Week 7 Nursing

Question 1

Body Temperature

Answer 1

▪ Body temperature is the heat of the human body.
▪ Core body temperature is normally within a range of 35.8 to 37.5\c
▪ Normal variations occur with age, health status & time of day
▪ Cellular metabolism requires a core temperature of 37.20c
▪ Normal body temperature is known as normothermia or euthermia

Question 2

Body Temperature Physiology

Answer 2

▪ Heat Production
– Primary source of heat production is cellular metabolism
– Heat is produced as a by-product of cellular activities
– Hormones, muscle movement and exercise increase
temperature
▪ Heat Loss
– The skin is the primary site of heat loss from the body
– Blood vessels in the skin bring heat to the skins surface
– Surface heat escapes via the process of radiation,
convection, evaporation or conduction

Question 3

Factors Affecting Body Temperature

Answer 3

▪ Body temperature may vary due to age, gender, stress,
environmental temperatures and surgery
▪ Circadian Rhythm
– Temperature is usually 0.60c lower in the morning than late afternoon and evening
▪ Age and Gender
– The very young, the old & infirm are more sensitive to temperature
changes in the environment
– During the menstruation cycle, progesterone secretion occurs with
ovulation - increases temperature 0.15-0.450c
▪ Environment
– Patients exposed to extremes of temperature may suffer from
hypothermia/hyperthermia

Question 4

Temperature Assessment Sites

Answer 4

▪ Surface Temperature Sites
– Oral, axillary, forehead and temporal sites
▪ Core Temperature Sites
– Tympanic (eardrum) membrane (same blood supply as
the hypothalamus)
There are invasive sites for temperature checking
you will discuss later in the course

Question 5

Pyrexia

Answer 5

▪ A person has an elevated core temperature above 38 degrees
▪ May occur as a response to tissue injury or trauma
▪ Patients may experience:
– Loss of appetite, headache, hot dry skin, flushed face, thirst, general malaise, fatigue, shivering and nausea/vomiting.

Question 6

Pulse

Answer 6

▪ A wave of pressure through an artery wall that follows each contraction of the left ventricle of the heart.
▪ With every beat the heart pumps an amount of blood (stroke volume) into the ascending (then descending) aorta.
▪ Heart rate or pulse rate is the number of pulsation felt over a peripheral artery or auscultated over the apex of the heart in one (1) minute.

Question 7

Pulse Physiology

Answer 7

▪ Volume- With each beat of the heart, a new volume of blood distends the aorta & spreads to smaller arteries in the peripheries
▪ Rhythm- Normal rhythm is regular. The pattern & time interval between pulsations is even is most people
▪ Arrhythmia/Dysrhythmia
– An irregular pattern of heartbeats is called an arrhythmia
▪ Rate - is assessed by counting the pulsations in 1 minute
Pulse rate is controlled by a group of specialised cells -
sinoatrial node (located in the upper right atrium)
▪ Tachycardia
– A rapid heart rate which can impact on cardiac output
– Occurs in adults when the pulse is more than 100 bpm
▪ Bradycardia
– A slow pulse rate can also impact upon cardiac output
– Occurs in adults when the pulse rate is below 60 bpm

Question 8

Assessing Pulse

Answer 8

▪ Can be measured at any artery including these common sites:
▪ Radial
▪ Brachial
▪ Carotid
▪ Femoral
▪ Use the pads of your first three fingers lightly compress
the artery so pulsations can be felt and counted.

Question 9

Assessment of Respirations

Answer 9

▪ Respiratory Rate
– RR should be measured for a full minute
– Ensure the patient is not aware you are counting their respirations
▪ Ventilatory Depth
– Depth is measured by the degree of excursion (movement) in the chest wall
– Ventilatory depth is described as normal, shallow or deep
– Indicates degree of respiratory effort
▪ Characteristics
– Refers to sounds that can be heard during respiration
– Crackles indicate fluid within the lung or collapse of alveoli
– Wheeze results from narrowing of the airways from inflammation/mucud

Question 10

Factors Affecting Respiration Rate

Answer 10

▪ Exercise
▪ Temperature
▪ Emotions
▪ Medications\Drugs
▪ Haemorrhage
▪ Smoking
▪ Pulmonary Conditions
▪ Pain
▪ Neurological Damage
▪ Anaemia

Question 11

Oxygen Saturation

Answer 11

▪ Blood flow through the pulmonary capillaries provides red blood cells (RBC) for oxygen attachment.
▪ RBC carry oxygen attached to haemoglobin molecules
through the left side of the heart to the peripheral arteries.
▪ The percentage of haemoglobin bound to oxygen in the
arteries is the saturation of haemoglobin (SaO2).
▪ Normal range is between 95-100%
▪ It’s very important to assess SaO2 – but assessing the
patient and how they are maintaining their saturation (eg.
Positioning) is also important!

Question 12

Measuring Oxygen Saturation

Answer 12

▪ Oxygen saturation is measured using pulse oximetry - a
non-invasive method of measuring oxygen saturation.
* Pulse oximetry provides an estimation of arterial
oxygen saturation (Sp02).
* True arterial oxygen saturation must be obtained using
arterial blood gas analysis (Sa02).
▪ Pulse oximetry is effective when the Sa02 saturation is
within 70-100%, lower saturation will result in inaccurate
results.

Question 13

Pulse Oximeter

Answer 13

▪ Pulse oximetry works by passing red and infrared light through the finger and capillary beds.
▪ The receiving probe detects the amount of red and infrared light that has not been absorbed by the blood
▪ Oxygen saturation (Sp02) detects pulsatile blood flow through the capillaries in the limb the oximeter is attached.
▪ Patients with chronic respiratory conditions may tolerate an oxygen saturation of between 88-94%.

Question 14

Blood Pressure

Answer 14

▪ Blood pressure is the force (pressure) of the blood pushing
against the blood vessel wall.
▪ The strength of the pressure changes with the events that
occur during the normal cardiac cycle.
▪ BP is measured in millimetres of mercury (mmHg).
▪ It is a reflection of the relationship between cardiac output
and peripheral vascular resistance.
▪ BP is expressed as a ratio of the systolic pressure over the
diastolic pressure.

Question 15

Systolic and Diastolic Blood Pressure

Answer 15

▪ There are two (2) blood pressure measurements:
– SYSTOLIC
▪ The higher pressure occurring during ventricular
contraction
– DIASTOLIC
▪ The lower pressure occurring during ventricular
relaxation
▪ Blood Pressure is usually expressed as 120/80mmHg and
is usually taken on the person’s right upper arm
– Need to indicate where BP was taken if not on right
upper arm.

Question 16

Determinants of Blood Pressure

Answer 16

1. Cardiac Output
   ▪ The amount of blood ejected from the left ventricle
2. Vascular Resistance
   ▪ The opposition to blood flow through the arteries
3. Blood Volume
   ▪ The amount of circulating blood through the arteries
4. Blood Viscosity
   ▪ Internal friction of adjacent fluid layers within blood
5. Compliance
   ▪ Elasticity of blood vessel wall and ability to expand
   and contract

Question 17

Factors Affecting Blood Pressure

Answer 17

▪ Age
▪ Circadian Rhythm
▪ Gender
▪ Diet
▪ Ethnicity
▪ Incorrect Cuff Size
▪ Exercise
▪ Weight
▪ Emotional State
▪ Body Position
▪ Medications\Drugs
▪ Incorrect Arm Position
▪ Renal Disease
▪ Neurological Disease

Question 18

Types of Blood Pressure Monitoring

Answer 18

▪ Non-Invasive
– Manual or automatic sphygmomanometer & stethoscope
– Most commonly used type of monitoring device
– Easily portable and can be used on arms or legs

Question 19

Hypertension

Answer 19

▪ Hypertension is BP above normal for a sustained period of
time.
▪ Leading cause of cardiovascular disease due to organ
damage from sustained elevated pressure.
▪ There are two types of hypertension:
– Primary hypertension where the cause is unknown
– Secondary hypertension where there is a known cause
▪ A single elevated reading does not constitute hypertension
Severe hypertension (SBP ≥ 200mmHg) can produce
headache, chest pain and shortness of breath and is a
medical emergency.

Question 20

Hypotension

Answer 20

▪ Hypotension is a blood pressure that is consistently below
normal (40mmHg less than baseline reading or SBP ≤
90mmHg).
▪ Most causes of hypotension are the result of pathology
(haemorrhage, excessive vasodilation, medications and
heart failure).
▪ Clinical manifestations may include dizziness, diaphoresis,
confusion, blurred vision and tachycardia.

Question 21

Orthostatic (Postural) Hypotension

Answer 21

▪ A transient low BP associated with weakness and fainting
when rising to an upright position.
▪ Postural hypotension is the result of peripheral
vasodilation without a compensatory rise in cardiac output.
▪ It is a significant risk factor for unwitnessed falls in elderly
patients and those taking antihypertensives.
▪ An increase of 40 beats in the pulse rate or a decrease in
systolic blood pressure of 30mmHg are abnormal and
suggest postural hypotension.

Question 22

Assessing for Orthostatic Hypotension

Answer 22

▪ Ask the person to lie in a supine position for 3-5 minutes.
▪ Assist the person to sit. After 1 minute, take the blood pressure and pulse rate.
▪ Assist the person to stand. After 1 minute, take the blood pressure and pulse.
▪ Recording findings for both and report as necessary.

Question 23

Equipment to Measure Blood Pressure

Answer 23

▪ Sphygmomanometer
– Consists of a cuff and the manometer
– The cuff contains an airtight, flat, encased rubber bladder
– Appropriate cuff size must be selected for limb and patient
▪ Width of the cuff should be about 40% the circumference of the limb
▪ The bladder inside the cuff should encase 2/3 of the limb
▪ Stethoscope
– Consists of ear pieces, elastic tubing and an end piece
– The diaphragm/bell can be used to listen to the Korotkoff sounds
▪ The diaphragm end piece is usually adequate for blood pressure
▪ The bell is preferred as it is designed to pick up low-pitched sounds

Question 24

Korotkoff Sounds

Answer 24

▪ The series of sounds to listen for when measuring the blood pressure are called Korotkoff sounds.
▪ The first sound heard through the stethoscope, which is the onset of phase 1, represents the systolic blood
pressure (SBP).
▪ The second number, which represents the diastolic pressure, notes the level at which there is a cessation of sound, during phase 5.

Question 25

Blood Pressure Monitoring

Answer 25

Sites:
▪ The brachial and popliteal artery are the most commonly used sites for NIBP
Sites to avoid:
Limb with IV infusion
The site of an injury
The side of an axillary clearance
following mastectomy
Limb with an arterio-venous fistula
A limb with a skin graft or skin-fat-
muscle flap.

Question 26

Documentation

Answer 26

▪ Vital signs are measured graphically on a standard
observation and response chart.
▪ Additional notation should be made of accompanying
symptoms and the reason for the measurement.
▪ Abnormal readings should be communicated appropriately
(hypertension/hypotension).
▪ Any interventions initiated as a result of the vital signs
measurement should be documented.
▪ Documentation must be clear, contemporaneous and
follow healthcare facility protocol for documentation.

Question 27

Escalation

Answer 27

▪ Look at the patient
▪ Do they look like their vital sign reading?
▪ Take the measurement again
▪ Tell your buddy / preceptor
▪ Inform management (ANUM/NUM)
▪ Does the Doctor need to know?
▪ Explain to the patient without scaring them!
▪ Do you need to escalate further?
– MET call
– Code Blue