Module 03: Vital Signs Assessment Flashcards
What part of the brain is responsible for the neural and vascular control?
Hypothalamus
Where is the hypothalamus located?
Located between the cerebral hemisphere
What does the hypothalamus control?
Body temperature
Which part of the hypothalamus in the neural and vascular control is responsible for heat lost?
Anterior Hypothalamus
Which part of the hypothalamus in the neural and vascular control is responsible for heat production?
Posterior Hypothalamus
This is produced by the body and a by-product of metabolism, which is the chemical reaction in all body cells.
Heat production
What are the different types of heat loss?
(1) Radiation
(2) Conduction
(3) Convection
(4) Evaporation
This is the transfer of heat from the surface of one object to the surface of another without direct contact between the two.
Radiation
This is the transfer of heat from one object to another with direct contact.
Conduction
This is the transfer of heat away by air movement. A fan promotes heat loss through this approach.
Convection
This is the transfer of heat energy when a liquid is changed to a gas. The body continously loses heat by this approach.
Evaporation
This is the visible perspiration primarily occurring on the forehead and upper thorax, although you can see it in other places on the body.
Diaphoresis
What are the factors affecting body temperature?
(1) Exercise
(2) Hormone Level
(3) Circadian Rhythm
(4) Stress
(5) Environment
How does exercise affect the body temperature?
The form of exercise increases metabolism and heat production as well as body temperature.
How does the hormone level affect the body temperature?
Hormonal variations during menstrual cycle make cause body temperature fluctuations.
What is the normal circadian rhythm?
Temperature normally changes 0.5 to 1 degree Celsius (0.9 to 1.8 degrees F)
When is the circadian rhythm low?
Temperature is low between 1:00am and 4;00 am.
How does stress affect body temperature?
Physical and emotional stress increase body temperature through hormonal and neural stimulation.
How does environment affect body temperature?
Environmental temperatures affect infants and older more often because their temperature regulating mechanisms are less efficient.
This is the abnormal rise in body temperature.
Fever or pyrexia
When can the nurse conclude that the patient has fever or pyrexia?
When the patient’s body temperature is above 100.4 degrees F or 38 degrees C.
What is the body temperature of a patient with fever or pyrexia when recorded by a rectal thermometer?
38 degrees C or 100 degrees F
What is the body temperature of a patient with fever or pyrexia when recorded by an oral thermometer?
37.8 degrees C or 100 degrees F
What is the body temperature of a patient with fever or pyrexia when recorded by an axillary thermometer?
37.2 degrees C or 99 degrees F
This form of temperature alteration pertains to an elevated body temperature related to the inability of the body to promote heat loss to reduce heat production.
Hyperthermia
What does FUO mean?
Fever of Unknown Origin
This type of temperature alteration is caused by the environmental heat exposure and presents with diaphoresis that results in excess water or electrolyte loss.
Heat exhaustion
What is the range based on the mild hypothermia by core temperature?
32 to 35 degrees C (90.0 to 95 degrees F)
What is the range based on the moderate hypothermia by core temperature?
28 to 32 degrees C (82 to 90 degrees F)
How should the nursing process be applied in terms of checking for the patient’s body temperature?
Knowledge on the physiology of body temperature regulation is essential to assess and evaluate a patient’s response to temperature alterations and intervene safely
What is the formula when converting Fahrenheit to Celsius?
C = (F - 32) x 5/9
What is the formula when converting Celsius to Fahrenheit?
F = (9/5 x C) + 32
What are the different types of thermometer?
(1) Digital Thermometer with disposable probe
(2) Tympanic Thermometer
(3) Temporal Thermometer
(4) Disposable Thermometer Strips
What should the nurse do in terms of diagnosis under the nursing process in body temperature?
(1) Identify patterns or clusters of assessment data to form a nursing diagnosis
(2) Accurately select the related factor for problem-focused diagnosis
What are some examples of nursing diagnosis under body temperature?
(1) Impaired thermoregulation
(2) Risk for impaired thermoregulation
(3) Hyperthermia
(4) Fever
(5) Chronic fever
What should the nurse do in terms of planning under the nursing process in body temperature?
Integrate knowledge gathered from assessment and the patient’s clinical condition to develop individualized plan of care.
What should the nurse do in terms of implementation under the nursing process in body temperature?
(1) Health promotion maintain balance between heat production and heat loss.
(2) Restorative and continuing care educate the patient with a fever about the importance of taking and continuing any antibiotics as directed.
What are the different types of nursing interventions for febrile patients?
(1) Obtain cultures of body fluids such as urine, sputum, or blood (before beginning antibiotics) if ordered.
(2) Obtain blood culture specimen
(3) Minimize heat production, reduce frequency of activities and allow for rest periods
(4) Minimize heat loss; reduce external covering on patient’s body without causing shivering.
(5) Satisfy requirements for increase metabolic rate: provide supplemental oxygen therapy as ordered to improve oxygen delivery to body cells.
(6) Promote patient comfort
(7) Identify onset and duration of febrile episode phases
(8) Initiate health teaching
(9) Control environmental temperature to 21 to 27 degrees C ( 70 - 80 degrees F)
What should the nurse do in terms of evaluation under the nursing process in body temperature?
(1) Evaluate your patient’s perspectives about the care provided.
(2) Evaluate all nursing interventions.
This is the palpable bounding of blood flow in a peripheral artery.
Pulse
The pulse is an indirect indicator of what?
Circulatory Status
The impulse from this travel through the heart muscle to stimulate muscle contraction.
Impulse from sinoatrial node (SA)
What should the nurse do in terms of assessment of the the patient’s pulse?
When auscultating the apical pulse, assess the rate and rhythm only.
What is the acceptable range of heart rate among infants?
120 to 160 beats per minute
What is the acceptable range of heart rate among toddlers?
90 to 140 beats per minute
What is the acceptable range of heart rate among preschoolers?
80 to 110 beats per minute
What is the acceptable range of heart rate among school age children?
75 to 100 beats per minute
What is the acceptable range of heart rate among adolescents?
60 to 90 beats per minute
What is the acceptable range of heart rate among school age adults?
60 to 100 beats per minute
This is abnormally elevated heart rate above 100 beats per minute among adults.
Tachycardia
This is slow rate and below 60 beats per minute in adults.
Bradycardia
This is known as the difference between the apical and radial pulse rates,
Pulse deficit
Apical rate of 92 - Radial rate 0f 78 = 14 beats (pulse deficit)
This is the interval interrupted by an early or late beat or a missed beat that indicates an abnormal rhythm.
Dysrhythmia
Dysrhythmia is commonly described as ________.
This is described as regularly irregular or irregularly irregular.
What are the other types of diagnosis of pulse problems?
(1) Activity intolerance
(2) Dehydration
(3) Hypervolemia
(4) Impaired cardiac function
(5) Impaired peripheral tissue perfusion
What should the nurses do in terms of planning under the nursing process in pulse?
The nursing care plan includes individualized, independent patient-centered nursing interventions based on the nursing diagnoses identified and the risk factors.
What should the nurses do in terms of evaluation under the nursing process in pulse?
Evaluate the patient’s outcomes.
(Example: If a patient is beginning to ambulate after prolonged immobility, measure the pulse as the patient ambulates and when ambulation is completed to identify any change)
This is the exchange of respiratory gases, oxygen (O2) and carbon dioxide (CO2) between cells of the body and atmosphere.
Respiration
This is the mechanical movement of gases into and out of the lungs.
Ventilation
This is the movement of oxygen and carbon dioxide between the alveoli and the red blood cells.
Diffusion
This is the distribution of red blood cells to and from the pulmonary capillaries.
Perfusion
This is classified as normal breathing.
Eupnea
This is known as the low levels of arterial O2 and the increase of rate and depth of ventilation.
Hypoxemia
During a normal and relaxed breath, a person inhales how many mL of air?
500 mL
What should the nurse do when assessing the respiratory rate under the nursing process?
Observe a full inspiration and expiration when counting ventilation or respiratory rate.
This is measured by using a pulse oximeter and permits the indirect and noninvasive measurement.
Oxygen Saturation
This is the measurement of exhaled carbon dioxide throughout exhalation.
Capnography
What is the normal range of PaCO2 (Partial Pressure of Carbon Dioxide)?
35 to 45 mmHg
What does capnography approximates?
PaCO2 (Partial Pressure of Carbon Dioxide)
What is the normal oxygen saturation?
A saturation greater than 92% is acceptable and 75% or less is considered a critical value.
What is the acceptable range of oxygen saturation among newborns?
30 to 60 breaths per minute
What is the acceptable range of oxygen saturation among infants (6 months)?
30 to 50 breaths per minute
What is the acceptable range of oxygen saturation among toddler (2 years)?
25 to 32 breaths per minute
What is the acceptable range of oxygen saturation among child?
20 to 30 breaths per minute
What is the acceptable range of oxygen saturation among adolescent?
16 to 20 breaths per minute
What is the acceptable range of oxygen saturation among adult?
12 to 20 breaths per minute
What are the different types of diagnosis under respiration?
(1) Activity intolerance
(2) Hyperventilation
(3) Impaired Airway Clearance
(4) Impaired Gas Exchanged
What should the nurse do when evaluating the patient’s respiration?
(1) Evaluate patient outcomes by reassessing the respiratory rate (RR), ventilatory depth, rhythm, and SPO2
(2) Consider the physiological changes expected from nursing interventions
This is measured on all patients receiving health care.
Blood Pressure (BP)
Why is the accurate measurement on BP important?
It is essential to guide patient management, determine a patient’s response to interventions and prevent adverse outcomes (AACN,2016)
This is the force exerted on the walls of an artery by the pulsing blood under the pressure from the heart.
Blood Pressure
This occurs when the ventricles of the heart contract and force blood under high pressure into the aorta.
Systolic Pressure
This is when the ventricles relax, the heart fills, and the pressure of blood in the arteries; minimal pressure exerted against the arterial walls at all times.
Diastolic Pressure
What is the standard unit for blood pressure?
mmHg (millimeters of mercury)
This is the difference between systolic and diastolic pressure.
Pulse pressure (120/70 = 50)
What is the average blood pressure among newborns?
40 (mean)
What is the average blood pressure among 1 month?
85/54 mmHg
What is the average blood pressure among 1 year?
95/65 mmHg
What is the average blood pressure among 6 years?
105/65 mmHg
What is the average blood pressure among 10 to 13 years?
110/65 mmHg
What is the average blood pressure among 14 to 17 years?
119/75 mmHg
What is the average blood pressure among 18 years and older?
<120/<80 mmHg
What are the factors affecting blood pressure?
(1) Age
(2) Stress
(3) Ethnicity and Genetics’
(4) Gender
(5) Daily Variation
(6) Medications
(7) Activity and Weight
(8) Smoking
What is normal blood pressure in terms of systolic and diastolic pressure?
Systolic Blood Pressure: <120mmHg
Diastolic Blood Pressure: <80mmHg
What is elevated blood pressure in terms of systolic and diastolic pressure?
Systolic Blood Pressure: 120 to 129 mmHg
Diastolic Blood Pressure: <80mmHg
What is the stage 1 hypertension blood pressure in terms of systolic and diastolic pressure?
Systolic Blood Pressure: 130 to 139 mmHg
Diastolic Blood Pressure: 80 to 89 mmHg
What is the stage 2 hypertension blood pressure in terms of systolic and diastolic pressure?
Systolic Blood Pressure: >140 mmHg
Diastolic Blood Pressure: >90 mmHg
This is the elevated blood pressure (associated with thickening and loss of elasticity in the arterial walls).
Hypertension
This is when the systolic blood pressure falls to 90 mmHg or below.
Hypotension
This occurs when a normotensive person develops symptoms (light headedness or dizziness) and a drop in systolic pressure by 20 mmHg or a drop in systolic by 10 mmHg.
Orthostatic hypotension or postural hypotension
What should the nurse do in terms of assessment of blood pressure?
Before assessing the blood pressure, make sure that you are comfortable using the equipment.
What does a sphygmomanometer include?
This includes a pressure manometer occlusive cuff and pressure bulb
What are the different types of diagnosis under blood pressure?
(1) Activity Intolerance
(2) Anxiety
(3) Impaired Cardiac Output
(4) Fluid Imbalance
(5) Acute Pain
What should the nurse do when planning and implementing under blood pressure?
(1) Nursing care plan includes individualized patient-centered interventions
(2) Health promotion (educate about BP values, long term follow up care and therapy)
What should the nurse do when evaluating under blood pressure?
(1) Know a patient’s baseline trend when evaluating blood pressure values in response to therapies
(2) Known the expected effects of an intervention for BP alterations
