CH 12 Vitals

Infrared (tympanic) thermometers

Handheld probe inserted into the ear canal. Rechargeable unit. Infrared sensor that detects the warmth radiating from the tympanic membrane and it converts that heat into a temperature measurement in 2 to 5 seconds.

A nurse notes that the body temperature of a client with fever is 104.7 degrees F. In collaboration with the client's physician, which of the following actions should be undertaken to bring the client's body temperature back to normal?

If a person has a body temperature between 104% and 105.8%F (40% to 40.6%C), physical cooling measures should be used to control the fever. If the fever remains below 102%F (38.9%C) and the person does not have a chronic medical condition, fluids or rest may be all that is necessary. Antipyretics (drugs that reduce fever) are helpful when a temperature is 102% to 104%F (38.9% to 40%C). If the temperature is higher than 105.8%F (40.6%C), or if a high temperature is unchanged after a sufficient response time with conventional interventions, more aggressive treatment is warranted.

SIMS' POSITION

POSITION THE CLIENT ON THE SIDE WITH UPPER LEG SLIGHTLY FLEXED AT THE HIP AND KNEE. Helps to locate the anus and facilitate probe insertion.

OFFSETS

PREDICTIVE MATHEMATICAL CONVERSIONS

During daily rounds on a hospital unit, the nurse is reviewing a client's vital signs with a colleague and the nurses observe that the client's heart rate shows high variability since the time of admission. These nurses should consider which of the following factors that influence heart rate? Select all that apply.

Pulse is affected by numerous factors, including stress, drugs, and temperature. Food intake and personality, however, are not noted to significantly influence heart rate.

Frenulum

Structure that attaches the underneath surface of the tongue to the fleshy portion if the mouth.

ADVANTAGES Infrared (tympanic) thermometers

THE POTENTIAL FOR TRANSFERRING MICROORGANISMS FROM ONE CLIENT TO ANOTHER IS REDUCED BECAUSE THE PROBE IS COVERED AND THE EAR DOES NOT CONTAIN MUCOUS MEMBRANES OR THEIR ACCOMPANYING SECRETIONS. FROM A INFECTION CONTROL STANDPOINT ITS ONE OF THE SAFEST METHODS.

A school nurse is assessing the blood pressure of a team of healthy athletes. Which of the following phenomena can be indirectly assessed by the nurse by measuring the blood pressure?

Measuring the blood pressure helps to assess the efficiency of the client's circulatory system. Blood pressure measurements reflect the ability of the arteries to stretch, the volume of circulating blood, and the amount of resistance the heart must overcome when it pumps blood. Measuring the blood pressure does not help in assessing the thickness of blood, oxygen level in the blood, or the volume of air entering the lungs.

A nurse must assess the blood pressure of a client who has intravenous catheters in both arms. As a result, the nurse will assess the client's blood pressure on his thigh. How will this assessment result differ from blood pressure that is measured on a client's arm?

The systolic measurement in the thigh tends to be 10% to 20% higher than that obtained in the arms, but the diastolic measurement is similar.

Chemical thermometers

The temperature is determined by noting how many dots change color after the strip is held in the mouth. Chemical dot thermometers are discarded after one use. They are used to access the temperature of clients who require isolation precautions for infectious disease. THEIR USE ELIMINATES THE NEED TO CLEAN A MULTI USE ELECTRONIC OR INFRARED THERMOMETER.

Electronic thermometers

Use most because they are so much faster. Rechargeable battery operated and they are portable. Use temperature probe cover once then dispose. The electronic unit senses when the temperature ceases to change and emits a beep. The audible sign alerts the nurse to remove the probe and read the displayed measurement. Red- Rectal Blue- Oral

Continuous monitoring devices

Used primarily in critical care areas. They measure body temp. using internal thermistor probes within the esophagus of anesthetized clients, inside the bladder, or attached to the a pulmonary artery catheter. These measurements are generally required when caring for clients with extreme hypothermia or hyperthermia. Warming or cooling blankets are usually used at the same time. Temperature assessment aid in evaluating the effectiveness of these treatment devices.

A nurse is assessing the blood pressure of a client using the Korotkoff sound technique. The nurse notes that the phase I sounds disappear for 2 seconds. What should the nurse document on the progress record?

An auscultatory gap is a period during which sound disappears. An auscultatory gap can range as much as 40 mm Hg. A widening in the diameter of the artery takes place in the phase II of the Korotkoff sound technique. An adult diastolic pressure takes place in the phase IV of the Korotkoff sound technique.

Digital Thermometers

Are cleaned similar to glass thermometers except that they are wiped rather than soaked with isopropyl alcohol. Disposable plastic sheaths can be used to cover the probe with each use as an alternative

A nurse is reviewing the trends of a client's vital signs since the client's admission and has noted significant variations in the client's blood pressure readings over the course of each day. Which of the following statements best describes the typical circadian rhythm of blood pressure?

Blood pressure tends to be lowest after midnight, begins rising at approximately 4 or 5 a.m., and peaks during late morning or early afternoon. Blood pressure does not normally rise in response to food intake.

A nurse who is on a night shift has checked on the status of each sleeping client and has observed that a client's breathing occasionally stops for several seconds before resuming spontaneously. The nurse should document the presence of: A) Orthopnea B) Stertorous breathing C) Apnea D) Dyspnea

C) Apnea Apnea is an absence of breathing. Dyspnea is difficulty breathing and orthopnea is breathing that is aided by upright positioning. Stertorous breathing is a term used to describe noisy breathing.

A nurse needs to assess the temperature of a client with high fever. Which of the following sites will most closely reflect core body temperature of the client? A) Rectum B) Axilla C) Ear D) Mouth

C) Ear Of the four sites, the ear, or more specifically the tympanic membrane, is the peripheral site that most closely reflects core body temperature.

1online book A nurse is caring for a Caucasian client who has an active infection and whose skin appears pinkish and warm to touch. The client shivers when the windows are opened. Which phase of fever is the client experiencing? A) Prodromal Phase B) Stationary Phase C) Invasion Phase D) Defervescence Phase

C) Invasion Phase The client is going through the onset or invasion phase, in which obvious mechanisms for increasing body temperature, such as shivering, develop. The client is not going through the prodromal, stationary, or defervescence phase. In the prodromal phase, the client has nonspecific symptoms just before the temperature rises, whereas in the stationary phase, the fever is sustained. In the resolution or defervescence phase, the temperature returns to normal.

DRAWDOWN EFFECT

COOLING OF THE EAR WHEN IT COMES IN CONTACT WITH THE PROBE.

INSERT THERMOMETER HOW DEEP IN RECTUM FOR A) ADULT? B) CHILD? C) INFANT?

A - 1.5 INCHES (3.8 cm) B - 1 inch (2.5 cm) C - 0.5 inches (1.25 cm)

postprandial hypotension

A condition that produces a drop in blood pressure when a person stands up after eating a meal. It is most often seen in elderly people. Postprandial hypotension is a form of orthostatic hypotension.

Cleaning glass thermometers

Don gloves if there is potential for contact with blood or stool. Hold thermometer at the tip of the stem. Keep the bulb downward and away from your hand. Using a firm twisting motion and a clean, soft tissue, wipe the soiled thermometer toward the bulb. Wash the thermometer WITH SOAP OR DETERGENT SOLUTION, again using friction, while holding the thermometer over a towel or other soft material to reduce the potential for breaking if dropped. Rinse under COLD running water Dry with soft towel Soak the thermometer in 70% to 90% isopropyl alcohol or a 1:10 solution of household bleach. Rinse the thermometer after disinfecting it Store in clean dry container clean from cleanest to dirtiest. Clean end is where you hold it in your mouth.

Cerumen

Ear wax

Automated Monitoring devices

Equipment that allows for the simultaneous collection of multiple data. Chief advantage they save time and money. Favored for unstable clients who require frequent assessments. To ensure reliable data the accuracy of the device is compared with manual devices on a regular basis.

Disadvantages of electronic thermometer

Expensive, recharging necessary, Probe needs to be held by the client or nurse, interferes with simultaneously taking the clients pulse while holding probe in one hand and unit in other.

Advantages of electronic

Faster than glass, accurate, no sterilization or disinfectant needed, Easy to use.

READ SKILLS

212-226

Implementation for body temp. RECTAL METHOD

*** PROVIDE PRIVACY - LUBRICATE APP. 1 IN (2.5 CM) OF THE RECTAL PROBE COVER. ***** USE THE RED PROBE. POSITION THE CLIENT ON THE SIDE WITH UPPER LEG SLIGHTLY FLEXED AT THE HIP AND KNEE (SIMS' POSITION). Helps to locate the anus and facilitate probe insertion. Instruct the client to breath deeply. Relaxes the sphincter and reduces discomfort during insertion. *** INSERT THE THERMOMETER APPROXIMATELY 1.5 INCHES (3.8 CM) IN ADULT. 1 INCH (2.5 CM) IN A CHILD AND 0.5 IN (1.25 CM) IN AN INFANT. When you take a rectal you have to make sure you have the probe inside the rectum far enough. HOLD PROBE IN PLACE TILL IT BEEPS. Maintain the probe in position until audible sound is heard. Remove probe eject probe in lined waste basket. Wipe lube and any stool from around clients rectum. WASH HANDS OR USE HAND ANTISEPSIS. ??? DOCUMENT 99.6 WITH A R SO YOU KNOW IT IS TAKEN RECTALLY BUT IN YOUR MIND YOU KNOW RECTUM TEMPERATURES ARE A DEGREE HIGHER THAN ORAL TEMPERATURE.

Assessment for body temp.

- Determine how frequently, and the type of thermometer that was used before. IF USING A ORAL ELECTRONIC OR DIGITAL THERMOMETER Observe the clients ability to support a thermometer within the mouth and breath adequately through the nose with the mouth closed. (BC heat can escape if mouth is opened) - Check for recent seizures or a seizure disorder. (Identifies possible CONTRAINDICATION for oral site) - DETERMINE IF THE PATIENT CONSUMED ANY HOT OR COLD SUBSTANCES OR SMOKED IN LAST 30 MINS. (These could alter accuracy of the temp of the oral cavity).

Vital signs are taken

- On admission, when obtaining database assess. - According to written medical orders. - Once per day when the client is stable. - At least every 4 hours when one or more vital signs is abnormal. - Every 5 to 15 min when a client is unstable or at risk for rapid physiological changes such as after surgery. - When a clients condition appears to have changed. - A second time or more frequently when there is a significant difference from the previous measurement. - When the client is feeling unusual. - Before, during, and after a blood transfusion. - Before admin meds that effect any of the vital signs and after to monitor the drug's effect. (CARDIAC MEDS)

Implementation for body temp. ORAL METHOD

- Place covered probe beneath the tongue to the right or left of the frenulum. (This locates the probe near the sublingual artery to ensure correct location. - Maintain the probe in position until an audible sound occurs. Signals when temperature remains constant. - Discharge probe into trash this confines contaminated objects to an area for proper disposal without direct contact. - THEY MUST GO BACK IN THE CHARGER TO BE RECHARGED OR THEY WILL NOT WORK.

Infrared (tympanic) thermometers can produce inaccurate measurements in the following circumstances.

- The ear canal is not straightened appropriately. - The probe which measures 6 to 8 mm, is too large for the ear canal (a problem with infants whose ear canals are 5mm or smaller.) The size difference alters the location where infrared light must be precisely directed. -USE OF TYMPANIC THERMOMETER IS CONTRAINDICATED FOR CHILDREN YOUNGER THAN 2 YEARS. - The sensor is directed at the ear canal rather than directly at the tympanic membrane. - THERE IS IMPACTED CERUMEN (EAR WAX) A COMMON PROBLEM AMONG OLDER ADULTS. - There is fluid behind the tympanic membrane, a problem that occurs with middle ear infections. - The DRAWDOWN EFFECT - The first use of a tympanic thermometer after recharging is not always as accurate as the second reading. Another complaint is that there is no standard for actual ear or core temperatures. AT PRESENT TYMP THERMOMETERS USE INTERNALLY CALCULATED OFFSETS. (PREDICTIVE MATHEMATICAL CONVERSIONS) FOR ORAL AND RECTAL TEMPERATURES . THESE OFF SETS VARY AMONG MANUFACTURES.

A nurse is assessing the pulse of a client with dehydration. The nurse notes that the client has a thready pulse. Which of the following is a description of a thready pulse?

A thready pulse is felt with difficulty or not easily felt, and slight pressure causes it to disappear. A weak pulse is stronger than a thready pulse, and light pressure causes it to disappear. A normal pulse is felt easily, and moderate pressure causes it to disappear. A bounding pulse is strong and does not disappear with moderate pressure.

A nurse is caring for a middle-aged client who appears anxious and flares his nostrils when breathing. The client complains of difficulty in breathing, even when he walks to the bathroom. Which of the following breathing disorders is most appropriate to describe the client's condition?

Clients with dyspnea frequently appear anxious. The nostrils flare as they fight to fill the lungs with air. Dyspnea is almost always accompanied by a rapid respiratory rate because clients work to improve the efficiency of their breathing. The client's condition cannot be termed hyperventilation, hypoventilation, or apnea. Hyperventilation and hypoventilation denote an abnormal breathing rate and apnea is total absence of breathing.

Glass thermometers

Contain mercury and are considered environmentally toxic. since 2002

Implementation for body temp. AXILLARY METHOD

Insert thermometer PROBE INTO THE CENTER OF THE AXILLA and lower the patients arm to enclose the thermometer between two skin folds. This confines the tip of the thermometer so that the room air does not affect it. Hold it until it beeps.

DISADVANTAGES Infrared (tympanic) thermometers

Some people do not like it because they say it is not accurate but again the problem with the accuracy is are we doing it correctly? Are we holding the ear canal correctly such that we can make sure that probe is aimed at the eardrum.

A nurse is assessing the blood pressure of a client who has come to the health care facility for the first time. Which of the following is the best site for obtaining the client's blood pressure reading?

The first time the blood pressure is measured, it is assessed in each arm. The two blood pressure measurements should not vary more than 5 to 10 mm Hg unless pathology (disease) is present. The blood pressure is not measured in shoulders, wrist, or thighs of clients for the first time. Nurses use the thigh to assess the blood pressure when they cannot obtain readings in either of the client's arms.

The nurse is caring for a male client who has a diagnosis of Alzheimer disease and is attempting to assess the client's temperature using an oral thermometer. However, the client is unable to follow the nurse's instructions to close his lips around the shaft of the thermometer and the nurse is unable to obtain an accurate temperature reading. How should the nurse respond to this event?

The nurse can obtain an accurate temperature reading at the client's axilla or tympanic membrane. Rectal temperature assessment is inconvenient and likely to cause distress to a cognitively-impaired client. Estimation of temperature is inaccurate and it is likely unnecessary to seek assistance from a family member if alternative forms of temperature assessment are available.

A nurse has assessed a client's blood pressure with the client lying supine in bed and then taken blood pressure readings with the client sitting at the edge of the bed and then standing upright. The nurse notes that the latter two readings are significantly lower than the client's lying blood pressure. What client teaching is warranted by these assessment findings?

This client exhibits the signs of postural hypotension. To reduce the risk of falls, the nurse should emphasize the importance of waiting for blood pressure to stabilize before standing. Bed rest is not necessary and carries many negative health consequences. Staying in bed after meals is likely unnecessary since there is no clear indication of postprandial hypotension.

A nurse is caring for a client with hypothermia. The client's skin looks pale and he is shivering with cold despite wearing warm clothes. Which of the following is another symptom of hypothermia that the nurse would observe?

When a client has hypothermia, the skin looks pale, cool, or puffy. The other signs and symptoms associated with hypothermia are shivering, impaired muscle coordination, listlessness, slow pulse and respiratory rates, and irregular heart rhythm among others. Nausea, diarrhea, and agitation are not associated with hypothermia.

A nurse is caring for an elderly client who has a history of postprandial hypotension. Which of the following nursing interventions should be implemented?

When postprandial hypotension is assessed in a client, the nurse should plan for frequent, smaller meals throughout the day. Bed rest or activity limitation prior to meals does not help in the management of this client's problem. The nurse needs to ensure that the client eats frequently but a high carbohydrate diet is not indicated.