VS: Temperature/Pulse

what are the 5 main vital signs

temperature, heart rate, respirations, oxygen saturation, and pain.

what is the expected oral temperature range for an adult?

96.8-100.4 F. (36-38 C).

what is the classic average of adult oral temperature

98.6 F

what is pyrexia

fever: temp over 38/100.4

what temperature indicated hyperthermia

core temp above 104 F (40 C)

manifestations of hyperthermia

dizziness, weakness, thirst, nausea, syncope, hypotension, tachycardia

how to treat hyperthermia

remove excess clothing, move to cooler enviornment, encourage cold fluids,

what is hypothermia

temp below 86 F (30 C)

manifestations of hypothermia

shivering, decreased motor skills, dialated pupils, loss of consciousness.

treating hypothermia

warm them up: warm oxygen, blankets, cover head.

Rectal temp compared to oral

0.9 F higher

axillary temp compared to oral

0.9 F lower

temporal temp compared to oral

close to rectal: 0.9 higher

what clients should NOT have a rectal temp

clients with diarrhea, low platelet count, bleeding, or disorders. Infants younger than 3 months.

newborn temperature considerations

95.9-99.5 F (33.5-37.5 C)

older adults temperature considerations

lower average: 95-97 F (35-36.1) Older=cooler.

normal adult heart rate

60-100 bpm

what is tachycardia

HR is over 100 BPM.

possible causes of tachycardia

exercise, anxiety, pain, fever, caffeine, nicotine, some medications

what is bradycardia

heart rate less than 60 bpm

possible manifestations of bradycardia

dizziness, fatigue, shortness of breath, chest pain and confusion

4 components of heart rate assessment

Rate, rhythm (regularity of beats), strength (force/volume of pulse), and equality (both sides). RRSE.

0

absent pulse

1+

diminished/thready

2+

brisk/expected

3+

increased/strong

4+

full/bounding

where do you ausculate adult apical pulse

5th intercostal space, left midclavicular line. Apex of heart.

when is apical pulse preferred

radial pulse is irregular, asses infant/young child, checking effects of cardiac medication, and needing a more accurate heart rate.

what is pulse deficit

the difference between the apical HR and radial HR. Apical-radial=deficit

temporal pulse

side of forehead

carotid

side of neck

femoral

groin

posterior tibial

behind medical ankle

dorsalis pedis

top of foot