Chapter 29 - Vital Signs

Front 1

Name the most frequent measurements of vital signs.

Back 1

Temperature, pulse, blood pressure, respirations, and oxygen saturation.

Front 2

Discuss some of the factors that can effect the vital signs.

Back 2

The temperature of the room you're in, the physical exertion of the patient, and the effects of illness.

Front 3

Discuss some of the outcomes expected from measuring vital signs.

Back 3

Identify diagnoses, implement interventions, and evaluate the outcome of care.

Front 4

Name the acceptable ranges for an adult's temperature.

Back 4

36-38 degrees Celsius or 96.8-100.4 degrees Fahrenheit.

Front 5

You take the temperature of an adult patient using a mercury thermometer in the mouth. They have a temperature of 37 degrees Celsius. Is this normal?

Back 5

Yes, this is the average oral temperature of an adult.

Front 6

You take the temperature of an adult using a tympanic thermometer. They have a temperature of 98.6 degrees Fahrenheit. Is this normal?

Back 6

Yes, this is the average tympanic temperature of an adult.

Front 7

You take the rectal temperature of an adult because he is intubated. You receive a rectal temperature of 39 degrees Celsius. Is this normal?

Back 7

No, this is not normal, average rectal temperature is 37.5 degrees Celsius (99.5 degrees Fahrenheit)

Front 8

You take an axillary temperature of a patient. They have a temperature of 35 degrees Celsius. Is this normal?

Back 8

No, this is not normal, the average axillary temperature of an adult is 36.5 degrees C or 97.7 degrees F.

Front 9

You take the pulse rate of a healthy adult male. His pulse rate is 70 b/min. Is this normal?

Back 9

Yes, the average adult's pulse rate is between 60 and 100 b/min.

Front 10

Explain what the pulse pressure is.

Back 10

The pulse pressure is the difference between the systolic and diastolic pressures, normally 30 to 40 mmHg.

Front 11

Discuss some of the times to measure Vital signs.

Back 11

On admission; during assessment; according to a routine schedule; before and after an invasive procedure; before during and after blood transfusions; before during and after meds that effect CV, respiratory or temperature systems; when a patient's condition changes; when a patient reports nonspecific symptoms of distress.

Front 12

Discuss the responsibilities related to taking blood pressure.

Back 12

The nurse is responsible for either obtaining the vital signs, or delegating the task and then interpreting them. The nurse must then make decisions about interventions from this information. The nurse must also make sure that all equipment is working properly and appropriate for the patient. The nurse is responsible for knowing the normal range of all vital signs for each patient. The nurse is responsible for knowing anything in the medical history, the therapies, and prescribed medications that might cause changes in the vital signs. Be aware of environment that might cause a change in vital signs. Determine how often to obtain vital signs based on the patient's condition. The vital signs will effect the dosage of certain medications. The nurse must tell the health care provider of any significant changes, and document these. The nurse must instruct the patient "in vital sign assessment and the significance of findings."

Front 13

Discuss what gland regulates body temperature and which parts regulate what.

Back 13

The hypothalamus is responsible for temperature regulation. If the body loses heat, the posterior hypothalamus will cause vasoconstriction to protect the vital organs, raise the pili, and activate shivering to create heat. When the body heats up, the anterior hypothalamus signals the blood vessels to dilate, allowing blood to flow closer to the surface of the body and thus cool down. This can also activate sweating. Physical activity can increase heat production up to 50 times normal. Shivering can increase heat production 4 or 5 times normal. Neonates cannot shiver (nonshivering thermogenesis)

Front 14

Describe BMR and how certain glands can effect it.

Back 14

BMR is the basal metabolism rate: the amount of energy used in a unit of time by a fasting, resting subject to maintain vital functions. The thyroid gland promotes the breakdown of body glucose and fat, thus increasing the rate of chemical reactions. With large amounts of TSH, BMR can increase by 100%, with the lack of TSH, BMR can decrease by 50%. Men have a higher BMR than women because of testosterone.

Front 15

Discuss ways that heat radiation is effected.

Back 15

Peripheral vasodilation increases radiation because it brings the blood closer to the surface of the skin allowing it to be cooled by the environment. Peripheral vasoconstriction reduces heat lost. Standing increases heat lost (greater surface area = more heat lost); while the fetal position decreases heat loss by reducing surface area. Covering with clothes or blankets reduces heat loss by reducing conduction, the loss of heat by touching a cooler surface. Applying ice packs causes conduction. Convection reduces heat by air movement (e.g. a fan). Evaporation reduces heat by turning a liquid into a gas. Most of the body heat we lose is by this method through the skin and lungs. The anterior hypothalamus signals when the body gets too warm, and makes the sweat gland release sweat, which then evaporates.

Front 16

Describe diaphoresis.

Back 16

Diaphoresis is the visible sweat upon the brow and upper body (can occur elsewhere). We lose 1 liter of fluid for each hour of exercise in hot conditions. Excessive evaporation can cause dry skin.

Front 17

Discuss some things that might effect a person's ability to control body temperature.

Back 17

The temperature in the environment (extreme or not), the person's ability to recognize discomfort, the person's thoughts or emotions, the person's ability to remove or add clothing. E.g. infants, seniors, disabled persons.

Front 18

An infant's temperature was measured at 39 degrees C. Is this within normal limits?

Back 18

No, a normal temperature for an infant is between 35.5 degrees C to 37.5 degrees C. or 95.9 degrees F to 99.5 degrees F.

Front 19

Is the normal temperature range of an older adult more narrow or wider than a younger adult? Explain why or why not.

Back 19

It is more narrow. This is because of a breaking down in the mechanisms that control temperature, especially in the control of dilation/constriction of blood vessels. It is also due to lower amounts of fat, reduced sweat production, and reduced metabolism.

Front 20

Do men or women experience greater body temperature fluctuations? Explain.

Back 20

Women do. Hormones (particularly during menstruation) can cause fluctuations in temperature. P4 levels rise, ovulation occurs, and temperature rises to baseline levels or a little higher. P4 levels fall afterward to a few tenths of a degree below baseline. This helps predict fertility. During menopause, temperature can increase by 4 degrees C or 7.2 degrees Fahrenheit for 30 seconds to 5 minutes. (hot flash) This is caused by instability in the vasomotor controls.

Front 21

Describe how the circadian rhythm can effect temperature.

Back 21

A person's temperature rises about .5 to 1 degree C (0.9 to 1.8 F) every day reaching a peak around 4pm. It then declines steadily until reaching a natural low between 0100 and 0400.

Front 22

A visibly nervous person presents at the hospital, you take his temperature and find it slightly elevated. What could cause this temperature change?

Back 22

Stress can cause a slightly higher temperature than normal.

Front 23

A patient presents with pyrexia of 101.9 degrees F that has maintained for several hours. Is this a concern? Explain why or why not.

Back 23

The patient does have a low grade fever, but it is not dangerous because it is below the danger level of 102.2F or 39C. Up to 102.2 or 29C the elevated body temperature is helpful in enhancing the immune system. The white cell count is elevated to fight antigens; Iron count is lowered to suppress the growth of bacteria; and interferon is stimulated to fight viral infections.

Front 24

What causes a true fever?

Back 24

The set point of the hypothalamus gets changed. Pyrogens (bacteria, viruses, etc) elevate the body temp, causing immune response. The body responds by making the set point higher. The person's body responds with chills and feels cold because the body is trying to raise it's temperature to the set point. The duration and degree of fever depends on the strength of the pyrogen and the ability of the person to respond.

Front 25

What happens if the fever causing agent is removed?

Back 25

The hypothalamus set point drops, and the person's anterior hypothalamus activates its heat loss mechanisms, such as diaphoresis. The person feels warm and flushed. Once complete, the person is said to be afebrile.

Front 26

A patient presents with a constant temperature of 39 degrees. It has fluctuated very little over the last day. What kind of fever pattern is this?

Back 26

Sustained. A constant body temperature continuously above 38C (100.4F) that has little fluctuation.

Front 27

A patient has had a normal temp with fever spikes every few hours. what kind of fever pattern is this?

Back 27

Intermittent. Fever spikes interspersed with usual temperature levels (Temperature returns to acceptable value at least once in 24 hours)

Front 28

A patient has a temperature that rises and falls, but stays outside of normal limits. What kind of fever pattern is this?

Back 28

Remittent. Fever spikes and falls without a return to normal temperature levels.

Front 29

A home health patient has had a fever lasting about a day, with several days of afebrile episodes, then returning to a febrile state for about another day. What kind of fever pattern is this?

Back 29

Relapsing. Periods of febrile episodes and periods with acceptable temperature values. (Febrile episodes and periods of normothermia are often longer than 24 hours)

Front 30

What is the average respiratory rate for a newborn child?

Back 30

30 to 60 b/min

Front 31

What is the average respiratory rate for an infant 6 months to 1 year?

Back 31

30 to 50 breaths/min

Front 32

What is the average respiratory rate for a toddler (2 years)?

Back 32

25 to 32 breaths/min

Front 33

what is the average respiratory rate for a child from 3 to 12 years old?

Back 33

20 to 30 breaths/min

Front 34

What is the average respiratory rate for an older adult?

Back 34

16 to 25 breaths/min

Front 35

A patient presents with diabetic ketoacidosis. What respiratory phenomenon might you see in this patient?

Back 35

Kussmaul's respiration