Fever (pyrexia): Hyperthermia, febrile, afebrile 1. Intermittent 2. Remittent 3. Relapsing 4. constant Fever spike Not true fever: heat exhaustion, heat stroke

Nursing Interventions for Clients with Fever

Monitor vital signs Assess skin color and temperature Monitor white cbc, hematocrit value, and other pertinent laboratory reports for indications of infection or dehydration. Remove excess blankets when the client feels warm, but provide extra warmth when the client feels chilled. Provide adequate nutrition and fluids (e.g., 2.5-3liters/day) to meet the increased metabolic demands and prevent dehydration Measure intake and output Reduce physical activity to limit heat production, especially during the flush stage Administer antipyretics (drugs that reduce the level of fever) as ordered. Provide oral hygiene to keep the mucous membranes moist Provide a tepid sponge bath to increase heat loss through conduction provide dry clothing and bed linens.

Decreased body temperature, pulse, and respirations Sever shivering (initially) Feelings of cold and chills Pale, cool, waxy skin Frostbite (discolored, blistered nose, fingers, toes) Hypotension Decreased urinary output Lack of muscle coordination Disorientation Drowsiness progressing to coma

Hypothermia

Nursing Interventions for Clients with Hypothermia

Provide a warm environment Provide dry clothing Apply warm blankets Keep limbs close to body Cover the client's scalp with a cap or turban Supply warm oral or intravenous fluids Apply warming pads

Most common sites for body temperature vital signs:

Oral Rectal Axillary Tympanic membrane Skin/temporal artery

Sites for measuring body temperature: Most frequently used, least disruptive, most convenient, done for 3 minutes

Oral

Sites for measuring body temperature: Most accurate route, but invasive and uncomfortable to patient. Done for 2-3 minutes

Rectal

Sites for measuring body temperature: Safer than oral method, non-invasive, least accurate Done for 10 minutes

Axillary

Sites for measuring body temperature: accessible, less invasive Within two seconds up/back for adult and down/back for pedia

Tympanic membrane

Sites for measuring body temperature: Most useful for infants and children when a more invasive measurement is not necessary.

Forehead temperature measurement

Types of thermometer:

One-piece home electronic thermometer Institutional mode Chemical disposable thermometer: Chemical dot thermometers Temperature-sensitive skin tape. Infrared (tympanic) thermometer Infrared Forehead Thermometer Gun Pacifier thermometer Temporal artery thermometer

Quick quiz: You have delegated vital signs to assistive personnel. The assistant informs you that the patient has just finished a bowl of hot soup. The nurse's most appropriate advice would be to: a. Take a rectal temperature b. Take the oral temperature as planned c. Advise the patient to drink a glass of cold water d. Wait 30 minutes and take an oral temperature

Temperature scales: for Celsius from Fahrenheit

Fahrenheit temperature-32 multiplied by 5 and overall divided by 9

Temperature scales: Fahrenheit from Celsius

Celsius temperature multiplied by 9 then divided by 5 and add 32 to the product or answer.

Palpable bounding of blood flow noted at various points on the body The indicator of circulatory status

Pulse

Number of pulsing sensations in 1 minute

Pulse rate

Age Sex Fever Medications Hypovolemia/dehydration Stress Position Pathology

Factors affecting the Pulse

Assessment of Pulse sites:

Temporal Carotid Apical Brachial Radial Femoral popliteal Posterior tibial Dorsalis pedis

Reasons for using specific pulse site: Readily accessible

Radial

Reasons for using specific pulse site: Used when radial pulse is not accessible

Temporal

Reasons for using specific pulse site: Used during cardiac arrest/shock in adults Used to determine circulation to the brain

Carotid

Reasons for using specific pulse site: Routinely used for infants and children up to 3 years of age Used to determine discrepancies with radial pulse Used in conjunction with some medications

Apical

Reasons for using specific pulse site: used to measure blood pressure Used during cardiac arrest for infants

Brachial

Reasons for using specific pulse site: Used in cases of cardiac arrest/shock Used to determine circulation to a leg

Femoral

Reasons for using specific pulse site: used to determine circulation to the lower leg

Popliteal

Reasons for using specific pulse site: Used to determine circulation to the foot

Posterior tibial/ Dorsalis pedis

Assessment of Pulse: Character of the Pulse:

Rate rhythm Strength Quality

Movement of gases into and out of the lung

Ventilation

Movement of oxygen and carbon monoxide between alveoli and red blood cells

Diffusion

Distribution of red blood cells to and from the pulmonary capillaries

Perfusion

Ventilation Diffusion Perfusion Physiological control Hypoxemia

Respiration

Respiration includes three processes:

Ventilation Diffusion Perfusion

You will analyze respiratory efficiency and ventilation by assessing:

Respiratory rate Depth Rhythm

Assessment of Ventilation: Before assessing a client's respirations, a nurse should be aware of the following:

The client's normal breathing patter The influence of the client's health problems on respirations Any medications or therapies that might affect respiractions The relationship of the client's respirations to cardiovascular function

Terms: Eupnea Bradypnea tachypnea/polypnea

Eupnea- normal breathing Bradypnea- slow breathing Tachypnea- fast breathing, or polypnea- excessive breathing

Assessment of Diffusion and Perfusion:

Measure oxygen saturation of the blood Measurement of arterial oxygen saturation

Force exerted on the walls of an artery by pulsing blood under pressure from the heart

Blood pressure

Maximum peak pressure during ventricular contraction

Systolic

Minimal pressure during ventricular relaxation

Diastolic

Difference between systolic and diastolic pressures

Pulse pressure

Physiology of: Factors affecting arterial blood pressure:

Cardiac output Peripheral resistance Blood volume Viscosity Elasticity

Factors influencing Blood Pressure

Age Stress Ethnicity Gender

More common than hypotension Thickening of walls Loss of elasticity Family history Risk factors Means above normal tension

Hypertension

Measurement of Blood Pressure: Equipment:

Sphygmomanometer Aneroid manometer Occlusive cuff Release valve

Measurement of Blood Pressure

Auscultation Ultrasonic stethoscope Palpation Lower extremity blood pressure Electronic blood pressure devices

Self-measurement of blood pressure

Aneroid sphygmomanometer Digital readout devices that do not require use of a stethoscope Stationary automatic BP devices are often found in public places such as grocery stores, fitness clubs, airports or work sites; reliability is limited Benefits Disadvantages Education

Health promotion and vital signs

Monitor vital signs Include age-related factors Include environmental and activity factors

Record values on electronic or paper graphic Record in nurses' notes any accompanying or precipitating symptoms Document interventions initiated on the basis of vital sign measurement If a vital sign is outside anticipated outcomes, write a variance note to explain, along with the nursing course of action. In the nurse's variance note, address possible cause of keme

Recording vital signs

Cleaning devices between patients decrease the risk for infection Rotating sites during repeated measurements of BP and pulse oximetry decreases the risk for skin breakdown Analyze trends for vital signs, and report abnormal findings Determine the appropriate frequency of measuring vital signs based on the patient's condition.

Safety guidelines for Nursing Skills

Is a diverse range of human activities in creating visual, auditory or performing artifacts (artworks), expressing the author's imaginative or technical skill, intended to be appreciated for their beauty or emotional power.

Art

If it is to be made an art, it requires as exclusive a devotion, as heard a preparation, as any painter's or sculptor's work; for this is an art

Nursing is an art

Self-awareness

Is a type of motivation that works to make people fell good about themselves and to maintain self-esteem. This motive becomes especially prominent in situations of threat, failure or blows to one's self-esteem. Involves a preference for positive over negative self-views