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68 Cards in this Set
- Front
- Back
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normal adult temperature
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36° to 38° C (96.8° to 100.4° F)
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normal adult pulse
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60 to 100 beats/min
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normal adult respiration
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12 to 20 breaths/min
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normal adult blood pressure
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Average: <120/<80 mm Hg
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Vital signs can be delegated, but who is ultimate responsible for the patient's vital signs?
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Nurse
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Following surgery or treatment intervention you measure vital signs _______ frequently to detect complications.
more/less |
more
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As a patient's physical condition worsens, it is often necessary to monitor vital signs as often as every _______.
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5-10 minutes
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thermoregulation
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Physiological and behavioral mechanisms regulate the balance between heat lost and heat produced
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basal metabolism
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accounts for the heat produced by the body at absolute rest
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The average basal metabolic rate (BMR) depends on the patient's __________.
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body surface area
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Who has a higher BMR: women or men?
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Men
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radiation
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transfer of heat from the surface of one object to the surface of another without direct contact between the two
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conduction
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transfer of heat from one object to another with direct contact
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convection
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transfer of heat by way of air movement
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evaporation
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transfer of heat energy when a liquid is changed to gas
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Temperature regulation is unstable until children reach _______.
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puberty
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Identify why fever occurs.
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Because heat-loss mechanisms are unable to keep pace with excessive heat production, resulting in an abnormal rise in body temperature
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fever is usually not harmful if it stays below _______.
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39° C (102.2° F)
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Why is fever an important defense mechanism?
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-Enhances immune system
-WBC production is stimulated (febrile) -Reduces iron concentration in blood plasma, thus suppressing bacteria growth -Stimulates interferon |
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interferon
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natural virus-fighting substance of the body
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Body metabolism increases _____ for every degree Celsius of temperature elevation.
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10%
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What does an alternation in vital signs mean to the nurse?
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It signals a change in physiological function and the need for medical/nursing intervention.
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Identify the 9 situations vital signs would need to be measured.
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• On admission to a health care facility
• When assessing a patient during home care visits • In a hospital on a routine schedule according to the health care provider's order or hospital standards of practice • Before and after a surgical procedure or invasive diagnostic procedure • Before, during, and after a transfusion of blood products • Before, during, and after the administration of medication or therapies that affect cardiovascular, respiratory, or temperature-control functions • When a patient's general physical condition changes (e.g., loss of consciousness or increased intensity of pain) • Before and after nursing interventions influencing a vital sign (e.g., before a patient previously on bed rest ambulates or before a patient performs range-of-motion exercises) • When a patient reports nonspecific symptoms of physical distress (e.g., feeling “funny” or “different”) |
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Although measurement of vital signs can be delegated, who is ultimately responsible for them? Why is this?
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The nurse is ultimately responsible because she has to analyze and interpret their significance in order to make decisions about interventions.
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Identify the reason why it is important to know the patient's usual range of vital signs.
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They serve as a baseline for comparison with later findings.
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Identify the formula for body temp.
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Heat produced - Heat Loss = Body Temp
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core temperature
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temperature of the deep tissues
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Identify which part of the brain controls body temperature.
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hypothalamus
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Identify 3 methods the body uses to reduce body temperature.
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Sweating
Vasodilation (widening) of blood vessels Stop heat production |
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Identify 2 methods the body uses to increase body temperature.
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Vasoconstriction
Heat production through voluntary muscles (muscle shivering) |
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When vasoconstriction is ineffective in preventing additional heat loss, _______ begins.
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shivering
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When metabolism increases, _____ heat is produced..
When metabolism decreases, ____ heat is produced. |
When metabolism increases, more heat is produced..
When metabolism decreases, less heat is produced. |
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Identify 3 method(s) the nurse can do to promote radiation (heat loss to environment).
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Standing
Lying in fetal position Remove clothing/blankets |
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Identify 1 method(s) the nurse can do to promote radiation (heat loss to environment).
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Covering the body with dark, closely woven clothing
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Applying an ice pack or bathing a patient with a cool cloth increases _______,
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conductive heat loss (heat loss from between objects through direct contact)
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Identify 1 method(s) the nurse can do to reduce conduction.
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Apply several layers of clothing to patient
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How does evaporation occur within the human body in regards to thermoregulation? (2)
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Breathing
Sweating |
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Persons with more body fat have ______ natural insulation than do slim and muscular people.
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more
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In vasoconstriction, blood flow to the skin ______ to conserve heat.
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lessens
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If the core temp is too high, the hypothalamus initiates _________ so that ________.
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initiates vasodilation, so that more blood reaches the surface of the skin
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Identify the 4 factors that affect the ability of a person to control body temperature.
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(1) the degree of temperature extreme
(2) the person's ability to sense feeling comfortable or uncomfortable (3) thought processes or emotions (4) the person's mobility or ability to remove or add clothes |
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Identify the factor(s) affecting body temp in newborns and older adults need
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Newborns - Temp control mechanisms are immature; can't communicate; can't change their own clothes
Older adults - Deterioration in control mechanisms, poor vasodilation/vasoconstriction control, reduced subcutaneous tissue, reduced metabolism, and reduced sweat gland activity |
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Identify the factor(s) affecting body temp due to hormone level during menstrual cycle.
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Women's temperature fluctuates in menstrual cycle.
Progesterone low = lower temp Progesterone high (ovulation) = raise body temp |
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Identify the factor(s) affecting body temp in menopausal women.
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Hot flashes (intense body heat and sweating lasting 30s-5m) caused by instability of vasomotor controls (vasodilation/vasoconstriction)
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Identify during the day when body temp is the lowest.
Identify during the day when body temp is the highest. |
Lowest = 1:00-4:00 AM
Highest = Rises to max at about 4:00 PM |
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Identify how stress affects body temp.
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It raises body temp.
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How is fever a defense mechanism?
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Elevated temp enhances immune system, by stimulating WBC production
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Why does fever, pyrexia, occur?
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heat-loss mechanisms are unable to keep pace with excessive heat production
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hyperthermia
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elevated body temperature related to the inability of the body to promote heat loss or reduce heat production is hyperthermia
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heat stroke
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prolonged exposure to high environmental temp overwhelms mechanisms of the body; 104 degrees F or more
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Identify signs and symptoms of heat stroke. (8)
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Giddiness, confusion, delirium, excess thirst, nausea, muscle cramps, visual disturbances, and even incontinence
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Identify the most important sign of heatstroke. Why does this occur?
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Hot, dry skin
Victims of heatstroke do not sweat b.c of severe electrolyte loss and hypothalmic malfunction |
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heat exhaustion
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profuse diaphoresis results in excess water and electrolyte loss; caused by environmental heat exposure
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hypothermia
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heat loss during prolonged exposure to cold overwhelms the ability of the body to produce heat
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frostbite
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when the body is exposed to subnormal temperatures. Ice crystals form inside the cell, and permanent circulatory and tissue damage occurs
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Identify interventions for frostbite.
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gradual warming measures, analgesia, and protection of the injured tissue
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Identify how VS are affected in hypothermia.
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As the body temperature falls below 34.4° C (94° F), HR, respiratory rate, and BP fall.
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Identify intervention(s) for heat exhaustion.
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Promoting heat loss, such as moving pt. to a cooler environment.
Restore fluid and electrolytes |
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Identify intervention(s) for hypothermia.
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-Blankets/heating pad to head/neck
-Increase room temp -Lay next to warm person -Give warm liquids, no caffeine or alcohol -Remove wet clothes/dry clothes only |
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Identify intervention(s) for heat fever. (8)
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-Obtain blood cultures
-Minimize heat production by allowing rest and limiting physical activity -Maximize heat loss, reduce coverings -Provide fluids, due to increased BMR -Stimulate appetite; well-balanced meals -Apply damp cloth to head -Oral hygiene -Control room temp |
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Identify emergency intervention(s) for heat stroke.
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-Moving pt to cooler environment
-Remove excess body clothing -Placing cool, wet towels on skin -Use fans to increase convection heat loss -IV fluids -Irrigating stomach/lower bowels with cool solution -Hypothermia blanket |
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Identify 6 factors that influence pulse rate.
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Exercise
Temp Emotions Drugs Hemorrhage Postural changes Pulmonary conditions |
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How can you document that a pt. has a dysrhythmia?
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Physician often orders an electrocardiogram, Holter monitor, or telemetry monitor
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sinus dysrhythmia
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an irregular heartbeat that speeds up with inspiration and slows with expiration; normal finding in children
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An abnormal HR, exertional dyspnea, and a patient's verbal report of fatigue lead to a diagnosis of _________.
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Activity intolerance
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Identify the formula to convert from Celsius to Fahrenheit (and vice versa).
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(F - 32) X 5/9 =C
(9/5 X C) + 32 =F |
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How are VS affected in heat stroke/heat exhaustion?
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Increase in Temp
Increase in HR, RR Decrease in BP |
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How are VS affected in hyperthermia?
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Increase in Temp
Increase in HR, RR Decrease in BP Tip: Same as heat stroke/heat exhaustion |
