Funda (semi)

• Vital signs


  Important measures of a client's body temperature (T), Pulse (P) rate, Respiratory (R) rate and blood pressure (BP)
• Vital signs

  • Temperature
  • Pulse rate
  • Respiratory rate
  • Blood pressure
  • Oxygen saturation
  • Pain
• Vital signs are a health status indicator
• Vital signs are the first step in the physical examination
• Change in vital signs

  Indicates a change in health
• When to assess vital signs

  • On admission
  • Before and after surgery/invasive procedure
  • Before and after medication administration
  • Before and after nursing interventions that could affect vital signs
• Body temperature


  Measure of heat of the body in degrees
• Thermoregulation


  • Core body temperature remains relatively constant (36°C to 37.55°C)
  • Surface body temperature can be influenced by the environment
• Hypothalamus


  Part of the brain that controls body temperature
• Heat balance


  Amount of heat produced by the body equals the amount of heat lost
• Heat production


  • Metabolism
  • Muscle activity
  • Thyroid hormone
  • Epinephrine/norepinephrine
  • Inflammation/fever
• Mechanisms of heat loss

  • Convection
  • Evaporation
  • Conduction
  • Radiation
• Regulation of body temperature


  • Shivering increases heat production
  • Sweating inhibited to decrease heat loss
  • Vasoconstriction decreases heat loss
• Afebrile


  A person with normal body temperature
• Febrile


  A person with increased body temperature
• Pyrexia


  Increased body temperature resulting from a response to bacterial or viral infection and tissue injuries
• Hyperpyrexia


  High fever usually above 41°C
• Types of fever


  • Intermittent
  • Remittent
  • Constant
  • Fever strike
  • Relapsing
  • Neurogenic
• Heat exhaustion


  Result of excessive heat and dehydration
• Heat stroke


  Often do not sweat, have a temperature of 41.1°C or higher, and may be delirious, unconscious, or having seizures
• Clinical manifestations of fever

  • Onset (cold or chill phase)
  • Course (plateau phase, hot stage)
  • Defervescence (fever abatement/flush phase)
• Hypothermia


  Decreased body temperature, pulse, and respirations
• Sites used for body temperature measurement

  • Oral
  • Rectal
  • Axillary
  • Tympanic membrane
  • Temporal artery
• Electronic thermometer


  Very fast at taking temperature
• Temperature sensitive tape


  Disposable tape that reacts to temperature by changing color
• Respiration


  Act of breathing
• Types of respiration

  • External respiration (exchange of O2 and CO2 between alveoli and lungs)
  • Internal respiration (exchange of O2 and CO2 between blood and tissue cells)
• Respiratory physiology

  • Inspiration/inhalation (thorax expands, diaphragm contracts)
  • Expiration/exhalation (thorax and diaphragm relax)
• Respiratory center


  Medulla oblongata and pons (part of the brain stem)
• Increased CO2 is the most powerful respiratory stimulant, causing an increase in respiratory rate and depth
• Eupnea


  Normal respiration
• Tachypnea


  Increased respiratory rate (difficulty breathing)
• Bradypnea


  Decreased respiratory rate
• Apnea


  Periods during which there is no breathing
• Expiration/exhalation


  Act of breathing out
• Ventilation


  Movement of the air in and out of the lungs
• Pulmonary ventilation/respiration


  Movement of air in and out of the lungs
• Inhalation


  Thoraces expand and diaphragm contracts
• Exhalation


  Thorax and diaphragm relax
• Respiratory center


  Medulla oblongata and pons (part of brain stem)