Vital Signs - Unit 1 (Basics & TEMP)

Question 1

What are the 5 vital signs?

Answer 1

Body Temp, Pulse, Blood Pressure, Respirations and Pain

Question 2

Why do we take vital signs?

Answer 2

To get an idea of what’s going on.

Question 3

When to take vital signs?

Answer 3

per agency policy, doctor’s order’s, on admission (baseline), prior to discharge, when a client has a change in health status, before or after surgery or procedure, before and/or after giving certain medication, before/after nursing interventions, nursing judgment/PRN.

Question 4

Body Temp = balance between heat ___ and heat ___ by the body.

Answer 4

Produced/lost.

Question 5

What are the two types of body temps? Give examples!

Answer 5

Core (abdominal cavity, cranial, etc.) and Surface (temp of skin, mucous layer, etc.)

Question 6

What is considered a normal temp?

Answer 6

98-98.6 F (but 97-100 can be normal, too.)

Question 7

What are some factors that effect body heat production?

Answer 7

BMR (cost of energy of things such as breathing, eating, etc.), thyroxin output (produced by the thyroid), fever, Epi, etc.

Question 8

What are the five most common sites for measuring temperature?

Answer 8

Oral, rectal, axillary, and tympanic and temporal!

Question 9

Oral and Temporal Temps are most accurate. T/F?

Answer 9

True!

Question 10

If a person has eaten or drank something hot or cold within 30 minutes of getting the temp, it’s fine. T/F?

Answer 10

False - you have to wait 30 minutes!

Question 11

Oral Temp - least accessible and convenient. T/F?

Answer 11

False - it is the most accessible and convenient!

Question 12

Rectal Temp - possible perforation of the ___. It is also ____.

Answer 12

Bowel/embarrassment.

Question 13

With a rectal temp, we can walk away while it’s being done. T/F?

Answer 13

False - we have to stay there!

Question 14

Axillary Temp - least safe and very invasive. T/F?

Answer 14

False - it is very safe and very non-invasive!

Question 15

Tympanic Membrane Temp - it is __ accessible, reflects the __ temp, and is very fast.

Answer 15

readily/core.

Question 16

Bladder and esophageal temps - most or least reliable?

Answer 16

Most!

Question 17

Which temp is best for older people?

Answer 17

Axillary!

Question 18

What are the 5 types of thermometers?

Answer 18

Electronic, Tympanic Membrane, Chemical Disposable, Temperature Sensitive Tape, and Mercury

Question 19

What regulates the body temp? Think anatomy….

Answer 19

Shell and Core, Hypothalamus, Sensory Receptors.

Question 20

Temp Set Point - it is the …

Answer 20

control center of body temp level at which the hypothalamus maintains temp.

Question 21

If we get too cold, __ is released.

Answer 21

Epi (vasoconstriction.)

Question 22

If we get too warm, we ___.

Answer 22

Sweat (vasodilation.)

Question 23

What are some factors affecting body temp?

Answer 23

Age, diurnal variation (circadian rhythms), exercise, hormones, stress, environment, etc.

Question 24

Around what time of day are our temps the highest and lowest?

Answer 24

4p-8p = highest.

2-6 AM = lowest.

Question 25

What are the four common types of Temps?

Answer 25

Intermittent, Remittent, Relapsing, Constant.

Question 26

Intermittent Fever - def

Answer 26

Body temp fluctuates between periods of fever and no fever.

Question 27

Remittent Fever - def

Answer 27

body temp fluctuates more than 3.6 degrees above normal and does not go back to normal between fluctuations. It is above 102.2 and doesn't go below that.

Question 28

Relapsing Fever - Def

Answer 28

body temp returns to normal for at least a day, then comes back.

Question 29

Constant fever -def

Answer 29

body temps remains constantly elevated, but always less than 3.6 degrees (doesn't go above 102.2)

Question 30

What are some symptoms of a fever?

Answer 30

Increased HR, hot/dry skin, thirst, flushed face, etc.

Question 31

Infant fever - above ___ is considered signifiant.

Answer 31

100.4

Question 32

Infants and children are at a greater risk for febrile convulsions as the fever is elevating. T/F?

Answer 32

True!

Question 33

Adult __ - ___ = low grade favor.

Answer 33

98.8-100.4

Question 34

Above __ = significant fever.

Answer 34

100.4

Question 35

Above ___ = Hyperpyrexia.

Answer 35

105.8

Question 36

Nursing Interventions for Clients with fever - what are some?

Answer 36

Monitor vital signs frequently, provide adequate nutrition and fluids, measure input and output, remove excess blankets unless chilled or shivering.

Question 37

Hyperthermia = non-regulated elevation in body temp with an imbalance between heat gain and heat loss. T/F?

Answer 37

True!

Question 38

Hyperthermia - set point is/is not elevated?

Answer 38

Is not!

Question 39

Neurogenic Fever - fever that is not elevating the set point. T/F?

Answer 39

True!

Question 40

What are some heat exhaustion symptoms?

Answer 40

S&S weakness, fatigue, headache, giddiness, anorexia, nausea, etc.

Question 41

Heat stroke - symptoms?

Answer 41

Hot, dry skin, absence of sweating, neurological symptoms - confusion, coma, seizures, acute renal failure, etc.

Question 42

Malignant Fever - def

Answer 42

autosomal dominant genetic disorder that affects calcium levels within the skeletal muscle - occurs with administration of anesthesia. Dantrolene is given.

Question 43

How do we treat hypothermia?

Answer 43

Prevent is, warm air spray, cooling blanket, etc.

Question 44

Hypothermia - decrease what?

Answer 44

Body temp, pulse, and respirations.

Question 45

Hypothermia - what else is a part of this?

Answer 45

Severe shivering (initially), feelings of cold and chills, hypotension, disorientation, etc.

Question 46

How do we treat a patient with hypothermia?

Answer 46

Provide a warm environment, provide dry clothing, apply warm blankets, cover the scalp with a cap or turban, etc.