Basic nursing

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raininx
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106541
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Basic nursing
Updated:
2011-10-04 22:53:34
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Basic nursing
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Chapter 14
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  1. Vital signs
    temp,pulse,resp,b/p,O2,pain
  2. guidlines for measuring vital signs
    • 1. review vital sign measurements, interpret their significance, and make decisions about interventions
    • 2. make sure equiptment is in working order and appropriate to ensure accurate findings
    • 3. select equiptment based on the patients needs. for example a small cuff for small people ect
    • 4. know the patients usual vitals. a patients usual vitals can range out from the standard rangefor that age for physical state.
    • 5 know the patients medical history therapies and prescribed medications. some illnesses or treatments can cause predictable vital sign changes.
    • 6 control or minimize enviromental changesthat affect vitals. getting a pulse after a patient exercises will not give a normal reading.
    • 7. use an organized systematic approach
    • 8. based on the patients condition collaberate with their healthcare provider the frequency the vitals need to be taken
  3. when to masure vital signs
    • on admission to a health care facility
    • when assesing a patient during home care visits
    • in a hospital on a routine schedule according to a healthcare providers orders or standards or practice
    • before during and after a surgical procedure or invasive diagnostic procedure
    • before during and after the administration of medications or applications of therapies that affect the cardiovascular system,respiratory, ot temp control functions
    • before during and after the transfusion of blood
    • when a patients general conditin changes
    • before during and after some nursing interventions that affect the vitals
    • when ever the patient feels funny or distressed
  4. body temperature
    heat produced -heat lossed =body temp
  5. core temp
    temp of deep tissues, relatively constant during sleep during exposure to cold and strenuous exercise. however, surface temp regulates depending on blood flow to the skin
  6. temp ranges
    96.8 to 100.4 but no single temp is normal for all people. time of day also affects temp with the lowest at 6am and the highest at 4 pm
  7. women and temp
    women generally experience greater fluctuations in temp than men because of hormonal variations during the menstral cycle. progesterone levels rise and fall
  8. neural and vascular control
    the hypothalamus located btw the cerebral hemispheres controls body temp by attempting to maintain a comfortable temp or ''set point''. when the hypothalamus senses an increase in body temp it sends impulses out to reduce boey temp by sweating and vasodilation. thd increased blood flow to the skin enables heat loss through radiation.
  9. vasodilation
    widening of the blood vessels
  10. what ahppens during heat loss
    if the hypothalamus senses the bodys temp to be lower than the set point it sends signals out to increase heat production by muscle shivering or heat conservation by vasoconstriction. disease or trauma to the brain and or spinal cord which cafries the hypothalamus messages decreases the bodys ability to control temp
  11. diaphoresis
    visually evident sweating usually on forehead upper chest and arms. body temp lowers
  12. pyrexia
    fever-occurs when heat loss mechanisms are unable to keep pace with excess heat production resulting in an abnormal increase in body temp
  13. when is a fever harmful
    a fever is usually not armful if it stays below 102.2 in adults and 104 in children.
  14. true fever
    a true fever results from an alteration in the hypothalamus set point. substances that trigger the immune system such as a release of hormones or a bacteria or virus in an effort to promote the bodys defense against infection.

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