Ch 24 Ex 2 Lec A
4 Classic Vital signs in order
Temp, Pulse, Resp, B/P
12 - 20
what else could be used to take VS (vital signs)?
pulse ox or a pain reading (but not really VS
What is the silent killer
120-139 over 80-89
high b/p stage 1
140-159 over 90-99
high b/p stage 2
>/= 160 over 100
After you take VS what is the 1st thing you need to do? What is the 2nd thing?
Compare them with the normal and then compare with pt. normal
If pt VS are off what 2 things should you ask yourself?
Why are the pt VS off? What is the cause?
The standard for taking VS
Also take VS when you are concerned about
pt is sweaty, confused, dizzy, unconscious, traumatic injury, fall
take VS per policy and procedures. Post-Op & Pre-op Ex. used was post-op. Most concern was___ b/c of ___
heart rate b/c of bleeding
If pt is bleeding w/happens to pulse rate? B/P? Blood volume? The beat? Respiratory rate?
Faster. Down. Down. Faster and Faster. UP. (why-body is trying to get ox
If a person were in pain what VS would be altered
B/P, Pulse Respiratory
VS of T-101.2, P-110, R-24, B/P-120/81. What might this indicate?
VS of T-101.2, P-110, R-24, B/P-124/84. Which one of those should be of the most concern?
Temp. (the others are not that far off)
When to assess VS
Admission, per policy and procedure, Before and after invasive procedures, Before and after activity. Before and after Meds
Central Line (central IV), Needle into chest to pull off fluid, endoscopy or colonoscopy are what type of procedure? If one of these are being done when would VS be taken
invasive. Before and after, maybe during
VS are to be taken before and after meds. Give 3 ex of why?
Receiving med 1st time. 1st time getting out of bed after surgery. Getting up after having a baby. CNS depressants
Diuretic-Diuril, Lasix, Lozol. K sparing-Aldactone, Dyrenium. Loop diuretic-bumetanide. Beta Blockers- atenolol. Ace Inhibitors- catopril. Angiotensin II receptor blockers-irbesarten, valsartan. ETC.
Meds that we are concerned with and VS need to be taken? Which one did she make a huge point about?
B/P, Beta Blockers, *any Cardiac. CNS depressants (she said any CNS med can alter VS and 1st time giving VS have to be checked)
1st VS to be taken?
According to text what is the normal range
97 F- 99.5 F
Core temps that can be taken? People don't like them b/c they are considered? What is the preferred way to take a core temp?
Rectal and Tympanic. Invasive. Tympanic
Temp time of day Lowest__? Highest__? Females it will change due to __
Morning. Evening. Hormones
Thermoregulation in Older are not able to maintain heat as well B/C
Not as active. They don't have as much fat.
Men have a higher temp than women up till
Stress causes a ___ response of ___ &___.
Sympathetic. epinephrine and norepinephrine
Caused by exposure to heat or cold and both can lead to death? Body functions at its maximal capacity at?
hyperthermia or hypothermia. 97 F -99.5 F
Body compensates with __ when we are invaded by microorganisms. The ___ controls body heat.
Involuntary way to produce heat? Voluntary?
Who are we must concerned with loss of heat
When baby is born and covered with mucous the nurse wipes it off to prevent? Once it is wrapped it is put into a ___
Evaporation. Radiant warmer (Incubator)
Fan running on a person, they will loss heat by__. People sitting by a closed window loss heat by ___. Man leans on a cold wall he will loss heat by___. Your husband puts his cold, nasty toes on your hot leg, you give him heat by__
Convection. Radiation. Conduction. Conduction
Person is touching you__. When they sit next to you sucking up your warmth__
Man is in ICU and has a temp of 103.6 F (___) & Doc want to ↓↓ temp. The doc would order an___ and ___ if it is infection. But you can't let fevers get tha high b/c it will cause___
Hyperthermia. Antipyretic & Antibiotics. Seizures
If you put ice packs under arm pits or in the groin man will loss heat by? If that man is given a tepid sponge bath he will loss heat by __ & __
Conduction. Evaporation and conduction. Loss of heat due to being wet & cold object touching them
97 F - 98.6 F
100.4 - 104
105.8 - 111.2
Death would occur hyperpyrexia
Death would occur hypothermia
95 F - 93.2
With temp you need to know pt ___ b/c many people naturally run low temp. Grandma's temp might run__
Doc's make judgement if it is __degrees higher or lower than normal & that would be a fever for that pt
Fevers that go away on their own-called____. Redness and swelling is a sign of ___. What would be another sign ____
Self-Limiting. Inflammation. Temp
The body temp alternates regularly b/w a period of fever and a period of normal or subnormal temp
The body temp fluctuates several degrees more than 2 C (3.6 F) above normal but does not reach normal fluctuations
The body temp remains consistently elevated and fluctuates less than 2 C. (3.6 F)
The body temp returns to norm for at least a day, but then the fever recurs
The fever returns to normal suddenly
The fever returns to normal gradually
Oral fluids are given to maintain __and __ __, & prevent___
cellular and intravascular status and prevent dehydration
__ __ are included in the diet to prevent tissue breakdown form the hypermetabolic state
Thediffusion or dissemination of heat by electromanetic waves
The dissemination of heat by motion b/w areas of unequal density
The conversion of a liquid to a vapor
The transfer of heat to another object during direct contact
The body gives off waves of heat from uncovered surfaces
An oscillating fan blows currents of cool air across teh surface of a warm body
Body fluid in the form of perspiration and insensible loss is vaporized from the skin
The body transfers heat to an ice pack, causing the ice to melt
__ fever is the result of damage to the hypothalamus from pathologies such as intracranial trauma, intracranial bleeding, or ↑↑ incranial pressure. Do antipyretic Meds work (Yes or NO). A fever of 38.3 C/101 F or higher for 3weeks or longer w/out known cause is called___
Neurogenic. NO. Fever of unknown origin (FUO)
Happens nearly every 24 hours
May remain open on the surface of the skin during exercise or a hot day to allow heat to dissipate. ___ nervous system controls this. It would allow heat to __ on a hot day
arterioveonous shunts. Sympathetic. Evaporate