RLE

• Vital signs


  Reflect the body's physiologic status & ability to regulate temperature, maintain local and systemic blood flow, & oxygenate tissues
• Oxygen saturation


  How much oxygen does your blood have, usually checked by pulse oximeter
• Vital signs


  • Body temperature
  • Pulse
  • Respiration
  • Blood pressure
  • Pain
• Vital signs monitoring should not be an automatic or routine procedure. Instead, it should be thoughtful and scientific.
• When and how often should nurse assess vital signs

  1. On admission

  2. Institution Policy

  3. Before & after invasive procedure

  4. Before & after administration of medications

  5. Change in client's condition

  6. Before & after a nursing intervention
• Body temperature


  Reflects the balance between the heat produce and heat loss, measured in heat units called degrees

  
• Types of body temperature

  • Core temperature
  • Surface temperature
• Heat production


  • Basal Metabolic Rate (BMR)
  • Muscle activity
  • Thyroxine output
  • Stress
  • Fever
• Heat loss


  • Radiation
  • Conduction
  • Convection
  • Evaporization
• Factors affecting body temperature

  • Age
  • Diurnal variations (circadian rhythms)
  • Exercise
  • Hormones
  • Stress
  • Environment
• Pyrexia


  Abnormally high body temperature, also known as hyperthermia or fever
• Types of fever


  • Intermittent fever
  • Remittent fever
  • Relapsing fever
  • Constant fever
  • Fever spikes
• Vital signs


  Reflect the body's physiologic status & ability to regulate temperature, maintain local and systemic blood flow, & oxygenate tissues

  
• Oxygen saturation


  How much oxygen does your blood have, usually checked by pulse oximeter
• Vital signs


  • Body temperature
  • Pulse
  • Respiration
  • Blood pressure
  • Pain
• Vital signs monitoring should not be an automatic or routine procedure. Instead, it should be thoughtful and scientific.
• When and how often should nurse assess vital signs

  1. On admission

  2. Institution Policy

  3. Before & after invasive procedure

  4. Before & after administration of medications

  5. Change in client's condition

  6. Before & after a nursing intervention
• Body temperature


  Reflects the balance between the heat produce and heat loss, measured in heat units called degrees

  
• Types of body temperature

  • Core temperature
  • Surface temperature

  
• Heat production


  • Basal Metabolic Rate (BMR)
  • Muscle activity
  • Thyroxine output
  • Stress
  • Fever
• Heat loss


  • Radiation
  • Conduction
  • Convection
  • Evaporization
• Factors affecting body temperature

  • Age
  • Diurnal variations (circadian rhythms)
  • Exercise
  • Hormones
  • Stress
  • Environment
• Pyrexia


  Abnormally high body temperature, also known as hyperthermia or fever
• Types of fever


  • Intermittent fever
  • Remittent fever
  • Relapsing fever
  • Constant fever
  • Fever spikes
• Fever resolution


  • Resolution-by-crisis
  • Resolution-by-lysis
• Hypothermia


  Reflects body temperature that is lower than normal

  
• Types of hypothermia


  • Accidental
  • Induced
• Common sites for measuring body temperature

  • Oral
  • Rectal
  • Axillary
  • Tympanic

  
• Types of thermometers


  • Mercury-in-glass
  • Electronic
  • Chemical Disposable
  • Temperature-sensitive tape
  • Infrared
  • Temporal Artery
• Temperature scales


  • Celsius centigrade
  • Fahrenheit

  
• Pulse


  Wave of blood created by contraction of the left ventricle of the heart, represents the stroke volume output and the amount of blood that enters the arteries with each ventricular contraction
• Compliance


  Ability to contract and expand
• Cardiac output


  The volume of blood pumped into the arteries by the heart, CO = SV x HR
• Peripheral pulse


  A pulse located away from the heart
• Apical pulse


  A central pulse located at the apex of the heart
• Pulse sites


  • Temporal
  • Carotid
  • Brachial
  • Radial
  • Femoral
  • Popliteal
  • Posterior Tibial
  • Dorsalis Pedis
  • Apical
• Reasons for using pulse sites

  • Radial
  • Temporal
  • Carotid
  • Apical
  • Brachial
  • Femoral
  • Popliteal
  • Posterior Tibial & Dorsalis Pedis
• Assessing the pulse


  • Palpation (hand)
  • Auscultation (stethoscope)
  • Doppler Ultrasound Stethoscope
• Things to note when assessing the pulse

  • Rate
  • Rhythm
  • Volume
  • Arterial wall elasticity
  • Presence or absence of bilateral equality

  
• Tachycardia


  Excessively fast heart rate