Vital Signs (ch 24)

Question 0

When to assess vital signs

Answer 0

1) on admission
2) based on institutional policy& procedures
3) anytime theres a change in the patients condition
4) loss of consciousness
5) before and after surgical/invasive procedure
6) before & after activity that may incr risk (ex: ambulation after surgery
7) before admits tearing meds that affect cardiovascular and respiratory function

Question 1

Temperature

Answer 1

Difference between the amount of heat produced by the body versus the amount of heat lost to the environment.

Question 2

Physiology of body temperature

Answer 2

Heat production - primary source is metabolism. Influenced by hormones and exercise. Incr heat by shivering

Heat loss - primary site is skin. Evaporation of sweat through warming and humidifying of inspired air and through elimination of urine and feces.

Question 3

Factors affecting body temperature

Answer 3

1. Circadian Rhythms- temp lower in the morning
2. Age and Gender- elderly lose thermoregulatory control. Infants and children adjust quickly. Women (hormones) experience more fluctuations.
3. Environmental temp- hypo/hyperthermia without proper protection.

Question 4

Hypothermia

Answer 4

Low body temp. < 96f (35.5c)

Question 5

Hyperthermia

Answer 5

High body temperature

Question 6

Afebrile

Answer 6

Without a fever. Normal body temp

Question 7

Pyrexia

Answer 7

Fever

Question 8

Febrile

Answer 8

Person with a fever. Signals infection
Causes:
-tissue injury, myocardial infarction, pulmonary emboli, cancer, trauma, surgery.

Question 9

Difference between Fever and Hyperthermia

Answer 9

With hyperthermia the hypothalamic set point is not changed. Environmental factors (excessive heat) alter body temp and temp controlling mechanisms are ineffective.

Question 10

Intermittent fever

Answer 10

Body temp alternates regularly between feverish and afebrile states.

Question 11

Remittent fever

Answer 11

Body temp fluctuates several degrees above normal but does not reach normal between fluctuations.

Question 12

Constant fever

Answer 12

Temp remains consistently elevated and fluctuates less than 2*C

Question 13

Relapsing fever

Answer 13

Body temp returns to normal for at least a day, but then recurs

Question 14

Crisis fever

Answer 14

Fever returns to normal suddenly

Question 15

Lysis fever

Answer 15

Fever returns to normal gradually

Question 16

Normal body Temps

Answer 16

Oral-          98.6  /   37
Rectal-      99.5  /   37.5
Axillary-     97.7  /   36.5
Tympanic- 99.5  /   37.5
Forehead- 94.0  /   34.4

Question 17

Physical effects of fever

Answer 17

Loss of appetite, headache, hot and dry skin, flushed face, thirst, muscle aches, fatigue.

Increase respirations
Increase pulse rate

Elderly - confusion and delirium

At risk for fluid, electrolyte, acid-base imbalances

Question 18

Methods for reducing fever

Answer 18

1. Bacterial infection - antibiotics
2. Antipyretics; aspirin, acetaminophen (reset thermoregulatory mechanism)
3. Cool sponge baths, cool packs, &hypothermia

Question 19

NIC Fever Interventions

Answer 19

Monitor temp frequently as appropriate
Monitor BP, pulse, respiration
Monitor intake and output
Monitor seizure activities
Admin antipyretic med
Admin IV fluids as appropriate 
Apply ice bag covered with towel to axillary or 
     groin area

Question 21

NOC Fever Treatment

Answer 21

Vital signs, hydration, thermoregulation

Risk Control: Hypothermia

Question 22

Where are surface body temperatures measured at?

Answer 22

oral
axillary
and skin surface sites

Question 23

Where are core body temperatures measured at?

Answer 23

tympanic or rectal

Question 24

When is the temperature the hottest?

Answer 24

between 4-7 pm

Question 25

Radiation

Answer 25

diffusion or dissemination of heat by electromagnetic waves

Question 26

Convection

Answer 26

dissemination of heat by motion between areas of unequal density

Question 27

Evaporation

Answer 27

conversion of a liquid to a vapor

Question 28

Conduction

Answer 28

transfer of heat to another object during direct contact

Question 29

Pulse

Answer 29

Throbbing sensation that can be palpated over a peripheral artery

Question 30

bradycardia

Answer 30

pulse rate below 60 beats per minute

Question 31

Tachycardia

Answer 31

pulse rate is 100-180 bpm

Question 32

Factors contributing to tachycardia

Answer 32

• decrease in blood pressure
• elevated temperature
• any condition related to poor oxygenation
• exercise
• prolonged application of heat
• pain
• strong emotions
• some medication

Question 33

dysrhythmia

Answer 33

irregular pattern of heartbeats

Question 34

pulse deficit

Answer 34

difference between the radial and the apical pulse

Question 35

Respiration

Answer 35

includes ventilation, diffusion, and perfusion

Question 36

eupnea

Answer 36

normal breathing

Question 37

tachypnea

Answer 37

increased respiratory rate

Question 38

bradypnea

Answer 38

decrease in respiratory rate

Question 39

apnea

Answer 39

periods during which there is no breathing

Question 40

dyspnea

Answer 40

difficult or labored breathing

Question 41

orthopnea

Answer 41

breathing easier sitting upright

Question 42

blood pressure

Answer 42

force of the moving blood against the atrial walls

Question 43

pulse pressure

Answer 43

difference between systolic and diastolic pressure

Question 44

Hypertension

Answer 44

blood pressure that is above normal for a sustained period of time

Question 45

Hypotension

Answer 45

below normal blood pressure

Question 46

Orthostatic hypotension

Answer 46

drop in systolic blood pressure of a number greater than or equal to 20 mm Hg or diastolic pressure or a number greater than or equal to 10 mm Hg within three minutes of standing