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Ruben's Nursing 50A > Fundamentals: Chapter 29; Temp > Flashcards

Fundamentals: Chapter 29; Temp Flashcards

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1
Q

What are the most frequent measurements obtained by health care providers

A

temperature, pulse, blood pressure (BP), respiratory rate, and oxygen saturation

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2
Q

What is the term for a patient’s a patient’s usual state of health?

A

baseline

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3
Q

What is the acceptable temperature range for adults?

A

36° to 38° C (96.8° to 100.4° F)

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4
Q

What is the acceptable respiratory rate for adults?

A

12-20 breaths/min

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5
Q

What is the average oral/tempanic temperature for adults?

A

37° C (98.6° F)

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6
Q

What is the average rectal temperature for adults?

A

37.5° C (99.5° F)

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7
Q

What is the average axillary temperature for adults?

A

36.5° C (97.7° F)

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8
Q

What is the average BP for adults?

A

<120/80 mm Hg

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9
Q

What is the normal pulse rate for adults?

A

60 to 100 beats/min

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10
Q

What is the average pulse pressure in adults?

A

30 to 50 mm Hg

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11
Q

Who is responsible for measurement of vital signs?

A

the nurse caring for the patient (individual stats can be delegated)

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12
Q

What is the term for the difference between the amount of heat produced by body processes and the amount of heat lost to the external environment (Heat produced-heat loss = temp)

A

body temperature

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13
Q

What is the body core temperature?

A

temperature of the deep tissues

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14
Q

Why does the body surface temperature vary?

A

depends on blood flow to the skin and the amount of heat lost to the external environment

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15
Q

List the possible sites for measuring temperature

A

oral

rectal

axillary

tympanic membrane

temporal artery

esophageal

pulmonary artery

urinary bladder

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16
Q

What is the term for the physiological and behavioral mechanisms regulate the balance between heat lost and heat produced

A

thermoregulation

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17
Q

Which part of the brain regulates body temperature?

A

hypothalamus

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18
Q

Which part of the brain senses and regulates heat loss?

A

anterior hypothalamus

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19
Q

What part of the brain senses and regulates heat production?

A

posterior hypothalamus

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20
Q

What mechanisms does the body use to control heat loss?

A

sweating

vasodilation

inhibition of heat production

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21
Q

What mechanisms does the body use to control heat production?

A

vasoconstriction

shivering

voluntary muscle contraction

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22
Q

What kind of injury/illness can cause serious alterations in body’s ability to temperature control

A

injury to the hypothalamus or the spinal cord

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23
Q

What is the primary source of energy for the body?

A

food

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24
Q

Explain how metabolism effects heat loss/production

A

increased metabolism increases heat production. decreased metabolism reduces heat production

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25
Q

What accounts for the heat produced by the body at absolute rest

A

basal metabolism

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26
Q

How is the average BMR determined?

A

body surface area

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27
Q

How do thyroid hormones effect BMR?

A

promote the breakdown of body glucose and fat, and increase the rate of chemical reactions in almost all cells of the body

28
Q

Why do men have a higher BMR?

A

testosterone increases BMR

29
Q

Where does nonshivering thermogenesis usually occur? Why?

A

neonatesneonates cannot shiver and a limited amount of vascular brown tissue, present at birth, is metabolized for heat production

30
Q

What are the 4 types of heat loss?

A

radiation, conduction, convection, and evaporation

31
Q

What is the term for the transfer of heat from the surface of one object to the surface of another without direct contact between the two?

A

radiation

32
Q

What is the term for the transfer of heat from one object to another with direct contact?

A

conduction

33
Q

What is the term for the transfer of heat away by air movement

A

convection

34
Q

What is the term for the transfer of heat energy when a liquid is changed to a gas

A

evaporation

35
Q

What is the term for visible perspiration primarily occurring on the forehead and upper thorax

A

diaphoresis

36
Q

What determines the amount of blood flow and heat loss to the skin?

A

the degree of vasoconstriction

37
Q

What are 4 factors that affect a persons ability to control body temperature?

A

(1) the degree of temperature extreme(2) the person’s ability to sense feeling comfortable or uncomfortable(3) thought processes or emotions(4) the person’s mobility or ability to remove or add clothes

38
Q

What factors must a nurse be aware of when assessing temperature variations and evaluating deviations from normal?

A

AgeExerciseHormone levelCircadian RhythmStressEnvironment

39
Q

What are temperature related conditions that a nurse must be aware of?

A

FeverHyperthermiaHypothermiaHeat StrokeHeat Exhaustion

40
Q

What is a newborn’s normal body temperature?

A

35.5° to 37.5° C (95.9° to 99.5° F).

41
Q

At what stage in life does temperature regulation become more stable?

A

puberty

42
Q

Why are older adults particularly sensitive to temperature extremes?

A

deterioration in control mechanismsreduced amounts of subcutaneous tissuereduced sweat gland activityreduced metabolism

43
Q

How does progesterone effect body temperature?

A

low progesterone lead to a few tenths of a degree increase in body temperature until ovulation occurs

44
Q

What causes “hot flashes” ?

A

the instability of the vasomotor controls for vasodilation and vasoconstriction (up to 4° C [7.2° F] increase)

45
Q

What is the source of a true fever?

A

an alteration in the hypothalamic set point

46
Q

How does a pyrogen cause an increase in temperature?

A

act as antigens, triggering immune system responses

47
Q

What are the 4 physiological signs of chills?

A

vasoconstrictionpiloerectionepinephrine secretionshivering

48
Q

What are the benefits of a fever?

A

increased WBC productioneduces the concentration of iron in the blood plasma (suppressing the growth of bacteria)stimulating interferon (the natural virus-fighting substance of the body)

49
Q

How do fever patterns serve a diagnostic purpose?

A

Fever patterns differ, depending on the causative pyrogen

50
Q

What are the 4 patterns of a fever?

A

Sustained: A constant body temperature continuously above 38° C (100.4° F) that has little fluctuationIntermittent: Fever spikes interspersed with usual temperature levels (Temperature returns to acceptable value at least once in 24 hours.)Remittent: Fever spikes and falls without a return to normal temperature levels.Relapsing: Periods of febrile episodes and periods with acceptable temperature values (Febrile episodes and periods of normothermia are often longer than 24 hours.)

51
Q

What is an important nursing action for patients who are experiencing a fever?

A

Maintaining optimum fluid volume status

52
Q

What is the term for a hereditary condition of uncontrolled heat production that occurs when susceptible people receive certain anesthetic drugs

A

malignant hyperthermia

53
Q

What is the condition that occurs when prolonged exposure to the sun or a high environmental temperature overwhelms the heat-loss mechanisms of the body?

A

heatstroke>40° C (104° F)

54
Q

What is the most important sign of heatstroke?

A

hot, dry skin

55
Q

What condition occurs when profuse diaphoresis results in excess water and electrolyte loss?

A

heat exhaustion

56
Q

What are the 3 classifications of hypothermia?

A

Celsius FahrenheitMild 34°-36° 93.2°-96.8°Moderate 30°-34° 86.0°-93.2°Severe <86°

57
Q

What is a nurses role when a patient is experiencing temperature alterations?

A

Implement independent measures to increase or minimize heat loss, promote heat conservation, and increase comfort

58
Q

Where do ICUs usually take a patient’s temperature?

A

core temperatures of the pulmonary artery, esophagus, and urinary bladder

59
Q

Why is the tempanic membrane considered a core temperature?

A

shares the same arterial blood supply as the hypothalamus

60
Q

What should a nurse do if they find a mercury-in-glass thermometer in a patient’s home?

A

teach the patient about safer temperature devices and encourage the disposal of mercury products at appropriate neighborhood hazardous disposal locations

61
Q

What are important instructions to NAPs when delegating temperature taking responsibilities?

A

• Obtain temperature for select patient with ordered frequency.• Report abnormalities to the nurse for further assessment.

62
Q

What would an increase in body temperature, flushed skin, skin warm to touch, and tachycardia indicate?

A

hyperthermia

63
Q

In regard to caring for a patient with temperature alteration, what influences a nurse’s priorities? What is the main priority?

A

The severity of a temperature alteration and its effects, together with the patient’s general health statussafety

64
Q

Which kind of antipyretics reduce a fever by increasing heat loss?

A

Nonsteroidal antiinflammatory drugs such as acetaminophen, salicylates, indomethacin, and ketorolac

65
Q

Which kind of antipyretics reduce a fever by interfering with the immune system and mask signs of infection

A

corticosteroidsNote: Should NOT be used to treat a fever unless the fever is being caused by a pyrogen

66
Q

What should a nurse keep in mind when using nonpharmacological therapy to increase heat loss (reduce fever)?

A

use nursing measures to enhance body cooling that do not stimulate shivering

67
Q

What is the priority treatment for hypothermia?

A

prevent a further decrease in body temperature

Ruben's Nursing 50A (40 decks)

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