Ch 30: Vital Signs - SG PT1 Flashcards
Identify the guidelines that assist the nurse with incorporating vital sign measurements into practice.
- 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.
Body Temperature
Define the following terms that address the physiology of body temperature:
Core temperature
Temperature of the deep tissues
Body Temperature
Define the following terms that address the physiology of body temperature:
Thermoregulation
Mechanisms that regulate the balance between heat lost
and heat produced
Body Temperature
Define the following terms that address the physiology of body temperature:
Hypothalamus
Controls body temperature
Body Temperature
Define the following terms that address the physiology of body temperature:
Basal metabolic rate
The heat produced by the body at absolute rest
Body Temperature
Define the following terms that address the physiology of body temperature:
Shivering
Involuntary body response to temperature differences in the body
Body Temperature
Define the following terms that address the physiology of body temperature:
Nonshivering thermogenesis
Vascular brown tissue is metabolized for heat production
in the neonate
Body Temperature
Define the following terms that address the physiology of body temperature:
Radiation
Transfer of heat from the surface of one object to the surface of another without direct contact
Body Temperature
Define the following terms that address the physiology of body temperature:
Conduction
Transfer of heat from one object to another with direct
contact
Body Temperature
Define the following terms that address the physiology of body temperature:
Convection
Transfer of heat from one object to another with direct
contact
Body Temperature
Define the following terms that address the physiology of body temperature:
Evaporation
Transfer of heat energy when a liquid is changed to a gas
Diaphoresis is:
Visible perspiration primarily and upper thorax
The skin regulates temperature through…
- Insulation of the body
- Vasoconstriction
- Temperature sensation
The ability of a person to control body temperature depends on:
- 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
Identify the factors that affect body temperature
- Age
- Exercise
- Hormone level
- Circadian rhythm
- Stress
- Environment
- Temperature alterations (fever, hyperthermia, heat
stroke, heat exhaustion, hypothermia)
Define the following terms that address temperature alterations.
Pyrexia
Fever
Define the following terms that address temperature alterations.
Pyrogens
Bacteria and viruses that elevate body temperature
Define the following terms that address temperature alterations.
Hyperthermia
The body’s inability to promote heat loss or reduce heat
production
Define the following terms that address temperature alterations.
Malignant hyperthermia
Hereditary condition of uncontrolled heat production
Define the following terms that address temperature alterations.
Heatstroke
A dangerous heat emergency
Define the following terms that address temperature alterations.
Heat exhaustion
Profuse diaphoresis with excess water and electrolyte loss
Define the following terms that address temperature alterations.
Hypothermia
Cold that overwhelms the body’s ability to produce heat
Define the following terms that address temperature alterations.
Frostbite
Occurs when the body is exposed to subnormal temperatures
List at least three advantages and disadvantage for the following temperature site:
Oral
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
List at least one advantage and one disadvantage of each of the following temperature sites.
Tympanic
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
List at least one advantage and one disadvantage of each of the following temperature sites.
Rectal
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
List at least one advantage and one disadvantage of each of the following temperature sites.
Axilla
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
List at least one advantage and one disadvantage of each of the following temperature sites.
Skin
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
List at least one advantage and one disadvantage of each of the following temperature sites.
Temporalartery
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
Identify four nursing diagnoses related to thermoregulation.
- Risk for Imbalanced Body Temperature
- Hyperthermia
- Hypothermia
- Ineffective Thermoregulation
Provide examples of goals for temperature alterations related to the environment.
- Short term
- Long term
- Short term: Regain normal range of body temperature
- Long term: Obtain appropriate clothing to wear in cold weather.
Identify the patients who are at risk for hypothermia.
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.
Explain the differences related to febrile states in each of the following.
- Children:
- Hypersensitive response to drugs:
- 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.
Give an example of each type of fever therapy.
- Pharmacologic:
- Nonpharmacologic:
- 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.
First aid treatment for heatstroke is:
Move the patient to a cooler environment; remove excess body clothing; place cool, wet towels over the skin; and use fans.
Summarize the treatment for hypothermia.
Remove wet clothes; wrap the patient in blankets.
Identify evaluative measures for temperature alterations.
Body temperature will return to an acceptable range, other vital signs will stabilize, and the patient will report a sense of comfort
Identify the two common sites to assess the pulse rate.
- Radial
- Apical
List the characteristics to identify when assessing the following.
- Radial pulse
- Apical pulse:
- When assessing the radial pulse, consider rate, rhythm, strength, and equality
- When assessing the apical pulse, consider rate and
rhythm only
What is the acceptable pulse range for adults?
60-100
Identify seven factors that may increase or decrease the pulse rate.
- Exercise
- Temperature
- Emotions
- Medications
- Hemorrage
- Postural changes
- Pulmonary conditions
What are the 9 pulse sites?
- Temporal
- Corotid
- Apical
- Brachial
- Radial
- Femoral
- Popliteal
- Tibial popliteal
- Dorsalis pedis
