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Vital Signs - Coggle Diagram
Vital Signs
Temperature
Basic Physiologic Processes r/t regulation
hyothalamus important in regulation
heat loss
skin is primary site
transferred to external environment through:
radiation - release of heat waves by body
convection - conducted to air then carried away by currents
conduction - flow of heat from body to object
evaporation
heat production
primary source is metabolism
temp is generated in core tissues then distributed through circulation
Factors that can alter
Circadan rhythm (lower in morning, highest in afternoon)
Age / Sex
Older Adults - more sensitive to environment, lower basal temp, risk for harm d/t impaired thermoregulatory responses
Infants/Children - respond rapidly to environmetn
Women - fluctuations/ higher temp @ ovulation
Physical Activity (more = increased)
State of Health
Environment
Normal Ranges
97.0-99.5 F (36-37.5 C)
Appropriate assessment sites
oral (37.0 C, 98.6 F)
wait 15-30 mins after drinking, not for kids under 5
Rectal (36.5 C, 97.7 F) - best core
not for newborns, children w/ diarrhea or surgury/disease
Axillary (36.5 C, 97.7 F)
most common for neonates
Tympanic (37.5 C, 99.5 F
Temporal (37.5 C, 99.5 F)
more accurate than axillary
Nursing interventions for alterations
Fever/Pyrexia
increase comfort and prevent complications
From infection = antibiotic, antipyretic drug (aspirin, ibuprofen)
modifications of external environment - dry clothing and linens
increase oral fluids
lots of rest
oxygen if needed
Hypothermia
blankets, warm dry clothing, hot drinks, warm IVs
Nursing responsibilities in assessment
Hypothermia - low body temp (below 96 F orally)
Symptoms
- shivering, chills, pale cool kin, ecreased muscular coordination, disorientation, rowsiness progessing to coma
Hyperthermia - increase above normal w/o change of thermoregulatory set point
Heat stroke - prolonged exposure to increased temps overwhelms hypothalamus
Malignant hyperthermia - uncontrolled heat production when susceptible person receives anesthetics
Pyrexia - increase d/t change of thermoregulatory set point (above 100.4 O)
Symptoms
- malaise, chills, shivering, aches, pains, fatigue, headache, drowsiness, confusion, nausea, decreased appetite, hot dry flushed skin, increased pulse and respirations, dehydration and thirst, sweating (diaphoresis)
Types
intermittent - returns to normal at least once every 24 hours
Remittent - doesnt return to normal but fluctuates few degrees upa nd down
Sustained/continuous - remains above normal w/ minimal variations
Relapsing/Recurring - return to normal for 1+ days w/ 1+ episodes of fever as long as several days
Pulse
Basic Physiologic Processes r/t regulation
controlled by variety of mechanisms to maintain tissue perfusion (sufficient supply of blood to the cells at all times)
regulated by nervous system (Not voluntary)
Factors that can alter
Developmental/Age
decreases with age - high in infants
Women higher than men
Exercise
Heat
Stress, pain
Medication
Hemorrhage
Postural changes
Diseases causing poor oxygenation
Valsalva maneuver
Normal Ranges
60-100 bpm
Appropriate assessment sites
Central pulses
(1) Carotid
(2) Femoral
Peripheral
Temporal
Brachial
Radial
Popliteal
Posterior tibial
Dorsalis pedis
Nursing interventions for alterations
Nursing responsibilities w/ assessment
tachycardia
bradycardia
Respirations
Basic Physiologic Processes r/t regulation
Factors that can alter
Normal Ranges
Appropriate assessment sites
Nursing interventions for alterations
Nursing responsibilities
Blood Pressure
Basic Physiologic Processes r/t regulation
Factors that can alter
Normal Ranges
Appropriate assessment sites
Nursing interventions for alterations
Nursing responsibilities