fnp 2

• VITAL SIGNS

  ●      “Cardinal signs”

  ●      Indicators of an individual's health status

  ●      Monitor functions of the body
• When to asses VS?

  ●      On admission

  ●      Change in client’s health status

  ●      Client reports symptoms such as chest pain, feeling hot, or faint

  ●      Pre and post surgery/invasive procedure

  ●      Pre and post medication administration that could affect CV system

  ●      Pre and post nursing interventions that could affect vital signs
• Thermoregulation

  ○      A balance between heat produced and heat lost from the body
• Thermogenesis

  ○      Heat is produced through metabolism
• ●      Hypothalamus

  Temperature regulating center
• ●      Anterior hypothalamus

  ○      Senses if body temperature is beyond the set point

  ○      Controls heat loss
• ●      Posterior hypothalamus

  ○      Senses if body temperature is lower than the set point

  ○      Controls heat production
• MOST RELIABLE IS ANAL ROUTE/RECTAL - but only done once which is at birth
• Kinds of Body Temp

  1. Core
  2. Surface
• Core:   Temperature of deep tissues

  cranium, thorax, abdominal cavity, pelvic cavity

  ● Take through the rectum, tympanic membrane, esophagus, pulmonary artery, urinary bladder)

  Relatively constant at 37°
• Surface

  ●      Temperature of the skin, subcutaneous tissues, fats

  ●      Rise and fall in response to the environment

  ●      36° - 38°
• Factors that Affect Heat Production

  • Basal metabolism
  • BMR (Basal Metabolic Rate)
  • Muscle ActivityStimulation of thyroid gland

  Stimulation of SNS

  Increase in  Body Temp (Fever)
• Basal

  metabolism: Energy produced at rest
• BMR (Basal Metabolic Rate): Rate of energy utilization to maintain essential activities; decreases with age (younger = higher BMR)
• Muscle Activity: Shivering, exercise, increased metabolic rate
• Stimulation of thyroid gland: ●      (Thyroxine output)

  Increased rate of cellular metabolism (chemical thermogenesis)
• Stimulation of SNS: ●      EPINEPHRINE, NOREPINEPHRINE & SYMPATHETIC STIMULANTS

  Increased metabolism
• Increase in  Body Temp (Fever): -        Increased metabolic rate

  For every 1℃ increase, 12% increase in chemical reaction
• Heat is LOST THROUGH: Radiation, conduction, convection, evaporation
• RADIATION

  transfer of heat from one surface to another without contact between surfaces
• CONDUCTION

  transfer of heat from one molecule to another & that are in contact with one another

  -        Ex. body immersed in cold water
• CONVECTION

  Dispersion of heat through air currents

  -        Ex. opening windows in a hot room
• EVAPORATION

  Vaporization of moisture from the respiratory tract & from mucosa of the mouth and the skin leads to insensible water loss, thus, leading to insensible heat loss (10%-basal heat loss)

  -        When body temp increases, vaporization accounts for greater heat loss

  • -        Diaphoresis visible respiration
• Factors Affecting Body Temperature

  ●      Age

  ●      Diurnal variations (circadian rhythms)

  ●      Exercise

  ●      Hormones

  ●      Stress

  ●      Environment
• Alterations in Body Temperature:

  1.  Pyrexia, hyperthermia, fever
  2. Hyperpyrexia
  3. Hypothermia
  4. Heat stroke
  5. Heat exhaustion
• Pyrexia, hyperthermia, fever

  ●      Above normal

  ●      38° - 40°C
• Hyperpyrexia

  ●      Very high fever

  ●      41°C and above
• Hypothermia

  ●      Subnormal or below normal level of core temperature

  ●      Severe hypothermia

  ○      decreased rate of heat production

  ○      Sleepiness and coma

  ○      Further depress the activity of heat control mechanisms

  ●      3 physiologic mechanisms of Hypothermia::

  a.     Excessive what loss

  b.     Inadequate heat production to counteract heat loss

  c.     Impaired hypothalamic thermoregulation
• Heat stroke

  ●      Prolonged exposure to sun or high environmental temperatures

  ●      Signs and symptoms:

  ○      Hot, dry skin (due to hypothalamic malfunction)

  ○      Confusion

  ○      Delirium

  ○      Muscle cramps

  ○      Nausea

  ○      Very high fever as high as 45°C

  ○      Increased heart rate

  ○      Excess thirst

  ○      Visual disturbances

  ○      incontinence
• Heat exhaustion

  ●      Occurs when there is profuse diagnosis resulting to excess water and electrolyte loss

  ●      Signs and symptoms:

  ○      Diaphoresis

  ○      Hypotension

  ○      Weakness

  ○      Normal pulse
• FOUR TYPES OF FEVER

  • Intermittent
  • Remittent
  • Relapsing (me)
  • Constant
• Intermittent

  Alternate fever & normal temp

  -        Ex. malaria
• Remittent

  Fluctuations (more than 2℃) occurs over the 24 hr period but remains above normal (cold or influenza)
• Relapsing (me)

  Febrile for a few days then with 1 or 2 days normal temperature
• Constant

  Temperature fluctuations minimally but consistently above normal

  -        Ex. typhoid fever
• • Fever strike temperature that rises to fever level rapidly following a normal temperature, returns to normal within few hours

  Ex. bacterial blood infections
• TEMPERATURE: Lifespan Considerations

  1. Infants

  • Unstable
  • Newborns must be kept warm to prevent hypothermia

  2. Children

  • Tympanic or temporal artery sites preferred

  3. Elders

  • Tends to be lower than that of middle-aged adults
• CLINICAL MANIFESTATIONS (Temp)

  • ONSET (Cold or chill stage)
  • PLATEAU (Course)
  • DEFERVESCENCE
• ONSET (Cold or chill stage)

  ●      Complaints of feeling cold cyanotic nail beds gooseflesh appearance of the skin cessation of sweating

  ○      Increases HR

  ○      Increases RR and depth

  ○      Shivering

  ○      Cold skin
• PLATEAU (Course)

  ●      Skin warm and dry

  ●      Glassy eyed appearance

  ●      Increased thirst

  ●      Drowsiness, restlessness, delirium, convulsion

  ●      Loss of appetite

  ○      Chills subside

  ○      photosensitivity