HA WEEK 3 FLASHCARDS

Vital Signs

Also termed as cardinal signs, they reflect the body’s physiological status and include temperature, pulse, respiration, blood pressure, and pain.

○      Temperature

○      Pulse

○      Respiration

○      Blood pressure

○      and Pain

five critical assessment areas

Frequency of Vital Signs

Determined by the client’s health status, physician’s orders, and established standards of care for the setting; should be checked when changes are suspected.

Body Temperature

Measure of heat inside the body, influenced by heat production and loss, measured in degrees Celsius or Fahrenheit.

Core Temperature

Deep tissue temperature that remains relatively constant.

Surface Temperature

Skin, subcutaneous tissue, and fat temperature that fluctuates in response to the environment.

Factors Affecting Body Temperature

Include age, exercise, hormones, stress, environment, and diurnal variations.

Common Sites for Measuring Body Temperature

Oral, axillary, rectal, and tympanic sites with specific considerations for each.

ORAL

-        accessible & convenient

-        can break if bitten

inaccurate if client ingested hot or cold food        or drinks or smoked

AXILLARY

-        safe and noninvasive

thermo must be left in place a long time to obtain an accurate measurement

RECTAL

-        reliable measurement

-        inconvenient & unpleasant for clients

-        presence of stool may interfere with result

TYMPANIC

-        readily accessible; fast

-        reflects core temperature

-        uncomfortable and risky

R and L measurements can differ

Thermometer Types

Electronic, temperature-sensitive tape, chemical disposable, and temporal artery thermometers.

Rationale for Temperature Measurement

To assess core temperature, establish baselines, monitor disease conditions, and evaluate therapy responses.

TAKING ORAL TEMPERATURE

1. Patient must be conscious & can hold the thermometer securely under his tongue & can breathe through his nose.

2. Allow 15 minutes to lapse before taking the temperature by mouth if client has taken hot or cold drink or has been smoking.

Take note of the contraindications for taking oral temperature

TAKING AXILLARY TEMPERATURE

1. This method should be used only when there is no other way of obtaining the body temperature.  This is considered the least reliable method.

2. Use this procedure when no individual clean oral thermometer is available.

TAKING RECTAL TEMPERATURE

➢     Indications:

○      critically ill, disoriented, senile & unconscious

○      dyspneic, unable to keep the mouth closed for    any reason.

➢     Contraindications:

○      coronary precaution

○      rectal or perineal surgery

○      inflamed rectum

○      eye surgery

TAKING TYMPANIC TEMPERATURE

➢     Apply disposable cover onto the tympanic thermometer

➢     Turn device “on” by pressing button on front

➢     Place thermometer in ear and depress top button to make reading

➢     After reading, flop the blue tab to release the disposable probe cover without contact

➢     Turn the client's head to one side. For an adult, pull pinna upward and back; for a child, pull down and back

➢     Gently insert probe with firm pressure into ear canal.

1. Age

2. Sex

3. Exercise

4. Fever

5. Medications

6. Hemorrhage

7. Stress

8. Position changes

FACTORS AFFECTING THE PULSE

RADIAL ARTERY

Commonly used pulse site

Respiration

-        Is the act of breathing. It includes intake of oxygen (inhalation) and output of carbon dioxide (exhalation).

RATE

DEPTH

QUALITY

RHYTYM

EFFECTIVENESS

ASSESSMENT OF RESPIRATION

RATE

how many breaths per minute

DEPTH

breathing may be normal, deep or shallow

QUALITY

breathing different from normal, effortless breathing

RHYTYM

regularity of expiration & inspiration

PURPOSE DO WE CHECK OR COUNT THE CLIENT’S RESPIRATION

○      Quiet down an infant or child before        respirations are counted.

○      Observe the rise and fall of the abdomen if the client is a young child.

○      Ask the older adult to remain quiet or count respirations after taking the pulse.

Sphygmomanometer

instrument used in measuring the blood pressure in the arteries.

Aneroid sphygmomanometer

has       calibrated dial with a needle that points to the calibrations

Do not measure BP in any limb

●      when there is injury or disease

●      when there is a cast or bulky bandages

●      When client has had mastectomy or removal of axillary lymph nodes

●      When client has an IV or blood transfusion in the limb.

To allow the bladder of the cuff to compress the artery.

Why must the cuff be wrapped evenly around the upper arm?

approximately 2.5 cm above the antecubital space

How far should the lower border of the cuff be positioned on the arm?

Pump up until 30 mmHg above the point where the brachial pulse disappeared.

When does the nurse stop pumping up the cuff when taking the blood pressure?

wait 2 minutes before taking a second reading

How long must one wait if the BP has to checked the second time?

BP increases when arm is below the level of the  &  decreases when above the

Why do we position the arm at heart level?

Crossing the knee results in elevated systolic and diastolic pressures.

Why should we put the client’s feet flat on the floor when taking the blood pressure?