Chapter 24 - Vital Signs

Question 1

Vital Signs

Answer 1

A person’s temperature, pulse, respiration, and blood pressure. (abbreviated as T, P, R, BP). Pain is often included as a fifth vital sign.

Question 2

Temperature

Answer 2

the difference between the amount of heat produced by the body and the amount of heat lost to the environment measured in degrees. - Heat is generated by metabolic processes in the core tissues of the body, transferred to the skin surface by circulating blood, and then dissipated to the environment.

Question 3

Core body temperature

Answer 3

higher than surface body temperature. Normally maintained within a range of 36.0˚ C (97.0˚F) to 37.0˚C (99.5˚F). Core temp is usually lowest in the morning and highest in the afternoon.

Question 4

Where is core body temperature of a healthy person maintained?

Answer 4

Maintained at a fairly constant range by the thermoregulatory set point of the thermoregulatory center in the hypothalamus. - This center receives messages from warm and cold thermal receptors located throughout the body, compares that information with its temperature set point, and initiates responses to either produce or conserve body heat or to increase heat loss.

Question 5

What is the Primary source of Heat in the body?

Answer 5

Metabolism. Heat is produced as a byproduct of metabolic activities.

Question 6

Factors that affect body temperature

Answer 6

circadian rhythms (every 24 hrs), age, gender, stress, and environmental temperatures.

Question 7

Hypothermia

Answer 7

low body temperature

Question 8

hyperthermia

Answer 8

high body temperature.

Question 9

Afebrile

Answer 9

without fever

Question 10

Fever

Answer 10

AKA Pyrexia. An increase in body temperature above the normal. - it signals infection and increases immune function. Not dangerous unless it’s extremely high or low.

Question 11

Febrile

Answer 11

A person with fever

Question 12

Other types of increased body temperature

Answer 12

hyperthermia, neurogenic fever, fever of unknown origin (FUO)

Question 13

Neurogenic Fever

Answer 13

result of damage to the hypothalamus from pathologies such as intracranial trauma, intracranial bleeding, or increased intracranial pressure. This type of fever does not respond to antipyretic medications.

Question 14

Physical effects of fever

Answer 14

loss of appetite headache hot, dry skin flushed face thirst muscle aches fatigue respiration and pulse rate increase seizures (in young children) periods of confusion and delirium (older adults) Fever Blisters (may develop if fever activates the type I herpes simplex virus.

Question 15

Methods of reducing fever

Answer 15

cool sponge bath, cool packs, hypothermia (cooling ) blanket, oral fluids to maintain cellular and intravascular status and prevent dehydration.

Question 16

Decreased body temperature

Answer 16

Death may occur if temperature falls below 34˚C (93.2˚F). -Survival has been reported in isolated cases. Rates of chemical reactions in the body are slowed, thereby decreasing the metabolic demands for oxygen.

Question 17

pulse

Answer 17

throbbing sensation that can be palpated over a peripheral artery, such as the radial artery or the carotid artery.

Question 18

stroke volume

Answer 18

quantity of blood forced out of the left ventricle with each contraction.

Question 19

Age-related variations in normal vital signs

Answer 19

Question 20

Cardiac Output

Answer 20

(CO) is the amount of blood pumped per minute, and averages 3.5L/min to 8.0 L/min in a healthy adult.Volume is determines by Cardiac Output = Stroke Volume X Heart Rate. Ex: Cardiac Output of an adult w/ stroke volume of 70 mL and a heart rate of 70 beats/min is 4.9 L/min. Cardiac Output increases during pysical activity and decreases during sleep. Also varies on body size and metabolic needs.

Question 21

Normal Pulse rate for adults and adolescents

Answer 21

ranges from 60 to 100 beats/min. Might be altered by activity, medications, emotions, pain, heat, cold and disease processes. Normal pulse rates diminish from birth to adulthood.

Question 22

Tachycardia

Answer 22

Rapid heart rate. It decreases cardiac filling time, whihc in turn decreases stroke volume and cardiac output. An adult has tachycardia when pulse rate is 100 to 180 beats/min

Question 23

Bradycardia

Answer 23

pulse rate below 60 beats/min in an adult.

Question 24

dysrhythmia

Answer 24

an irregular pattern of heartbeats

Question 25

Assessing the pulse

Answer 25

• May be assessed by palpating peripheral arteries - by auscultating the apical pulse with a stethoscope

Question 26

Auscultation

Answer 26

Listening to sounds within the body

Question 27

How is the circulation of the legs and feet assessed?

Answer 27

It is assessed at the following arterial pulses: femoral, politeal, posterior tibial, doralis pedis

Question 28

What site do you use for emergency assessments?

Answer 28

The carotid pulse. Used for patients in shock or ones who have caridac arrest. When taking the carotid pulse, lightly palpate one side to preent any decrease in cerebrovascular circulation.

Question 29

Brachial pulse site

Answer 29

most often used in infants

Question 30

When is an apical pulse assessed?

Answer 30

If the peripheral pulse is difficult to assess because it is irregular, weak, or very rapid. The apical pulse should be assessed using a stethoscope. - also assessed when giving medications that alter heart rate and rhythm.

Question 31

When assessing an apical pulse where is the contraction of the heart heard?

Answer 31

in the space between the 5th and 6th ribs, about 8 cm (3in) to the left of the median line and slightly below the nipple - the apical rate of an infant can easily be palpated witht he fingertips as well as being auscultated.

Question 32

pulse deficit

Answer 32

The difference between the apical and radial pulse rates. It indicates that all of the heart beats are not reaching the peripheral arteries or are too weak to be palpated.

Question 33

Respiration

Answer 33

involves ventilation, diffusion, and perfusion. Ventilation (breathing) is movement of gases in and out of lungs inspiration (inhalation) is the act of breathing in. Expiration (Ehalation) the act of breathing out. Ventilation has both autonomic and voluntary control. Diffusion is the exchange of oxygen and carbon dioxide between the alveoli and the lungs and the circulating blood. Perfusion is the exchange of oxygen and carbon dioxide between the circulating blood and the tissue cells. . The component measured by nurses as a vital sign is ventilation (respiration).

Question 34

Normal respiratory rate of adults

Answer 34

12 to 20 times per minute. Infants and young children breathe more rapidly.

Question 35

Eupnea

Answer 35

Is the normal respiration. The relationship of 1 respiration to 4 heartbeats is fairly consistent in healthy people.

Question 36

Tachypnea

Answer 36

an increased respiratory rate. May occur in response to an increased metabolic rate when a person has a fever.. Rate increases as much as 4 breaths/min with every .6 C (1 F) that the temperature rises above normal. Also caused by an increase in carbon dioxide and a decrease in oxygen in the blood.

Question 37

Bradypnea

Answer 37

a decrease in respiratory rate

Question 38

Apnea

Answer 38

periods during whihc there is no breathing. If apnea lasts longer than 4 - 6 min, brain damage and death may occur.

Question 39

Dyspnea

Answer 39

difficult or labored breathing. A Dyspneic patient usually has rapid, shallow respirations and appears anxious. Dypnei people can often breathe more easily in an upright position, a condition known as othopnea. While sitting/standing, gravity lowers organs in the abdominal cavity away from the diaphragm.

Question 40

Blood pressure

Answer 40

refers to the force of the moving blood against arterial walls. Maximum blood pressure is exerted on the walls of arteries when the left ventricle of the heart contracts and pushes blood through the aortic valve into the aorta at the beginning of systole. The pressure rises as the ventricle contracts (systole) and falls as the heart relaxes (diastole)

Question 41

systolic pressure

Answer 41

highest pressure on the arterial walls

Question 42

diastolic pressure

Answer 42

the lowest pressure on the arterial walls.

Question 43

pulse pressure

Answer 43

difference between the systolic and diastolic pressures.

Question 44

Hypertension

Question 45

Hypotension

Answer 45

below-normal blood pressure

Question 46

orthostatic hypertension

Answer 46

(postural hyperstension) a drop in systolic blood pressure of a number equal to or greater than 20 mm Hg or in diastolic blood pressure of a number equal to or greater than 10 mm Hg within 3 minutes of standing.

Question 47

Korotkoff Sounds

Answer 47

Series of sounds that the nurse listens to when assessing blood pressure. These sounds are only heard when using a stethoscope.