Ch 30: Vital Signs - SG PT1

Question 1

Identify the guidelines that assist the nurse with incorporating vital sign measurements into practice.

Answer 1

• The nurse may delegate the measurement of vital signs but is responsible for analyzing and inter- preting their significance and selecting appropri- ate interventions.
• Equipment needs to be appropriate and functional.
• Equipment needs to be based on the patient’s condition and characteristics.
• Know the patient’s usual range of vital signs.
• Know the patient’s medical history.
• Control or minimize environmental factors.
• Use a systematic approach.
• Collaborate with health care providers to decide on the frequency.
• Use measurements to determine the indications for medication administration.
• Analyze the results.
• Verify and communicate significant changes with

the patient’s health care provider. l. Develop a teaching plan.

Question 2

Body Temperature
Define the following terms that address the physiology of body temperature:

Core temperature

Answer 2

Temperature of the deep tissues

Question 3

Body Temperature
Define the following terms that address the physiology of body temperature:

Thermoregulation

Answer 3

Mechanisms that regulate the balance between heat lost
and heat produced

Question 4

Body Temperature
Define the following terms that address the physiology of body temperature:

Hypothalamus

Answer 4

Controls body temperature

Question 5

Body Temperature
Define the following terms that address the physiology of body temperature:

Basal metabolic rate

Answer 5

The heat produced by the body at absolute rest

Question 6

Body Temperature
Define the following terms that address the physiology of body temperature:

Shivering

Answer 6

Involuntary body response to temperature differences in the body

Question 7

Body Temperature
Define the following terms that address the physiology of body temperature:

Nonshivering thermogenesis

Answer 7

Vascular brown tissue is metabolized for heat production
in the neonate

Question 8

Body Temperature
Define the following terms that address the physiology of body temperature:

Radiation

Answer 8

Transfer of heat from the surface of one object to the surface of another without direct contact

Question 9

Body Temperature
Define the following terms that address the physiology of body temperature:

Conduction

Answer 9

Transfer of heat from one object to another with direct
contact

Question 10

Body Temperature
Define the following terms that address the physiology of body temperature:

Convection

Answer 10

Transfer of heat from one object to another with direct
contact

Question 11

Body Temperature
Define the following terms that address the physiology of body temperature:

Evaporation

Answer 11

Transfer of heat energy when a liquid is changed to a gas

Question 12

Diaphoresis is:

Answer 12

Visible perspiration primarily and upper thorax

Question 13

The skin regulates temperature through…

Answer 13

• Insulation of the body
• Vasoconstriction
• Temperature sensation

Question 14

The ability of a person to control body temperature depends on:

Answer 14

• The degree of temperature extreme
• The person’s ability to sense feeling comfortable or uncomfortable
• Thought processes or emotions
• Person’s mobility or ability to remove or add clothes

Question 15

Identify the factors that affect body temperature

Answer 15

• Age
• Exercise
• Hormone level
• Circadian rhythm
• Stress
• Environment
• Temperature alterations (fever, hyperthermia, heat
  stroke, heat exhaustion, hypothermia)

Question 16

Define the following terms that address temperature alterations.

Pyrexia

Answer 16

Fever

Question 17

Define the following terms that address temperature alterations.

Pyrogens

Answer 17

Bacteria and viruses that elevate body temperature

Question 18

Define the following terms that address temperature alterations.

Hyperthermia

Answer 18

The body’s inability to promote heat loss or reduce heat
production

Question 19

Define the following terms that address temperature alterations.

Malignant hyperthermia

Answer 19

Hereditary condition of uncontrolled heat production

Question 20

Define the following terms that address temperature alterations.

Heatstroke

Answer 20

A dangerous heat emergency

Question 21

Define the following terms that address temperature alterations.

Heat exhaustion

Answer 21

Profuse diaphoresis with excess water and electrolyte loss

Question 22

Define the following terms that address temperature alterations.

Hypothermia

Answer 22

Cold that overwhelms the body’s ability to produce heat

Question 23

Define the following terms that address temperature alterations.

Frostbite

Answer 23

Occurs when the body is exposed to subnormal temperatures

Question 24

List at least three advantages and disadvantage for the following temperature site:

Oral

Answer 24

Advantage

• Easily accessible—requires no position change
• Comfortable for patient
• Provides accurate surface temperature reading
• Reflects rapid change in core temperature
• Reliable route to measure temperature in patients who are intubated

Disadvantage

• Causes delay in measurement if patient recently ingested hot/cold fluids or foods, smoked, or is receiving oxygen by mask/cannula
• Not for patients who had oral surgery, trauma, history of epilepsy, or shaking chills
• Not for infants, small children, or patients who are confused, unconscious, or uncooperative
• Risk of body fluid exposure

Question 25

List at least one advantage and one disadvantage of each of the following temperature sites.

Tympanic

Answer 25

Advantages

• Easily accessible site
• Minimal patient repositioning required
• Obtained without disturbing, waking, or repositioning patients
• Used for patients with tachypnea without affecting breathing
• Sensitive to core temperature changes
• Very rapid measurement (2 to 5 seconds)
• Unaffected by oral intake of food or fluids or smoking
• Used in newborns to reduce infant handling and heat loss
• Not influenced by environmental temperatures

Disadvantages

• More variability of measurement than with other core temperature devices
• Requires removal of hearing aids before measurement
• Requires disposable sensor cover with only one size available
• Otitis media and cerumen impaction distorts readings
• Not used in patients who have had surgery of the ear or tympanic membrane
• Does not accurately measure core temperature changes during and after exercise
• Does not obtain continuous measurement
• Affected by ambient temperature devices such as incubators, radiant warmers, and facial fans
• When used in neonates, infants, and children under 3 years old, use care to position device correctly because anatomy of ear canal makes it difficult to position
• Inaccuracies reported caused by incorrect positioning of handheld unit

Question 26

List at least one advantage and one disadvantage of each of the following temperature sites.

Rectal

Answer 26

Advantages

• Argued to be more reliable when oral temperature is difficult or impossible to obtain

Disadvantages

• Lags behind core temperature during rapid temperature changes
• Not for patients with diarrhea, rectal disorders, or bleeding tendencies or those who had rectal surgery
• Requires positioning and is often source of patient embarrassment and anxiety
• Risk of body fluid exposure and injury to rectal lining
• Requires lubrication
• Not for routine vital signs in newborns
• Readings influenced by impacted stool

Question 27

List at least one advantage and one disadvantage of each of the following temperature sites.

Axilla

Answer 27

Advantages

• Safe and inexpensive
• Reliable in stable term and preterm infants

Disadvantages

• Long measurement time
• Requires continuous positioning
• Measurement lags behind core temperature during rapid temperature changes
• Not recommended for detecting fever
• Requires exposure of thorax that can result in temperature loss, especially in newborns
• Affected by exposure to environment, including time to place the thermometer
• Underestimates core temperature

Question 28

List at least one advantage and one disadvantage of each of the following temperature sites.

Skin

Answer 28

Advantages

• Inexpensive
• Provides continuous reading
• Safe and noninvasive
• Used for neonates

Disadvantages

• Measurement lags behind other sites during temperature changes, especially during hyperthermia
• Adhesion impaired by diaphoresis or sweat
• Reading affected by environmental temperature
• Cannot be used for patients with allergy to adhesives

Question 29

List at least one advantage and one disadvantage of each of the following temperature sites.

Temporalartery

Answer 29

Advantages

• Easy to access without position change
• Very rapid measurement
• Comfortable with no risk of injury to patient or nurse
• Eliminates need to disrobe or be unbundled
• Comfortable for patient
• Used in premature infants, newborns, and children (Reynolds et al., 2014)
• Reflects rapid change in core temperature
• Sensor cover not required

Disadvantages

• Inaccurate with head covering or hair on forehead
• Affected by skin moisture such as diaphoresis or sweating

Question 30

Identify four nursing diagnoses related to thermoregulation.

Answer 30

1. Risk for Imbalanced Body Temperature
2. Hyperthermia
3. Hypothermia
4. Ineffective Thermoregulation

Question 31

Provide examples of goals for temperature alterations related to the environment.

• Short term
• Long term

Answer 31

• Short term: Regain normal range of body temperature
• Long term: Obtain appropriate clothing to wear in cold weather.

Question 32

Identify the patients who are at risk for hypothermia.

Answer 32

Those at risk include the very young and very old;
persons debilitated by trauma, stroke, or diabe- tes; those who are intoxicated by drugs or alcohol; patients with sepsis; and those who have inadequate home heating and shelter. Fatigue, dark skin color, malnutrition, and hypoxemia also increase the risk.

Question 33

Explain the differences related to febrile states in each of the following.

• Children:
• Hypersensitive response to drugs:

Answer 33

• Children: Children have immature temperature-control mechanisms, so their temperatures can rise rapidly, and they are at risk for fluid-volume deficit.
• Hypersensitive response to drugs: Drug fevers are often accompanied by other allergy symptoms such as rash or pruritus.

Question 34

Give an example of each type of fever therapy.

• Pharmacologic:
• Nonpharmacologic:

Answer 34

• Pharmacologic therapy includes nonsteroidal drugs and corticosteroids.
• Nonpharmacologic therapy includes tepid sponge baths, bathing with alcohol water solutions, applying ice packs to the axillae and groin sites, and cooling fans.

Question 35

First aid treatment for heatstroke is:

Answer 35

Move the patient to a cooler environment; remove excess body clothing; place cool, wet towels over the skin; and use fans.

Question 36

Summarize the treatment for hypothermia.

Answer 36

Remove wet clothes; wrap the patient in blankets.

Question 37

Identify evaluative measures for temperature alterations.

Answer 37

Body temperature will return to an acceptable range, other vital signs will stabilize, and the patient will report a sense of comfort

Question 38

Identify the two common sites to assess the pulse rate.

Answer 38

1. Radial
2. Apical

Question 39

List the characteristics to identify when assessing the following.

• Radial pulse
• Apical pulse:

Answer 39

• When assessing the radial pulse, consider rate, rhythm, strength, and equality
• When assessing the apical pulse, consider rate and
  rhythm only

Question 40

What is the acceptable pulse range for adults?

Answer 40

60-100

Question 41

Identify seven factors that may increase or decrease the pulse rate.

Answer 41

1. Exercise
2. Temperature
3. Emotions
4. Medications
5. Hemorrage
6. Postural changes
7. Pulmonary conditions

Question 42

What are the 9 pulse sites?

Answer 42

1. Temporal
2. Corotid
3. Apical
4. Brachial
5. Radial
6. Femoral
7. Popliteal
8. Tibial popliteal
9. Dorsalis pedis