Vital Signs (Temperature)

Question 1

What are the vital signs ?

Answer 1

1. body temperature
2. pulse
3. respiration
4. blood pressure
5. pain
6. oxygen saturation

Question 2

Why do we measure vital signs?

Answer 2

They are measured and checked to monitor the functions of the body. They are checked in total.

Question 3

Should nurses monitor clients vital signs as a routine checking?

Answer 3

No, it should be thoughtful & a scientific assessment.

Question 4

When do we assess vital signs?

Answer 4

1. on admission
2. when client’s health status, changes
3. when client experiences symptoms like chest pain, feeling hot or faint
4. before & after surgery or invasive procedure
5. before & after medications affecting respiratory or cardiovascular system
6. before & after nursing interventions affecting vital signs.

Question 5

What does body temperature reflect?

Answer 5

It reflects the balance between heat production & heat loss from the body, measured in heat units - degrees.

Question 6

What is heat balance?

Answer 6

It is when the production of heat is equal to the loss of heat in the body.

Question 7

What are the 2 types of body temperature?

Answer 7

1. core temperature - temperature of deep tissues of body, abdominal cavity & pelvic cavity. It remains relatively constant.
2. surface temperature - temperature of skin, subcutaneous tissue & fat. It rises & falls in response to environment.

Question 8

What are the ways our body produces & loses heat?

Answer 8

Heat production :
- basal metabolic rate
- Exercise / shivering
- Secretion of thyroxine, epinephrine, norepinephrine
- inflammation / fever
Heat loss :
- Evaporation
- Conduction
- Convection
- Radiation

Question 9

What is insensible heat & water loss?

Answer 9

It is the continuous & unnoticed water & heat loss.

Question 10

How is body temperature regulated?

Answer 10

• through sensors in periphery & core
• the integrator in hypothalamus
• effector system adjusting heat production & loss

Question 11

What are the physiological processes that increase body temperature?

Answer 11

• shivering
• sweating glands inhibited
• vasoconstriction

Question 12

What are the factors that affect body temperature?

Answer 12

• Age
• Sex
• Environment
• Exercise
• Hormones
• Stress
• Diurnal variations / circadian rhythms

Question 13

What’s the normal range of body temperature in adults?

Answer 13

96.8 F - 99.5 F
36 C - 37.5 C

Question 14

What are the statements used to describe a raise in body temperature?

Answer 14

Names :
- Pyrexia
- Hyperpyrexia
- Hyperthermia
- Fever
- Febrile state
Types :
- Intermittent. Body temperature fluctuates between normal and high
- Remittent. Body temperature fluctuates but never reaches normal
- Relapsing. Body temperature is high for days, then returns to normal for days/week, then goes back to being high again.
- Constant. Doesn’t fluctuate.
- Fever spike. Sudden rise in temperature in a short period of time
Causes :
- Heat exhaustion
- Heat stroke

Question 15

What’s the term used to describe a drop in body temperature below normal range?

Answer 15

Hypothermia.

Question 16

What are the clinical stages of a fever?

Answer 16

1. Onset (cold or chill phase)
2. Course (plateau phase)
3. defervescence (fever abatement & flush phase)

Question 17

What are the symptoms of an onset fever?

Answer 17

• increased heart rate
• increased respiratory rate & depth
• Shivering
• pallid, cold skin
• complaints of feeling cold
• cyanotic nail beds
• Goose flesh
• cessation of sweating

Question 18

What are the symptoms of a course fever?

Answer 18

• Absence of chills
• skin that feels warm
• photosensitivity
• glassy eyed appearance
• increased pulse & respiratory rates
• Drowsiness, restlessness, delirium or convulsions
• Herpetic lesions of the mouth
• Malaise, weakness & muscle ache
• loss of appetite if prolonged

Question 19

What are the symptoms of a defervescence fever?

Answer 19

• skin that appears flushed & feels warm
• sweating
• decreased shivering
• possible dehydration

Question 20

What are the nursing interventions of clients with a fever?

Answer 20

• Monitor vital signs
• Asses skin color & temperature
• Monitor white blood cell count
  hematocrit value
  and pertinent laboratory reports to indicate if infection or dehydration is present.
• remove or provide excess blankets according to how patient feels
• Provide adequate nutrition & fluids (2500-3000mL per day) to meet the increased metabolic demands & prevent dehydration
• measure intake & output
• reduce physical activity o limit heat production, esp during flushed state
• administer antipyretics as ordered
• provide oral hygiene to keep mucous membrane moist
• provide a tepid sponge bath to reduce body temperature through conduction
• provide dry clothing & bed linen

Question 21

What are the clinical signs of hypothermia?

Answer 21

• decreased body temperature, pulse & respirations
• pale, cold, waxy skin
• intense shivering initially
• feeling cold & chilly
• decreased urinary output
• hypotension
• lack of muscle coordination
• disorientation
• drowsiness that leads to coma
• frostbite

Question 22

What are the nursing interventions for hypothermia?

Answer 22

• provide warm environment
• apply warm blankets
• provide dry clothing
• keep limbs close to the body
• cover client’s scalp with cap or turban
• supply warm oral or iv fluids
• apply warming pads

Question 23

What are the sites for measuring body temperature?

Answer 23

• oral
• axillary
• rectal
• tympanic membrane
• skin / temporal artery

Question 24

Advantages & disadvantages of oral thermometer?

Answer 24

Advantages : accessible & convenient
disadvantages : if bitten, thermometer may break
may injure patient if following oral surgery
inaccurate if patient ingested hot or cold food or drink or smoked

Question 25

Advantages & disadvantages of rectal thermometer?

Answer 25

advantages : reliable measurement. accurate
disadvantages : unpleasant & inconvenient to patient
may injure rectum
stool may affect thermometers placement
difficult for clients who cant turn to the side

Question 26

Advantages & disadvantages of axillary thermometer?

Answer 26

advantages : safe & noninvasive
disadvantages : needs a long time to measure temperature ( 10 mins )

Question 27

Advantages & disadvantages of tympanic membrane thermometer?

Answer 27

advantages : very fast
readily accessible
reflects core temperature
disadvantages : may be uncomfortable
involves risk of injury if probe is inserted too far
presence of cerumen can affect reading
anatomic or pathologic differences may cause measurements to vary between left & right

Question 28

Advantages & disadvantages of temporal artery thermometer?

Answer 28

advantages : safe
non invasive
very fast
disadvantages : electronic may be expensive or unavailable
if perspiration present on forehead, variation in technique must be used

Question 29

What are the types of thermometers?

Answer 29

1. electronic
2. chemical disposable
3. temperature sensitive tape
4. infrared (tympanic)
5. temporal artery

Question 30

What is the formula for converting Fahrenheit to Celsius?

Answer 30

C = ( Fahrenheit temp - 32 ) * 5/9

Question 31

What is the formula for converting Celsius to Fahrenheit?

Answer 31

F = ( Celsius temp * 9/5 ) + 32

Question 31

What is the process of delegation of temperature measurement?

Answer 31

1. Routine measurement may be delegated to AP
2. AP reports abnormal temperatures
   - Nurse interprets abnormal temperature & determines response