health assessment midterm

• Vital Signs

  • Body Temperature
  • Pulse
  • Respiration
  • Blood Pressure
• Vital Signs


  Indicators of effectiveness of circulation, respiratory, neural, and endocrine body functions
• Baseline data


  Basis if the patient may have changes to compare if there is improvement
• Hypertension


  • Increase in blood pressure / high blood
• Hypotension


  • Decrease in blood pressure / low blood
• Tachypnea


  • Increase in respiratory rate
• Bradypnea


  • Decrease in respiratory rate
• Tachycardia


  • Increase in cardiac rate/heart rate
• Bradycardia


  • Decrease in cardiac rate / heart rate
• Guidelines for Measuring Vital Signs

  1. Measuring vital signs is the nurse's responsibility

  2. Assess equipment to ensure it is working correctly and provides accurate findings

  3. Select equipment based on patient's condition and characteristics

  4. Know the patient's usual range of vital signs

  5. Know patient's medical history, therapies, and prescribed medications

  6. Control or minimize environmental factors that affect vital signs

  7. Use an organized, systematic approach

  8. Collaborate with health care providers to decide the frequency of taking the vital signs

  9. Use vital sign measurements to determine indications for medication administration

  10. Analyze the results of vital signs measurement on the basis of the patient's condition and past medical history

  11. Verify and communicate significant changes in vital signs
• When to Take Vital Signs

  1. Rest for 5 minutes or sit before checking vital signs

  2. Upon admission to a health facility

  3. When assessing during home visits

  4. Routine schedule in a hospital

  5. Before, during, and after blood transfusion

  6. Before, during, and after the administration of medication or therapies that affect cardiovascular, respiratory and temperature functions

  7. When a patient's general physical condition changes

  8. Before, during, and after nursing interventions influencing a vital sign

  9. When a patient reports non-specific symptoms of physical distress
• Body Temperature


  Difference between amount of heat produced by body processes and the amount lost to the external environment
• Febrile


  Refers to having a fever, which means an elevated body temperature above the normal range
• Afebrile


  Refers to not having a fever, indicating that the body temperature is within the normal range
• Core Temperature


  Temperature of deep tissues, relatively constant, depends on blood flow to the skin and the amount of heat loss to the external environment
• Surface Temperature

  Temperature of the skin
• Body Temperature Regulation

  1. Thermoregulation - balance between heat loss and heat produced

  2. Neural and Vascular control

  3. Heat Production

  4. Heat loss

  5. Skin in temperature regulation

  6. Behavioral control
• Anterior Hypothalamus


  • Controls heat loss
• Posterior Hypothalamus


  • Controls heat production
• Basal metabolism


  Accounts for the heat produced by the body at absolute rest
• Shivering


  An involuntary body response to temperature differences in the body
• Non-Shivering Thermogenesis


  Occurs in neonates, a limited amount of vascular tissue present at birth is metabolism for heat production
• Radiation


  Transfer of heat from the surface of one object to the surface of another without direct contact between the two
• Conduction


  Transfer of heat from one object to another with direct contact
• Convection


  Transfer of heat away by air movement
• Evaporation


  Transfer of heat energy when a liquid is changed to a gas
• Diaphoresis


  Visible perspiration primarily occurring on the forehead and upper thorax
• Skin in Temperature Regulation

  Insulation of the body, vasoconstriction, temperature sensation
• Behavioral Control


  Ability to control body temperature depends on degree of temperature extreme, person's ability to sense feeling comfortable or uncomfortable, through thought or emotions, and person's mobility or ability to remove or add clothes
• Factors Affecting Body Temperature

  • Age
  • Exercise
  • Hormone level
  • Circadian Rhythm
  • Stress
  • Environment
  • Temperature Alterations
• Infants


  • Immature temperature-control mechanisms, lose up to 30% of body heat through the head, normal body temperature 35.5 to 37.5 degrees centigrade
• Exercise


  Muscle activity requires an increased blood supply and carbohydrate and fat breakdown
• Hormone Level


  Women generally experience greater fluctuations in body temperature than men, progesterone levels rise and fall during the menstrual cycle, ovulation increases body temperature, menopause causes intense body heat and sweating (hot flashes)
• Circadian Rhythm


  Body temperature is lowest between 1:00-4:00 am, rises steadily during the day to a maximum at about 4:00 pm
• Stress


  Physical and emotional stress increases body temperature through hormonal and neural stimulation
• Environment


  Warm room/environment increases temperature, cool room/environment decreases temperature
• Fever/Pyrexia


  Heat loss mechanisms are unable to keep pace with excessive heat production, resulting in an abnormal rise in body temperature, caused by an alteration in the hypothalamic set point
• Clinical Signs of Fever

  1. Onset (Cold or Chill Phase): Increased heart rate, increased respiratory rate and depth, shivering, pallid cold skin, complaints of being cold, cyanotic nailbeds, "gooseflesh" appearance, cessation of sweating

  2. Course (Plateau Phase): Absence of chills, warm skin, photosensitivity, glassy-eyed appearance, increased pulse and respiratory rate, increased thirst, mild to severe dehydration, drowsiness, restlessness, delirium or convulsions, herpetic lesions of the mouth, loss of appetite, malaise, weakness and aching muscles

  3. Defervescence (Fever Abatement/Flush Phase): Flushed warm skin, sweating, decreased shivering, possible dehydration
• Fever


  An important defense mechanism, mild temperature elevation as high as 39 degrees centigrade enhances the immune system, stimulates WBC production, reduces concentration of iron in the blood plasma suppressing the growth of bacteria, fights viral infection by stimulating infection of the natural virus-fighting substance of the body
• Hyperthermia


  Elevated body temperature related to the inability of the body to promote heat loss or reduce heat production, results from an overload of the thermoregulatory mechanisms of the body due to disease or trauma to the hypothalamus