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NCM132/RLE102 > II - Taking Vital Signs > Flashcards

II - Taking Vital Signs Flashcards

1
Q

are body temperature, pulse, respiration, and blood pressure. Recently, many agencies have designated pain as a fifth vital sign.

A

The vital signs

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2
Q

Times to assess vital signs:

A

On admission to a health care agency to obtain baseline data
When a client has a change in health status or reports symptoms such as chest pain or feeling hot or faint
Before and after surgery or an invasive procedure
Before and/or after the administration of a medication that could affect the respiratory or cardiovascular systems; for example, before giving a digitalis preparation
Before and after any nursing intervention that could affect the vital signs (e.g., ambulating a client who has been on bed rest)

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3
Q

Purpose of taking vital signs

A
  • To assess the health status of an individual
  • To plan and implement nursing care
  • To understand the effectiveness of the treatment
  • To modify or change the mode of treatment
  • Routine part of complete physical assessment
  • To understand the present problem
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4
Q

The balance between the heat produced and heat lost from the body is measured in Celsius or Fahrenheit.

A

Body Temperature

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5
Q

The body continually produces heat as a by-product of ___.

A

metabolism

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6
Q

There are two kinds of body temperature:

A

Core temperature
Surface temperature

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7
Q
  • This is the temperature of the deep tissues of the body, such as the abdominal cavity and pelvic cavity. It remains relatively constant.
A

Core temperature

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8
Q

The normal core body temperature is a range of temperature ___.

A

37C

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9
Q
  • This is the temperature of the skin, the subcutaneous tissue, and fat. It rises and falls in response to the environment.
A

Surface temperature

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10
Q

Factors affecting the body’s heat production

A

Basal Metabolic Rate (BMR)
Muscle Activity
Thyroxine Output
Strong Emotions
Presence of disease/illness
Change in atmospheric temperature

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11
Q

It is the rate of energy utilization in the body required to maintain body essentials (breathing, digestion).

A

Basal Metabolic Rate (BMR)

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12
Q

Increases metabolic rate up to 2000 times and heat production can increase up to 50 times than normal.

A

Muscle Activity

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13
Q

Increased ___ output increases the rate of cellular metabolism throughout the body.

This effect is called ___, the stimulation of heat production in the body through increased cellular metabolism.

A

thyroxine

thermogenesis

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14
Q

Fight/Flight and stress hormones will be stimulated -> Increasing the rate of cellular metabolism

A

Strong Emotions

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15
Q

Increased levels of carbon dioxide and other greenhouse gases in the atmosphere -> Increased temperature of the earth’s atmosphere

A

Change in atmospheric temperature

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16
Q

Factors affecting the body’s heat loss

A
  1. Through the skin
  2. Through lungs
  3. Through kidneys
  4. Through bowel
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17
Q
  • is the transfer of heat from the surface of another without contact between two objects.
A

Radiation

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18
Q
  • is the transfer of thermal energy through direct contact.
A

Conduction

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19
Q
  • is the transfer of heat energy in a gas or liquid by movement of currents like the heat of the stove while cooking, or the breeze.
A

Convection

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20
Q
  • is the process of losing heat through the conversion of water to gas (sweat).
A

Evaporation

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21
Q

Factors affecting body temperature

A

Age
Diurnal variations
Exercise or Activity
Stress
Hormones
Environment

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22
Q

The point of highest body temperature is usually between ___

The lowest point is usually between ___

A

8 pm and midnight.

4 am and 6 am.

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23
Q

Sites for measuring body temperature and thermometers used

A
  1. Oral
  2. Rectal
  3. Axillary
  4. Tympanic membrane
  5. Skin/Temporal artery
  6. Peripheral
24
Q

Ensure that the patient has not taken any hot or cold food or fluids or smoked in ___ minutes prior to the procedure

A

15 – 30

25
Q

. A temperature above the normal range.

A

Pyrexia

26
Q

A very high temperature above 40°C.

A

Hyperthermia or fever.

27
Q

. Temperature below 34°C.

A

Hypothermia

28
Q

Hyperthermia or fever. A very high temperature above .

A

40°C

29
Q

Hypothermia. Temperature below

A

34°C.

30
Q

Common Types of Fever

A
  1. Intermittent fever
  2. Remittent fever
  3. Relapsing fever
  4. Continuous fever
  5. Fever Spikes
  6. Resolution of pyrexia by crisis
  7. Resolution of pyrexia by lysis
31
Q

A fever where temperature is elevated for several hours followed by an interval when temperature drops back to normal. Occurs in malaria, PTB

A
  1. Intermittent fever
32
Q

Sustained fever is a pattern in which there is little change (0.3°C or less) in the elevated temperature during a 24-hour period. In sepsis, RHF.

A
  1. Remittent fever
33
Q

A variant of the intermittent pattern, fever spikes are separated by days or weeks of intervening normal temperature like in lymphoma.

A
  1. Relapsing fever
34
Q

A type or pattern of fever in which temperature does not touch the baseline and remains above normal throughout the day like in viral pneumonia.

A
  1. Continuous fever
35
Q

A sudden sharp increase in temperature usually up as high as 105°F like in borreliosis (Lyme disease, is transmitted to humans by the bite of infected ticks).

A
  1. Fever Spikes
36
Q

a rapid drop of body temperature to normal, ina few hours. It can disrupt the functions of cardiovascular system and therefore isdangerous for the patient’s life.

A
  1. Resolution of pyrexia by crisis
37
Q

the fall in the body temperature follows a pattern of slow and gradual decrement of the body temperature. This type of fall in body temperature is seen in the case of infectious diseases (e.g., measles, typhoid, Scarlett fever).

A
  1. Resolution of pyrexia by lysis
38
Q

It is the wave of blood created by the contraction of the left ventricle of the heart.

A

Pulse

39
Q

is a pulse located away from the heart, like in the foot, wrist neck, etc.

A

Peripheral pulse

40
Q

Sites for peripheral pulses:

A

Temporal
Carotid
Apical
Brachial
Radial
Femoral
Popliteal
Posterior tibial
Dorsalis Pedis

41
Q

this pulse is located at the apex of the heart.

A

Apical pulse

42
Q

Factors affecting pulse

A
  1. Age
  2. Gender
  3. Exercise
  4. Fever
  5. Medications
  6. Hypovolemia
  7. Stress
  8. Position changes
  9. Pathology
43
Q

The average adult male heart rate is between ___ beats per minute, while the average for adult women is between ___ beats.

A

70 and 72

78 and 82

44
Q

___ decreases the heart rate, whereas ___ increases the PR.

A

Cardiotonics (digitalis)

epinephrine

45
Q

Loss of blood from the vascular system normally increases pulse rate.

A

Hypovolemia

46
Q

Description of a pulse

A

Volume
Rhythm

47
Q

– is the force or strength of the pulse.

A

Volume

48
Q

– is the pattern of long and short sounds in every beat.

A

Rhythm

49
Q

is a steady beat like a ticking clock or of a heartbeat. It can be measured in time by counting the number of beats per minute (BPM).

A

Pulse

50
Q

Palpation should be done using the fingertips and the intensity of the pulse graded on a scale of 0 to 4 +.

A

0 = no palpable pulse
1+ = faint, but detectable pulse;
2+ = slightly more diminished pulse than
normal
3+ = normal pulse
4+ = bounding pulse

51
Q

is the medical term for a heart rate over 100 beats per minute.

A

Tachycardia

52
Q

is slower than 60 bpm or a normal heart rate.

A

Bradycardia

53
Q

–the difference between the apical and peripheral pulse rates.

A

Pulse deficit

54
Q

is the difference between systolic and diastolic blood pressure.

A

Pulse pressure

55
Q

The normal range of pulse pressure is between ___ mm Hg. Pulse pressure tends to increase after the age of 50.

A

40 and 60

NCM132/RLE102 (9 decks)

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