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61 Cards in this Set
- Front
- Back
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What are the vital signs?
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Temperature, Respirations, Pulse, Blood Pressure, Pain
also Oxygen Saturation |
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When should vital signs be assessed?
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-On admission
-When there are reports of nonspecific symptoms of physical distress -before/after surgery or invasive procedure -before/after meds that could alter VS -before/after nsg interventions that could alter VS |
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______ reflects the difference between heat production and heat loss.
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Body temperature
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The normal range for body temperature is ____.
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98.6-100.4° F
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Heat loss can occur thru:
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radiation
conduction convection vaporization/evaporation |
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_____ is the transfer of heat energy from one surface to another object without contact. ex. taking a hat off
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Radiation
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______ is the transfer of heat energy from one molecule to a molecule of lower energy with contact.
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Conduction
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______ is the transfer of heat by air movement, usually currents. ex. fan blowing cool air over the body.
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Convection
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_____ is the transfer of heat energy when conversion of liquid to gas/vapor occurs. ex. sweat
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Evaporation/Vaporization
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_____ are the body's inner clock that are pretty consistent throughout the day.
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Circadian Rhythms
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____ and ____ are more susceptible to temperature changes.
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Infants and Elderly
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_____ temperatures fluctuate more because of hormonal changes.
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Females
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Stress leads to _____ metabolic activity and heat production.
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increased
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Medicines that lower fever are called _____.
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antipyretics
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_____ fever is when the body temperature alternates at regular intervals between fever and no fever.
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Intermittent
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_____ fever is when there is a wide range of temperature fluctuations during a 24 hr period.
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Remittent
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_____ fever is when short febrile periods of a few days are interspersed with periods of 1 or 2 days of normal temperature.
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Relapsing
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_____ fever is when the body temperature fluctuates minimally but always remains above normal.
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Constant
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Pyrexia is also known as _____.
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hyperthermia
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Clinical manifestations at the onset of a fever include:
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↑ heart rate
↑ respiratory rate and depth shivering pallid, cold skin complaints of feeling cold cyanotic nail beds "gooseflesh" appearance of skin cessation of sweating |
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Clinical manifestations during the course/plateau phase of a fever include:
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absence of chills and skin that feels warm
photosensitivity glassy-eyed appearance ↑ Pulse and Respiratory rates ↑ Thirst Mild to severe dehydration drowsiness, restlessness, delirium, convulsions herpetic lesions of mouth loss of appetite malaise, weakness, aching muscles |
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Clinical manifestations of fever during the defervescence (fever abatement/Flush) phase are:
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skin that appears flushed and feels warm
sweating decreased shivering possible dehydration |
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Nsg interventions for clients with fever are:
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monitor vital signs
assess skin color and temp monitor WBC count, HcT value and other lab work remove excess blankets when client feels warm provide extra warmth when client feels chilled provide adequate nutrition/fluids and measure intake/output reduce physical activity to limit heat production Administer antipyretics provide oral hygiene to keep moist oral muc. mem. Give tepid sponge bath to promote heat loss provide dry clothing and bed linens |
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Nsg interventions for a client with fever are designed to ______ normal physiologic processes provide _____ and prevent ______.
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support, comfort, complications
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_______ is an elevated body temperature related to the body's inability to promote heat loss or reduce heat production.
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Hyperthermia
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Hyperthermia is a result of an overload of the body's _____.
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thermoregulatory mechanisms
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2 complications of hyperthermia are:
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heat stroke and heat exhaustion
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____ is a condition caused by failure of the body's heat regulating mechanisms during or after exposure to heat and high relative humidity.
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Heatstroke
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The body temperature of a heat stroke victim can be as high as _____.
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106°F
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↑ heart rate, ↑respirations, ↑BP near beginning and ↓BP at end, confusion, excessive thirst, lack of sweat, nausea, dizzy, pale, hot skin, delirious, unconscious, and seizures are all indicative of _____.
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heat stroke
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Prevention of a heat stroke can be done by _____.
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staying hydrated and avoid wearing excessive clothing.
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______ occurs when profuse diaphoresis results in excess water and electrolyte loss.
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Heat exhaustion
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The main diff between heat stroke and heat exhaustion is
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the body temp doesn't get as high during heat exhaustion
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If heat exhaustion occurs you should...
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get the person to a cooler environment and get them hydrated.
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If a heat stroke occurs, you should...
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get the person inside, use cooling blankets, ice packs, etc... until you can get them to ER.
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____ is when heat loss during prolonged exposure to cold, overwhelms the body's ability to produce heat.
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Hypothermia
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In ____ more heat is lost than produced.
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hypothermia
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Clients at risk for hypothermia include:
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malnourished and intoxicated
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2 types of hypothermia are:
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accidental and induced
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Insufficient clothing or immersion in cold water are reasons for ____ hypothermia.
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accidental
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Deliberately lowering the body temperature to decrease the need for oxygen by the body tissues is ______ hypothermia.
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induced
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Clinical manifestations of hypothermia include:
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see p538 in book
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Nursing interventions for hypothermia include:
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see p 538 in book
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Name 5 locations that body temperature is measured:
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oral
axillary tympanic membrane rectal temporal artery |
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Types of thermometers are
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glass/plastic
electronic temperature sensitive tape infrared (tympanic) temporal artery |
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An electronic thermometer takes _____.
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2-3 seconds
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The least reliable type of thermometer is _____.
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temperature sensitive tape
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The time for oral temperature assessment with a glass thermometer is _____.
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3 minutes
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The time for rectal temperature assessment with a glass thermometer is ______.
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3 minutes
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The time for axillary temperature assessment with a glass thermometer is ______.
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2 mintues
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When taking an oral temperature assessment, do the following...
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identify client
explain procedure to client wash your hands place thermometer under client's tongue (close down not bite down) remove and read thermometer to the nearest tenth |
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The normal oral temperature is ____.
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98.6ºF
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If someone has an oxygen mask, take their temperature _____.
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axillary
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When taking an axillary temperature assessment, do the following...
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make sure under arm is completely clean and dry
place bulb of thermometer in the center of axilla and bring client's arm down close to the body remove and read |
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Normal axillary temperature is ______.
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97.5ºF - 97.6ºF
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When taking rectal temperature, you should...
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put on gloves
position client for comfort separate buttocks and insert lubricated thermometer remove and wipe thermometer with tissue wipe the anus of any feces and remaining lubricant |
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How far should you insert a rectal thermometer for infants?
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1/2 inch
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How far should you insert a rectal thermometer for a child?
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1 inch
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How far should you insert a rectal thermometer for an adult?
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1 1/2 inches
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When taking a tympanic assessment for a child under the age of three what do you do?
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pull the pinna back and down
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When taking a tympanic assessment for a child over the age of three what do you do?
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pull the pinna straight back and upward
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