Test 1

• Afebrile

  Without fever
• Pyrogens

  Substances that cause fever
• Hyperthermia

  High body temperature
• Hypothermia

  Low body temperature
• Tachycardia

  Rapid heart rate
• Bradycardia

  Decreased heart rate
• Tachypnea

  Increased respiratory rate
• Bradypnea

  Decreased respiratory rate
• Apnea

  Periods when no breathing occurs
• Dyspnea

  Difficult or labored breathing
• Orthopnea

  Changes in breathing when sitting or standing
• Hyperventilation

  Increased rate and depth (extreme exercise, fever)
• Hypoventilation

  Decreased rate and depth (irregular, overdose of narcotics)
• Cheyne-stokes

  Alternating periods of deep, rapid breathing followed by periods of apnea (typically seen in dying patient, drug overdose, heart failure)
• Dysrhythmia

  Irregular pattern of heartbeats (must report immediately)
• When to Assess Vital Signs

  • On admission
  • Based on policy
  • Any time change in patients condition/ loss of consciousness
  • Before/after surgical or invasive procedure
  • Before/after activity that may increase risk, such as ambulation after surgery
  • Before/after administration of meds that affect heart and respirations
• Delegation

  • As nurse cannot delegate teaching of a patient
  • When delegating: must make sure person (UAP) knows skills
  • If patient is unstable or change in vitals- CANNOT delegate vitals
  • Nurse's responsibility to ensure accuracy or the data, and report abnormal findings
• Medical diagnosis

  What brings patient to the hospital
• Patients level of acuity

  How sick patient actually is
• Interventions for fever

  1. Light clothing

  2. Antipyretics (need order)

  3. Increase fluids
• Signs of fever

  • Shivering
  • Dehydration
  • Sweat
  • Body's natural response to reduce temperature
• How does patient with fever present

  • Loss of appetite
  • Headache
  • Hot/ dry skin
  • Flushed in face
  • Thirst
  • Fatigue
  • Muscle aches
  • Increased respiration
  • Pulse rate
  • In older adult: delirium or delusion, confusion
  • In younger children: seizures
• Vital Signs

  • Body Temperature 96.7-100.5
  • Pulse Rate 60-100 (newborns have higher pulse rate/ older adults have lower pulse rates)
  • Respirations 12-20
  • Blood Pressure 120/80
  • Pulse Ox 95-100%
• Circadian rhythm

  24 hour sleep cycle, typically temperature is lowest in the morning
• Body temperature in older adults

  Maybe lower due to impaired thermoregulation response
• Pulse amplitude

  • 0 Absent
  • +1 Diminished, Weaker than expected
  • +2 Brisk, expected, normal
  • +3 Bounding
• Sites for Pulses

  • Temporal
  • Carotid- Neck
  • Brachial- pinky side, elbow
  • Radial- thumb side
  • Femoral- groin
  • Popilteal- behind knees
  • Posterior tibial- inside ankle
  • Dorsalis pedis- on top of foot
• Oral and rectal route

  NOT preferred for child under 5/ older confused patient/ or someone who just had oral surgery
• Rectal temperature

  Thermometer probe into the anus about 1.5 in in an adult or no more than 1 in in a child
• Oral temperature

  Sublingual; use protective probe, make sure patient can hold probe under tongue, close lips [if patient had something to eat or drink; wait 15-30 minutes after]- AVOID glass thermometers
• Axillary temperature

  The armpit; place in middle of axilla - most common for neonates
• Temporal temperature

  Swiped over the skin; forehead and back of ear
• Tympanic temperature

  Ear; can be used on adults/children for child pull down and back… for adult pull up and back on pinna [large wax deposit/ smaller canal/ wrong position could affect accuracy of temperature]
• Rhythm

  Regular or irregular
• Amplitude/ quality

  Strong or weak
• Apical pulse

  Found on left mid clavicular line, fifth intercostal space, listen for 1 minute
• Pulse deficit

  Difference between apical and radial pulse; which indicates that all of the heartbeats are not reaching in the peripheral arteries or are too weak to be palpated [need 2 nurses] assess the apical and radial pulse together for 1 minute
• Eupnea

  Normal/ unlabored breathing
• Listening Korotkoff sounds

  • Systolic (measurement of contraction of ventricles) typically 100-140- can be affected with emotional state
  • Diastolic (relaxation of ventricles) typically 60-90
• Pulse pressure

  Difference between systolic and diastolic pressure