Vrtrrt S,9 tls

Vs taken are-

temp, hr, bp, rr,o2 sat,pain scale which is subjective but none the

less v/s ;;i:r:":;;';;'-:*i:".i

Pts'conditions determine when q 4 hrs f*r in*atie;:i e.{{Ept f*r iorrg te;-rn r*r* *rrand by whom v/s should be taken if rne':is are uy's ri***r'r**tt ihai: i'n tai{es ihei"*

o{ l?il}}l, nt*

Nurse is ultimately responsible fsr ur pts vs, regardless of whetlrer u deligated to other ppl. Know baseline for ur pts!! Select appropriate equipment-tright size, right pt) and make sure eguipment works Know hx, meds, therapies Systematic approach works best! Nurse is responsible for judging how often v/s as measured depending on pts condition and recent --.:::'-' :i:lii:; hx example post-surgery, declining health...-:: ' '- :,:-'--

Make sure v/s are

Min

ranges for ur pt before administering any meds.

Communicate, document,

treat if needed after you inform hcp of changes'

the body and amount of heat lost to the

'|::i;

':.t::;;:.:. the difference between heat produced by

external environment.
Ranges from 36
.ir':..:

to 38 {96.8 to L0o.4} bc of surface temp. changes.

oral (17 /98.6f1, rectal, axillary, tympanig temporal artery, esophageal, pulmonary artery and urinary bladder
:"r::;:i:..ti:it,j- ]--:i1i'::::::'=i::.:..:t-r:::- Way the bOdy keepS temp. With in aCCeptable limitS SO that every tissue and cell can function. regulated by neuro and cardiac mechanisms hypotlralamus controls body temp. ( anterior controls heal loss, posterior controls heat production. ) aii*ua: t**:$. ta \,,ar.f ,1r: o,..hirh i= caiieci ih= s*i F*irii.
:;t-::'", :i.:,

i'

mechanisms of heat loss include- sweating, vasodilation, inhibiting of heat production and the body will redistribute blood to promote heat loss. ir*;iii,.l;.*.ri- tran$er from surfuce to surfuce yy/o direct contact ex- if its hot outside ur organs will eeiIilm;"Lgh radiation. 85% of bodies surfiace area radiates heat to the environment. i";r;::i:.;.:1,::r., loss of heat by air movement- { a fan on wet skin) evaporation- transfer of liquid is changed to a gas. About 600 to 9@mL evaporates from skin and -i-.1";; tyres *f he*t i*'ss are- ins*nsii:i* **rl*irati*n v*i:ich is l*ss af iluiris lungs a day tdiaphoresis) ia"'i**gh iungs {breat'1ing} *r:i :e*sibi* respir*li*rr i;lt* t:"'h*i'': 'gsi.i sleai"

mechanisms for increasing ternp. include- vasoconstriction, muscle contractiontshivering) can increase production up to 5x but pts burn more energ'y ( could be bad). Non-shivering thermogenisis occurs in neonates b/c they cant shiver. B[lR is responsible for how much heat is produced by the body at rest- may be affected bythyroid hoftrones, metabolism.
,*ci":':,1-r.rt:

*.i:'.*i::ii,

::i::r"it-;i:

\t

bOS{rSe

behavioral control- 1. degree of temp. extreme

.:-persons abiliry to sense feeling comf. Or uncomf.
3. thought process and emotions

4. persons ability or mobility to add or remove clothes.

Assess

for fis that pose a hiEh risk of inabiliw to thermgreeulate.

Factors affecting temp- exercise, hormone level, circadian rhythm, stress, and environment.

T:ai;:na, aiie i'ger:s

up with heat production. ';:v'i"i,=S,::::: responses.(a*? ienitr. r:uer 1*C.4 immune system elevate body temp. they act as antigens triggering
?';.t*::.,;:,^

feverl Happens when heat loss mechanisms cant keep

ie.":s:".i

l: c*i:siri*r*i

..-. \-/

During a febrile episode wbc's production increases. Concentration of iron in plasma decreases so that the bacteria cant grgw. Fevers fight infuction cuz they stimulate interferon whhh is the bodies naturalvirus fighter. Crllular metabolism increases and so does o2 consumption. Heart and resp. increase as well- prolonged fever= increased energy used which could be bad for a cardiac pt. bt for

fever should include o2:-:

t i:,8 ii..'':r.l'.:!;.'.i*- a n1r ts|Yi p.

b*ve L*5

"8 * l* i lV

: temfi. ai:*ve iC4 {r:*r ss pr*rI:-icti*i: *f hea'i biit f/s *f i:*dlrs irability i* i*se i,'eat- as in heat sir*k*. P;s tei:tp. is gai*g u* d*e tc s*b'ii.oi:*-r*ili. Heat supresses hypothalamic function s/s of i:+;i :;i,'riil*- giddiness, confusion, delirium, excess thirst, nausea, muscle cramps, visual disturbances and even incontinence * most important sign =hot, dry skin- severe electrolyte loss prevent sweating. Hypothermia- any temp. under 95.8. lethal is under 86' assessment of core temp. is critical in this pt.
l-i,,,:,-, .',

-,.

Oral temp- 97- 100'f it is considered a surface temp. pt must be able to close mouth. lt is contraindicated on unconscious, seizures, peds, mouth breathers and if pt. drank anything 30

prior,*Z v*i* nib.

Rectaltemp. 98.4- 99.8'f. h is considered a core temp. will always be 1' higherthan oral. Aiways rs.s3i glsr-rssll Ccr:train$icaii*n is pts v,,,ith he*rt di:*aE* cur it siimulates vag*s ileive v*hich aii*vt-c hea;"'l i* fili '*rit* exi.a .1is** sr:* ca* cair:e li:e eiteiiei iii tvi;c;at.
Axillary- 95.4- 98-8'f will be

t'

lowerthan oral and should be used only when oral and rectal are

contraindited.

Tympanic is considered a core reading only lf you do it the right way for adults pull ear back and up and for kids older than 3- up and back and for kids less than 3 is down and back. Chill phase happens when the hypothalamus increase the set point. The body needs to get to the required temp. so the surface blood vessels constrict and brings the blood to the core which is why pt will look pale. No sweat is created because body feels the need to conserve heat and will start to shiver in order to increase the temp to its new set point. The fever phase happens when the new set point has been reached. Care at this point is directed to keeping pt comfortable. Sometimes reducing a fever can be contraproductive because it can interfere with bodies ability to fight infection.
The flush or crisis phase happens when the set point re-sets itself

to normal again. Rapid dropping of temp. is called Qefefversense state . capillaries start to dilate which gives pt. flushed warm skin. Fluids are very important part of rns care. Room should be set slightly cooler and oral hygene should be done.
Pulse- palpable bounding of blood flow noted at varircus points of body. Approx. 6O.- 70mL of blood enter the aorta with each ventricular contraction{called stroke volume} the product of HR and sv is
called

theJffiiac output

ttiffi

d'------

Mechanical, neuro and chemical factors regulate the strength of venfficalcontraction and its stroke volume, horareyer when one of those is unahh to alter $ie stroke volume, the hr will change which will result in a change of cardiac output. When cardiac output decreases significantly, peripheral pulses weaken and are hard to palpate.
Decreased bp = increased HR because the bodywillcompensate. Decrease 02 availability will increase
hr.

Pulse'should be calculated by taking it for 30secs- Unless its irregutar or apical than you do it for a

minute

Pulse quality and amplitude is measured in #s.

o=

absent

-r-

+1= thready or weak (when you squeeze the pulse disappears)

+2= normal +3= bounding (will not disappear when squeezed) Assessment sites are=

r o o r o r r .

TemporalCarotid
Radial

Brachial Femoral

*
toQoilod

Popliteal
Dorsalis pedis

Posterior tibialis

z.'{oN

intermstals space at left midclavicular line. The Eglss pulse-it is created when an inefficient contraction the between the radial and apical difference IgEt of the heart fails to transmit a pulse wave {o the peripheral pulse site and are often associated with abnormal rhythms. ('ArvtVrl+nmia)
is
r---'

Apical pulse is measured between

tte$ggd.g

/eN5
,l/

Rspiratbn is the process of ventilation, perfusion and diffusion which is controlled levels in the arterial blood oblongata. The most important factor in the control of ventilation is the co2 for these pts hieh level of unless the pt suffers from hypoxemia then 02 would be the stimulus therefore 3o{orpm. when measuring resps 02 could be fatal. ttormaf-akft-m-tesare 12-20 rpm, and for infants = by illness, fever, you need to note il they are shalloddeep. Deviations from normal could be caused
pain, stress, excersice, altitude, body positioning.

by the medulla

Dggs

could be caused by q3tcs or cns

Fepressants.

the pulsing blood under pressure from Blood pressure is the force exerted on the walls of an artery by peripheral vascular resistance, blood the heart. lt reflscts the interrelationship of cardiac output, alter b/p. arterioles are volume, blood viscosity and artery elasticity. Any changes in any of these will always partially contracted which created peripheral resistance. Left ventricle pushes blood out of Systolic b/p is the peak of maximum pressure when ejection occurs. the aorta
walls at all times. constant pressure, Diastolic b/p is the minimal pressure exerted against the arterial most concern when its high and the pt is at rest' pulse pressure is the difference between the systolic and diastolic pressures. 120/80 pp=40 pm), gender (women have lower bp Factors affecting BIP includr: age, time of dayt low in am hiBh in Always watch for dizziness than men), eatint- bbod goes toitomach during digestion which lowers bp. when sitting.), activity (pulse after meals. ) emotions, position (decreases when laying down, increases increase b/p) pressure inereases as well as bp during exercise, and talking or listening can also loss b/c lost burns{fluid by caused Hy*tension is less than 90 systolic, decreases risk for cva, can be long bed rest' pts on that are diarrhea, bulimia, Ml. orthostatic b/p should be checked on prot"inl

-+

\a

pt has posilivelqrthostatic ' An increase of pulse more than 20 means the.bp has dropped and

nfv,

s*anclinX thembackdown. * mUSf DO 3 affiX lower arm. lf pt has lv do / F contraindicatiom for iite selection include= AV fissula, mastectom% Plc line,
+i-rrtV aoon
should be widthit in the other arm or thigh. For proper measurements the bladder of the cuff timb circumference and Lngth= 80% of limb

z)Si+'op ?)

bp.

Lay

4o96of

circumference.

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