Module 5

Normal Temperature

96.8-99.5 F (36-37.5 C)

Older adults tend to have a lower temperature because of a lack of subq fat, lack of activity, inadequate diet, etc.

Accurate VS

Thorough, Scientific, Specific

Wait 30 minutes to take temperature after client has consumed food or drink

Contraindications for Rectal Temp

Surgery, Diseases, Clotting, Hemorrhoids, Diarrhea, Immunosuppressed

Interventions for Fever

Monitor VS and WBC, I&O, Adequate Nutrition, Assess Skin temp and color, Oral Hygiene

-If pedal pulse is non palpable, use a doppler ultrasound

-Peripheral Pulse: assess corresponding pulse on opposite side

-Apical (point of maximal impulse) and Radial (easily accessible) should be identical

Increased RR

Exercise, Stress/Anxiety, Low O2, High Temperature

Position for assessing RR: Semi-Fowlers

Blood Pressure

Elevated Systolic: stress, older age (elasticity of arteries decrease)

Elevated Diastolic: Also age, diet, smoking and alcohol, obesity

-Phase 2 of Korotkoff: muffled, whooshing, swishing quality

BP assess: Direct: Cath into artery, Indirect: Auscultation/Palpation

Affecting Factors

O2 Sat: hemoglobin, circulation, activity, CO poisoning

BP: age, exercise, stress, sex, race, meds, obesity, temp, medical conditions

Korotkoff Sounds

Sounds heard when auscultating BP

Systolic: 1st Korotkoff sound

Diastolic: 5th Korotkoff sound

Heat

-Heat Stroke: warm, flushed skin and lack of sweat, delirious

-Fever: Increased sweat and head/muscle ache

-Heat Exhaustion: pallor, dizzy, n/v, fainting, increased temperature

Radiation

hovering close to face

Conduction

touch (Ice packs, sponge baths, etc)

Convection

AC on skin

Evaporation

sweating

Benefits of Rectal Temp

Most accurate (core), can be assessed when other sites can’t

NB Heat loss

keep in a warm environment and keep clothed

NB at risk for hypothermia: all but mainly low birth weight and underdeveloped

Pulse Locations

  • Temporal: Temple

  • Radial: thumb side on inner wrist

  • Carotid: side of neck

  • Apical: 5th Intercostal Space, Midclavicular line

  • Brachial: elbow crease, pinky side

  • Femoral: Femoral Artery, inner thigh

  • Popliteal: behind the knee

  • Posterior Tibial: medial surface of ankle

  • Dorsalis Pedis: Middle of foot in between big toe and second toe line

Proper Technique for RR assessment

Sitting, place hand against chest or place clients arm across the chest

HTN

-Prehypertension: below HTN stage one, 120-129 S, <80 D

-Hypertension: above normal. S= 130+, D=80+

Highest risk for HTN: older adults, African Americans, Women before menopause

False Increase in BP: Improperly sized cuff, unsupported arm, repeating too quickly, rushing, etc

Hypothermia

Remove from the cold environment, remove wet clothes if applicable, SLOWLY rewarm the body

Thermoregulation Temp: Rectal

Perfusion

Central Perfusion: force of blood movement generated by cardiac output

Perfusion: Flow of blood through arteries and capillaries, delivering nutrients and O2 to cells

Chapter 29 Fundamentals: https://quizlet.com/425892240/chapter-29-vs-flash-cards/