Vital Sign

Admission
Assessing client during home visit
Routine schedule order by health care provider
surgical or invasive diagnostic procedure before and after
Administration of medication or therapies
General phyiscal condition change
Nursing intervention influencing a vital sign
Nonspecific symptom of physical distress

36-38

60-100 beat/min

12-20 breath/min

120/80

oral, rectal, axiliary, tympanic membrane, temporal artery, esophageal, pulmonary artery, urinary bladder

rectum, tympanic membrane, temporal artery, esophagus, and urinary

regulate the balance b/w heat loss and heat production

regulate body temperature

Control heat loss

Controlled heat production

Heat production by the body during absolute rest

Total body surface area

Testosterone

Involuntary body response to temperature different in the body

can increase 4-5 time

Primarily found in neonates, because they don't shiver

Transfer of heat from the surface of one object to surface of another without direct contact
~80% body heat radiate to environment

Transfer heat from one object to another with direct contact

Transfer heat through air movement

Transfer heat energy when liquid turn to gas

Visible perspiration mainly found on the forehead and upper thorax

1. degree of temperature extreme
2. Feeling comfortable and uncomfortable
3. Emotion
4. Mobility and ability to remove/ add clothes

1. Age
2. Exercies
3. Hormone Level
4. Circadian Rhythm: high at 6pm; low at 1-4am - take 1-3 week to switch
5. Stress

Heat loss mechanisms are unable to keep up with heat production

102 F/ 39 C

Caused by Pryogens (bacteria/virus) trigger immune response

Fever

w/o having a fever - upward shirt in the set point

inability to promote heat lost

Uncontrollable heat production b/w to anesthetic drugs

Heat loss during prolong exposure to cold overwhelm the body ability to product heat.
CAUSE: skin=cyanotic; cardiac dysrhythmia loss of consciousness; unresponsiveness and painful stimili

exposure to the heat too long.
Sign: giddiness, confusion, delirium, excess thirst, nausea, muscle cramp, visual distrubance, incontinence

Loss of electrolyte; hypothalamic malfunction

profuse diaphoresis = excess water and electrolyte loss

Rectal temp is 0.5 C higher than oral
Axillary temp is 0.5 C lower than oral

Flushed skin, tachycardia, skin warm to touch

Objective: increase heat loss, reduce heat production, prevent complication
Intervention:
- Obtain blood culture;
-Minimize heat production by remove enternal covering w/o causing shivering;
-Satisfy requirement for increase metabolic rate - give O2 and fluid
-Promote client comfort - promote oral hygiene
- Identify onset and duration of febrile episode
- initiate health teaching
-Control environmental temp to 70-80

Fever is typically viral in origin.
Temperature raise rapidly b/w immature control mechanism
Dehydration and febrile seizure

Drug that reduce fever

1. mover person to cooler area
2. remove excess clothing
3. Place cool wet cloths over skin use oscillating fan to help convective heat loss
4. In ER give IV
5. Irrigate stomach and lower bowel w. cool solution
6. hypothermia blanket

1. remove wet clothes
2. wrap w/ blanket
3. give hot liquid
4. cover head or heat pad to head and neck

blood that enter the aorta with each ventricular contraction

volume of blood that is pump per minute

Tempororal
carotid
apical
brachial
radial
ulner
femoral
popliteal
posterior tibial
dorsalis peids

at the apex of the heart 5th intercostal

abnormal elevated heart rate above 100

Slow heart rate below 60

different b/w apical and radial pulse.

early or late beat or miss beat = abnormal rhythm = patient need echocardiogram

irregular heart beat that speed up when breathing,

movement of gas in and out lung

movement of O2 n CO2 b/w alveoli and RBC

distribution of RBC to and from pulmonary capillaries

low level of arterial O2

relaxed breathing