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Nursing Fundamentals > Vital Signs - Nrsg Fun Ch 17 > Flashcards

Vital Signs - Nrsg Fun Ch 17 Flashcards

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1
Q

What is the normal rang for a rectal core temp in adults?

A

97.2 - 101.4 F (35.7 - 38.6 C)

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2
Q

What is the ideal average for an oral or tympanic temp in adults?

A

98.6 F or 36.7-37 C

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3
Q

What is the ideal average for a rectal temp in adults?

A

99.5 F or 37.5 C

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4
Q

What is the ideal average for a Axillary temp in adults?

A

97.7F or 36.5C

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5
Q

What is the normal range foe pulse rate in adults?

A

60-100 bpm

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6
Q

What is the average for pulse rate in adults?

A

80 bpm

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7
Q

What is the normal range for respiration rates in adults?

A

12-20 rpm

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8
Q

What is the average for blood pressure in adults?

A

100-120 systolic

60-80 diastolic

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9
Q

What is the range for a prehypertensive blood pressure in adults?

A

120-130 systolic

80-89 diastolic

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10
Q

What is the the average for normal blood pressure in adults?

A

New recommendations say 110/70

Old norm was 120/80

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11
Q

What are the main vital signs?

A

Temp, pulse rate, respirations, blood pressure, pain

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12
Q

What are some common occasions for assessing vital signs?

A

On admission
Admission to general practitioner or clinic
Before, during or after surgery or special procedures
Monitoring affects of meds
Whenever the condition of the patient changes

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13
Q

At what frequency should you check VS for a patient in the hospital?

A

Every 4-8 hours

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14
Q

At what frequency should you check VS for a patient in a home health setting?

A

Each visit

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15
Q

At what frequency should you check VS for a patient in the clinic?

A

Each visit

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16
Q

At what frequency should you check VS for a patient in skilled nursing facilities/convalescence?

A

Weekly to monthly

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17
Q

If a patients Vs are abnormal how often should their VS be checked?

A

5-15 min

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18
Q

Which readings are considered core temps and which are surface temps?

A

Core - rectal and tympanic

Surface - oral and axillary

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19
Q

Body Temperature is controlled by the …

A

Hypothalamus

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20
Q

Body temperature is decreased by what physiological processes?

A

Vasodilation
Sweating
Inhibition of heat production

21
Q

Body temperature is increased by what physiological processes?

A

To produce heat
Shivering
Release of epinephrine to increase metabolism
To reduce heat loss
Vasoconstriction
Piloerection - hairs standing on end

22
Q

How is heat produced in the body?

A

Metabolism
Sketch muscle (catabolism of fats and carbs)
Nonshivering thermogenesis - metabolism of brown fat in infants only

23
Q

How is heat exchanged with the environment?

A

Radiation - heat loss through EM waves
Convection - transfer of heat through air or water currents
Evaporation - heat lost through water-vapor conversion (insensible loss - affected by humidity)
Conduction - heat transfer through direct contact

24
Q

How does developmental level affect body temp?

A

Infants and the elderly ca not regulate their body temp as efficiently.
Infants lose ~ 30% heat through head which is proportionately larger
Elderly have slower metabolic rates, decreased vasomotor control and loss of subcutaneous tissue.

25
Q

How do hormones affect body temp?

A

Women’s body temp can fluctuate 1F with menstruation and menopause can cause temperature fluctuations.

26
Q

How does exercise affect body temp?

A

Exercise increases metabolism which causes increased body temps

27
Q

How does stress affect body temp?

A

Stress stimulates the sympathetic nervous system which causes increased production of epinephrine and norepinephrine. These hormones increase metabolic rates which then increase temp.

28
Q

How does the circadian rhythm affect temp

A

Temperatures can fluctuate 1-2F over 24hrs.

Temps usually lowest in the early morning and highest in the lease afternoon or early evening.

29
Q

What is the conversion from F to C?

A

(F-32) x 5/9 = C

30
Q

What is the conversion from C to F

A

(C x 9/5) + 32 = F

31
Q

What are the phases of fever?

A

Initial/febrile/onset - T is rising, Pt feels chilly, uncomfortable and may shiver
Second/course - T reaches max, Pt feels warm, dry, may last days or weeks
Third/defervescence/crises/breaking - T returns to normal, Pt feels warm, flushed due to vasodilation, diaphoresis(sweating)

32
Q

What are the types of fever?

A

Intermittent - T alts between fever, normal and below-normal
Remittent - wide fluctuations all above normal
Constant/sustained
Relapsing fever - short periods of fever alt w periods of normal, each lasts 1 - 2 days

33
Q

High T up to 102.2F or 39C enhance immune response by…

A

Kill/inhibit growth of microorganisms
Enhance phagocytosis
Cause breakdown of lysosomes and self-destruction of virally infected cells
Cause the release of interferon to protect cells against viruses

34
Q

When would you diagnose hyperthermia?

A

T is above normal

Pt c/o fatigue, feels warm, is flushed, has an increased heart rate

35
Q

When would you diagnose Ineffective thermoregulation?

A

T fluctuates above and below normal (intermittent fever)

36
Q

When would you diagnose Risk for Imbalanced body temperature?

A

When T of Pt is normal, but Pt is at risk for failure of T regulation (e.g. Infants/frail elderly)

37
Q

What are the standardized outcomes for Hyperthermia and Ineffective thermoregulation

A

Thermoregulation, thermoregulation: Newborn, and VS

38
Q

What are the outcomes for risk for imbalanced body temperature

A

Adherence behavior, compliance behavior, risk control, risk detection

39
Q

What are some examples of Pt centered individual goals

A

Oral temp

40
Q

What are some interventions for fever/hyperthermia

A 
Help determine causality
Monitor T and other VS every 2hr
Observe for clinical signs
Administer prescribed antibiotics
Provide oral/IV fluids
Provide cooling blankets, baths, ice packs, fans, minimal bedcovers
Provide nutritional support
Provide special mouth care - lip lube
Keep linens and clothing dry
Provide emergency measures
41
Q

Hypothermia exists when …

A

Core T drops below normal

42
Q

Severe hypothermia exists when…

A

Core T falls below 82.4F or 28C

43
Q

Hypothermia is diagnosed when

A

A Pt body T is below normal

44
Q

What are some patient centered goals for hypothermia?

A

oral T >98.6F or 37C
No clinical signs of hypothermia
Pulse and RR within normal range

45
Q

What are some interventions for hypothermia?

A

Provide warm, dry clothing and warm drinks
Use warmed IV fluids, heating pads, blankets or baths
Rewarm Pt gradually
Monitor VS frequently
Observe for s/s of hypothermia

46
Q

What is the range for normal pulse rate in adults?

A

60-100 bpm

Avg 70-80 bpm

47
Q

Stroke volume is ….

A

The volume of blood forced out of the heart in a single contraction of the left ventricle (avg 70mL)

48
Q

What factors affect pulse rate?

A 
Age- decreases w age
Sex - higher in females
Exercise - increased during
Food - ingestion slightly increases
Stress - increases
Fever - increase ~ 10 bpm
Disease - either
Blood loss - can increase nominally
Position change - increases w sitting/standing
Medications - either
49
Q

What is the normal range for an oral core temp in adults?

A

96.2 - 100.4 F (35.7 - 38 C)

Nursing Fundamentals (24 decks)

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