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RLE 1a
VITAL SIGNS
Also known as Cardinal Signs
Includes TEMPERATURE, PULSE,
RESPIRATION, and BLOOD PRESSURE A persons physiologic status is reflected by these indicators of body function
ASSESSING TEMPERATURE
Taylors p. 8
TEMPERATURE heat of the body measured in degrees Difference between production of heat and loss of heat
TYPES of TEMPERATURE
Core Temperature measured thru tympanic and rectal routes Surface Temperature measured thru oral and axillary routes
ROUTE
ORAL
RECTAL AXILLARY TYMPANIC
SPECIAL CONSIDERATIONS
Done for 3 minutes Upon intake of hot/cold fluids, wait 30 minutes Done for 2-3 minutes Presence of fecal matter could result to a false reading Lubricate tip prior to inserting Done for 10 minutes Within two seconds Up/back for adult Down/back for pedia
Remittent fever
Constant fever Relapsing fever Resolution of Pyrexia by crisis
Fluctuations of several degrees above normal, but not reaching normal between fluctuations
Consistently elevated and fluctuates very little Returns to normal for at least a day then the fever occurs
ASSESSING PULSE
T a PULSE y A wave of blood being pumped into l the o arterial circulation by the contraction r of the left ventricle
Taylors p. 16
+3
+2 +1 0
Normal
weak
Feeble/thready: difficult to feel & easily obliterated by pressure
absent
ASSESSING A PULSE
Taylors p. 17
ASSESSING RESPIRATION
Respiration
Pulmonary ventilation (breathing) movement of air in and out of the lungs Inspiration (inhalation) act or breathing in Expiration (exhalation) act of breathing out External respiration exchange of O2 and CO2 between alveoli and blood Internal respiration exchange of O2 and CO2 between blood and tissue cells
Adults
12-20 bpm
2 TYPES OF BREATHING
1. Costal/thoracic breathing involves external intercostal muscles and other accessory muscles
Observed thru upward and outward movement of the chest
Faster and deeper than normal with abrupt pauses in between each breath
Faster and deeper respi. without pauses in between panting Prolonged grasping followed by extremely short insufficient exhalation difficulty of breathing DOB unless sitting narrowing of airways, causing whistling or sighing sounds high-pitched sounds heard on inspiration
Rhonchi
ASSESSING RESPIRATION
Taylors p. 20
BLOOD PRESSURE
-Force of the blood against the arterial walls -Measured in millimeters of mercury (mmHg) Systole the highest pressure Diastole the lowest pressure Pulse pressure difference between the systole and diastole
BLOOD PRESSURE
Basic Terms: Korotkoffs sound Hypertension above 140/90 mmHg Hypotension below 90/60 mmHg Orthostatic Hypotension decrease in Bp when changing position