VS Fall 10 - VITALSIGNS KIMBERLYGLENNMN,RN,CPN...

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KIMBERLY GLENN MN, RN,CPN CLINICAL ASSOCIATE PROFESSOR NURS 312 FOUNDATIONS VITAL SIGNS
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ASSESSMENT OF PHYSIOLOGIC FUNCTIONS-ALTERATIONS CAN  TABLE 17-1 PG 306 Vital Signs 
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Guidelines for Measuring  Vital Signs Establish a baseline for future assessments Appropriately delegate measurement Communicate findings Ensure equipment is in working order Accurately document findings
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Factors that can't be changed Factors that can be changed Age Gender Heredity Race Lifestyle Environment Meds Pain Factors influencing VS
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Temperature Regulation Temp is controlled by balancing metabolic heat  production and loss Core temperature: internal temperature  (rectal/tympanic means) Surface temp: oral and axillary
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Body Temperature Physiology Body temperature: Heat produced  Heat lost Temperature range: 98.6° F to 100.4° F (36° C to 38° C) Temperature sites: Oral, rectal, axillary, tympanic membrane, temporal  artery, esophageal, pulmonary artery
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EBP study pediatric patients seen in ER: no difference in results  obtained from various thermometers 137 adult inpatients: variability between ears using  the tympanic thermometer
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Heat Loss Radiation: heat emitted Conduction: heat transfer Convection: movement away from body  Evaporation=insensible water loss Accounts for greatest heat loss when body heat increases  (10%). Breathing, sweating and stool
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Factors affecting temperature Developmental age Environmental temperature Exercise Food or fluid intake WHY IS IT IMPORTANT TO KNOW WHAT FACTORS  HAVE OCCURRED THAT COULD AFFECT  TEMPERATURE
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Fever (>100.4°F) phagocytosis Pyrogens inducse secretion of prostaglandins-resets  Should we always give Tylenol??? What can we do  (interventions) IS 100.4 A MAGIC TEMPERATURE: THE ONE EVERYONE WILL  USE TO GAUGE ORDERING TYLENOL??
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Hyperthermia Heatstroke occurs from prolonged exposure to the  sun or high environmental temperatures. S/S:  giddiness, confusion, delirium, excessive thirst,  nausea, muscle cramps, visual disturbances, elevated  body temperature, increased heart rate, and lower  blood pressure Heat exhaustion occurs when profuse diaphoresis  results in water and electrolyte loss WHO IS AT GREATEST RISK??
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Hypothermia (<96.8°F) Metabolic processes slow Sereve hypothermia (<82.4°F) What should you do???
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VS Fall 10 - VITALSIGNS KIMBERLYGLENNMN,RN,CPN...

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