Vital Signs

Question 1

• measurements of the body’s basic functions

- the most frequent and routine measurements obtained by health care providers

Answer 1

Vital Signs

Question 2

What are the Vital signs

Answer 2

-temperature
-pulse
-blood pressure
-respiratory rate
often:
-oxygen saturation
-pain

Question 3

what can cause a patient’s vital signs to change

Answer 3

• temperature of environment
• patient’s physical exertion
• effects of illness

Question 4

guidelines for measuring vital signs

Answer 4

1. )measuring, reviewing, and interpreting is nurse responsibility
2. )make sure equipment is working properly
3. )select equipment based on the patient
4. )know the patient’s usual range of vital signs for basis
5. )know the patient’s medical history, therapies, and prescribed medication
6. )control or minimize environmental factors that can affect the patient’s vital signs
7. )use a system or step by step approach to ensure accuracy
8. )collaborate with health care providers for the frequency of vital sign assessments
9. )use vital sign measurements to determine indications for medication administration
10. )analyze results of vital signs based on patient’s condition and past medical history
11. )verify and communicate significant changes in vital signs
12. )instruct the patient and family in vital signs assessment and significant findings

Question 5

acceptable temperature range for adults

Answer 5

range: 36 to 38 degree C (96.8 to 100.4 degree F)
oral average: 37 degree C (98.6 degree F)
rectal average: 37.5 C (99.5 F)
Axillary average: 36.5 C (97.7 F)

Question 6

how much higher is rectal temperature than oral?

Answer 6

0.9 F or 0.5 C

Question 7

how much lower is axillary and tympanic from oral temperature?

Answer 7

0.9 F or 0.5 C

Question 8

When do you measure vital signs?

Answer 8

• on admission to health care facility
• when assessing a patient during home care visits
• on routine schedule under physician order
• standard procedure before, during, and after surgical procedures or invasive procedure
• before, during, and after blood transfusion
• before, during, and after administration of medication or therapies that affect cardiovascular, respiratory, or temperature functions
• when a patient’s general condition changes ( loss of conciseness or intense pain)
• before, during, after nursing interventions ( before ambulation or before performing exercises)
• when a patient reports nonspecific symptoms of physical distress

Question 9

Body temperature

Answer 9

heat produced - heat lost due to environment = Body temperature

Question 10

• Average body temperature for young adults

- average body temperature for elderly

Answer 10

• 37 C(98.6 F)

- 36 to 38 C (95 to 97 F)

Question 11

lowest and highest temperature during the day

Answer 11

lowest: 6:00 am
highest: 4:00pm

Question 12

physiological and behavioral mechanisms that regulate the balance between heat lost and heat produced

Answer 12

thermoregulation

Question 13

• anterior hypothalamus

- posterior hypothalamus

Answer 13

• anterior controls heat loss

- posterior controls heat production

Question 14

heat loss mechanisms

Answer 14

• sweating
• vasodilation
• inhibition of heat production

Question 15

Heat production

Answer 15

• BMR
• voluntary movement like exercise
• Shivering
• nonshivering thermogenisis

Question 16

Heat loss

Answer 16

• conduction
• convection
• radiation
• evaporation
• diaphoresis (sweating)

Question 17

the ability of a person to control body temperature

Answer 17

• 1.)degree of temperature extreme
  2. )person’s ability to sense feeling comfortable and uncomfortable
  3. )thought process and emotions
  4. )mobility and ability to add or remove clothes

Question 18

factors that affect the body temperature

Answer 18

• age
• exercise
• hormone level
• cardiac rhythm
• stress
• environment
• temperature alterations

Question 19

hormonal temperature in women

Answer 19

• childbirth: temperature maybe lower until ovulation

- menopause: periods of increased temperature

Question 20

temperature is lowest between?

Answer 20

1:00 to 4:00 am

Question 21

another term for fever?

Answer 21

pyrexia

Question 22

• occurs when heat loss mechanisms are unable to keep pace with excessive heat production
• upward shift of the set point of temperature

Answer 22

fever or pyrexia

Question 23

a pyrexia is not harmful when?

Answer 23

• in children: below 40 C (104 F)

- in adults: below 39 C (102.2 F)

Question 24

when the fever breaks the patient becomes?

Answer 24

afebril

Question 25

if the body cannot meet the demand for additional oxygen

Answer 25

cellular hypoxia

Question 26

myocardial hypoxia produces

Answer 26

angina

Question 27

cerebral hypoxia causes

Answer 27

confusion

Question 28

during fever pay attention to...

Answer 28

- the need for oxygen therapy | - fluids

Question 29

overload of the thermoregulatory mechanisms of the body

Answer 29

hyperthermia

Question 30

hereditary condition of uncontrolled heat production

Answer 30

malignant hyperthermia

Question 31

body temperature of 40 C or more due to environmental heat overwhelming heat loss mechanism of the body

Answer 31

heat stroke

Question 32

occurs when profuse diaphoresis results in excess water and electrolyte loss

Answer 32

heat exhaustion

Question 33

cold environments overwhelms the body's ability to produce heat

Answer 33

hypothermia

Question 34

permanent circulatory and tissue damage occur when ice crystals form inside cells

Answer 34

frost bite

Question 35

fever patterns - constant body temperature continuously above 38 C (100.4 F) - fever spikes interspersed with usual temperature levels - fever spikes and falls without a return to acceptable temperature level - periods with febrile episodes and periods with acceptable temperature levels

Answer 35

- sustained - intermittent - remittent - relapsing

Question 36

classification of hypothermia 1. ) 34-36 C (93.2- 96.8 F) 2. )30 -34 C (86 - 93.2 F) 3. )<30 C (<86 F)

Answer 36

1. )mild 2. )moderate 3. )severe

Question 37

increased body temperature, flushed skin, skin warm to touch, and tachycardia shows

Answer 37

hyperthermia

Question 38

examples of nursing diagnosis for patients with body temperature alterations

Answer 38

- risk of imbalance body temperature - hyperthermia - hypothermia - ineffective thermoregulation - risk of hypothermia