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What are the 5 vital signs
- Respirations (TPR)
- Blood Pressure
What are the frequency of Vital Signs Taken?
- On admission
- Change in health status
- Before and after any surgury
- Rouninely once a shift
- Before and after certain Meds
Normal Body Temp? Afebrile
Very High Fever
Fever due to brain injury. Non infectious.
Fever fluctuates from Fever - Normal - Below normal
Never falls to afebrile. Fluctuates in febrile range.
Fever breaks then comes back.
Physical Effects of Fever
- Loss Of appetite
- Dry hot skin
- Flushed Face/Thirst
Dangerous Manifestations of Fever
- Decreased urine output
- Rapid heart rate
What are the Nursing interventions for Fever?
- Monitor Vitals every 4 hours or more
- Supply blanket when cold/remove when hot
- Provide adequate nutrition
- Provide adequate Fluids (2500-300mL/day)
- Monitor I/o
- Reduce Physical Activity
- Administer antipyretics as ordrered
- Moisten oral cavity
- Tepid sponge bath
- Cooling blanket
- Linen Change
Sites for Measuring body temp
Contradictions for Oral Temp
- Children less than 5 years
- Oral Surgury
- Oral Infection
- Mouth Breathers
- O2B mask
Before any procedure...
- Gather equipt.
- ID patient
- Wash Hands
Contradictions to rectal temp...
- Rectal Surgury
- Cardiac disorders
- Clotting disorder
Respitory receptors - Medulla/pons
Chemoreceptors - Medulla/Carotid and aortic bodies - Respond to O2 CO2 and H+ In arterial blood
Less than normal rate
Faster than normal breathing
Cheyne Stokes Breathing
Slow to fast breathing returning to slow and stopping then speeding up again. Repeat.
Abnormal Pattern of breathing charaterized by groups of quick, shallow inspirations followed by irregular periods of apnea.
Caused by damage or disfunction to nervous system
Chronic Pain. Not releived by ordinary medical surgical or nursing measures.
Attributed to a body part that does not exist.
- Estimates Arterial Blood Oxygen (SpO2)
- Detects Hypoxia before signs and symptoms
- Sensor, photodetector, pulse, oximeter unit.