Vital Signs - Nrsg Fun Ch 17

Question 1

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

Answer 1

97.2 - 101.4 F (35.7 - 38.6 C)

Question 2

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

Answer 2

98.6 F or 36.7-37 C

Question 3

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

Answer 3

99.5 F or 37.5 C

Question 4

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

Answer 4

97.7F or 36.5C

Question 5

What is the normal range foe pulse rate in adults?

Answer 5

60-100 bpm

Question 6

What is the average for pulse rate in adults?

Answer 6

80 bpm

Question 7

What is the normal range for respiration rates in adults?

Answer 7

12-20 rpm

Question 8

What is the average for blood pressure in adults?

Answer 8

100-120 systolic

60-80 diastolic

Question 9

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

Answer 9

120-130 systolic

80-89 diastolic

Question 10

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

Answer 10

New recommendations say 110/70

Old norm was 120/80

Question 11

What are the main vital signs?

Answer 11

Temp, pulse rate, respirations, blood pressure, pain

Question 12

What are some common occasions for assessing vital signs?

Answer 12

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

Question 13

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

Answer 13

Every 4-8 hours

Question 14

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

Answer 14

Each visit

Question 15

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

Answer 15

Each visit

Question 16

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

Answer 16

Weekly to monthly

Question 17

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

Answer 17

5-15 min

Question 18

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

Answer 18

Core - rectal and tympanic

Surface - oral and axillary

Question 19

Body Temperature is controlled by the …

Answer 19

Hypothalamus

Question 20

Body temperature is decreased by what physiological processes?

Answer 20

Vasodilation
Sweating
Inhibition of heat production

Question 21

Body temperature is increased by what physiological processes?

Answer 21

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

Question 22

How is heat produced in the body?

Answer 22

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

Question 23

How is heat exchanged with the environment?

Answer 23

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

Question 24

How does developmental level affect body temp?

Answer 24

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.

Question 25

How do hormones affect body temp?

Answer 25

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

Question 26

How does exercise affect body temp?

Answer 26

Exercise increases metabolism which causes increased body temps

Question 27

How does stress affect body temp?

Answer 27

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

Question 28

How does the circadian rhythm affect temp

Answer 28

Temperatures can fluctuate 1-2F over 24hrs. | Temps usually lowest in the early morning and highest in the lease afternoon or early evening.

Question 29

What is the conversion from F to C?

Answer 29

(F-32) x 5/9 = C

Question 30

What is the conversion from C to F

Answer 30

(C x 9/5) + 32 = F

Question 31

What are the phases of fever?

Answer 31

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)

Question 32

What are the types of fever?

Answer 32

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

Question 33

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

Answer 33

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

Question 34

When would you diagnose hyperthermia?

Answer 34

T is above normal | Pt c/o fatigue, feels warm, is flushed, has an increased heart rate

Question 35

When would you diagnose Ineffective thermoregulation?

Answer 35

T fluctuates above and below normal (intermittent fever)

Question 36

When would you diagnose Risk for Imbalanced body temperature?

Answer 36

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

Question 37

What are the standardized outcomes for Hyperthermia and Ineffective thermoregulation

Answer 37

Thermoregulation, thermoregulation: Newborn, and VS

Question 38

What are the outcomes for risk for imbalanced body temperature

Answer 38

Adherence behavior, compliance behavior, risk control, risk detection

Question 39

What are some examples of Pt centered individual goals

Answer 39

Oral temp

Question 40

What are some interventions for fever/hyperthermia

Answer 40

``` 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 ```

Question 41

Hypothermia exists when ...

Answer 41

Core T drops below normal

Question 42

Severe hypothermia exists when...

Answer 42

Core T falls below 82.4F or 28C

Question 43

Hypothermia is diagnosed when

Answer 43

A Pt body T is below normal

Question 44

What are some patient centered goals for hypothermia?

Answer 44

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

Question 45

What are some interventions for hypothermia?

Answer 45

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

Question 46

What is the range for normal pulse rate in adults?

Answer 46

60-100 bpm | Avg 70-80 bpm

Question 47

Stroke volume is ....

Answer 47

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

Question 48

What factors affect pulse rate?

Answer 48

``` 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 ```

Question 49

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

Answer 49

96.2 - 100.4 F (35.7 - 38 C)