strength of the pulse |
| Factors that influence pulse rates | Acute pain/anxiety, age, exercise, fever/heat, hemorrhage, medications, metabolism, postural changes, pulmonary conditions, unrelieved severe pain/chronic pain |
| Absent pulse (0) | None felt |
| Thready pulse (1+) | Difficult to feel; not palpable when only slight pressure applied |