Fundamentals of Nursing - Lecture 6: Vital Signs

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Questions and Answers

What does orthopnea refer to?

The inability to breathe without assistance

The ability to breathe only in sitting or standing position (correct)

The difficulty of breathing in high altitudes

The ability to breathe only when lying down

What is arterial blood pressure a measure of?

The pressure exerted by blood in the veins

The pressure exerted by blood as it flows through the arteries (correct)

The overall blood volume in the circulatory system

The resistance of the heart to blood flow

Which position is typically associated with the difficulty of orthopnea?

Standing upright

Lying flat on the back (correct)

Reclining at an angle

Sitting at a 90-degree angle

Arterial blood pressure plays a significant role in assessing which of the following?

Cardiac output and vessel integrity Signup and view all the answers

Which scenario best describes a potential condition associated with orthopnea?

An individual unable to breathe comfortably while lying down at night Signup and view all the answers

What is the equivalent Fahrenheit temperature for a Celsius measurement of 100?

212 F Signup and view all the answers

Which equation correctly relates Celsius and Fahrenheit temperatures?

C = (F - 32) * 5/9 Signup and view all the answers

What physiological event causes the pulse?

Contraction of the left ventricle Signup and view all the answers

What is the primary process described by internal respiration?

Interchange of gases between blood and body tissues Signup and view all the answers

If the temperature in Fahrenheit is 32°F, what would be the Celsius temperature?

0 C Signup and view all the answers

During inhalation, which of the following statements is true?

Air is drawn into the lungs Signup and view all the answers

When converting 104°F to Celsius, what would be the result?

38.5 C Signup and view all the answers

Which of the following best describes exhalation?

Passive process of expelling air from the lungs Signup and view all the answers

What is the relationship between internal respiration and external respiration?

Internal respiration is the exchange of gases between blood and cells Signup and view all the answers

What occurs during the process of internal respiration?

Cellular uptake of oxygen occurs Signup and view all the answers

What is systolic blood pressure primarily a result of?

Contraction of the ventricles Signup and view all the answers

During which phase is diastolic blood pressure measured?

When the ventricles are relaxed Signup and view all the answers

Which of the following best describes diastolic blood pressure?

The lowest pressure in the artery when the heart is at rest Signup and view all the answers

What happens to systolic blood pressure during ventricular contraction?

It peaks due to increased blood flow Signup and view all the answers

How do systolic and diastolic pressures relate to heart function?

Systolic pressure reflects heart contraction and diastolic reflects relaxation Signup and view all the answers

What effect does fever have on cellular metabolism?

It increases the cellular metabolic rate. Signup and view all the answers

Which of the following is NOT a method by which heat is lost from the body?

Insulation Signup and view all the answers

During a fever, what physiological change occurs in body temperature regulation?

The metabolic processes speed up, raising body temperature. Signup and view all the answers

In thermoregulation, what role does vaporization play?

It helps to cool the body by releasing heat. Signup and view all the answers

Which of the following statements about heat loss mechanisms is accurate?

Conduction involves heat transfer from one object to another at different temperatures. Signup and view all the answers

What is one of the clinical signs indicating a patient is experiencing fever?

Loss of appetite Signup and view all the answers

Which of the following symptoms is characteristic of Stage II of fever?

Flushed and warm skin Signup and view all the answers

What symptom suggests potential dehydration during fever?

Excessive sweating Signup and view all the answers

Which of the following is a general symptom of malaise during fever?

Weakness Signup and view all the answers

What is a common response to the decreased sensation of shivering in a fever state?

Enhanced peripheral circulation Signup and view all the answers

Study Notes

Fundamentals of Nursing - 6th Lecture (Vital Signs)

Vital signs include body temperature, pulse, respiration, and blood pressure.

Body Temperature

Body temperature reflects the balance of heat produced and lost.
Measured in degrees.
Two types:
- Core temperature: deep tissues (abdominal and pelvic cavities).
- Surface temperature: skin and subcutaneous tissues, fat.
Factors affecting heat production:
- Basal metabolic rate (BMR): energy use for essential functions (breathing).
- Muscle activity (including shivering): increases metabolic rate.
- Thyroxine output: increased output leads to increased metabolic rate.
- Epinephrine, norepinephrine, and sympathetic stimulation.
- Fever: increases cellular metabolic rate.
Heat loss occurs through radiation, conduction, and vaporization.
- Radiation: heat transfer between surfaces without contact.
- Conduction: heat transfer between molecules of different temperatures.
- Convection: heat dispersion by air currents.
- Vaporization: continuous moisture evaporation (insensible heat loss).

Homeostasis and Temperature Control

The hypothalamus regulates body temperature.
A normal body temperature is 37°C (98.6°F).
Temperature rises or falls, the body initiates processes to restore homeostasis.

Factors Affecting Body Temperature

Age: Older adults are at higher risk for hypothermia.
Diurnal variation: Temperature fluctuations throughout the day (highest in late afternoon).
Exercise: strenuous exercise can increase body temperature to 38.3°C to 40°C.
Hormones: Women experience more hormonal fluctuations than men.
Stress: increased sympathetic stimulation increases epinephrine and norepinephrine production.
Environment: external temperature significantly affects temperature regulation.

Alteration in Body Temperature

Pyrexia (Fever/Hyperthermia): body temperature above the normal range.
Hyperpyrexia: very high fever (e.g., 41°C).
Febrile: having a fever; afebrile: not having a fever.
Types of fever: intermittent, remittent, relapsing, and constant.

Types of Fevers

Intermittent fever: temperature fluctuates with normal or below-normal periods.
Remittent fever: significant fluctuations above normal.
Relapsing fever: periods of fever with intervening periods of normal temperature.
Constant fever: temperature remains above normal consistently.
Fever spike: rapid increase followed by rapid return to normal.

Clinical Signs of Fever

Stage I (Cold/Chill Stage): increased heart and respiratory rate, shivering, cold/pale skin, complaints of cold, cyanotic nail beds, gooseflesh skin, cessation of sweating.
Stage II (Course Stage): absence of chills, warm skin, photosensitivity, glassy-eyed appearance, increased pulse and respirations, increased thirst, mild to severe dehydration, drowsiness, restlessness, delirium or convulsions, mouth lesions, loss of appetite, malaise and weakness.
Stage II (Course Stage): flushed skin, sweating, decreased shivering, possible dehydration.

Nursing Interventions for Clients with Fever

Monitor vital signs.
Assess skin color and temperature.
Remove excess blankets when warm, but provide extra blankets when chilled.
Monitor fluid and nutritional intake.
Reduce physical activity.
Provide oral hygiene.
Provide sponge baths
Administer antipyretics (fever-reducing drugs).

Alteration in Body Temperature (Hypothermia)

Hypothermia: core body temperature below the normal lower limit (less than 36°C).
Physiological mechanisms:
- Excessive heat loss
- Inadequate heat production
- Impaired hypothalamic thermoregulation.
- May be accidental or induced.

Clinical Signs of Hypothermia

Decreased body temperature, pulse and respiration.
Feeling of cold and chills.
Pale, cool, and waxy skin.
Hypotension
Decreased urinary output.
Lack of muscle coordination.
Disorientation, drowsiness progressing to coma

Nursing Interventions for Clients with Hypothermia

Provide warm environment.
Provide dry clothing.
Apply warm blankets.
Keep limbs close to the body.
Cover the head (cap or turban).
Supply warm fluids (oral or intravenous).
Apply warming pads.

Assessing Body Temperature

Common sites: oral, rectal, axillary, tympanic membrane.

Advantages and Disadvantages of Temperature Measurement Sites

Oral: accessible/convenient, can be inaccurate.
Rectal: reliable, inconvenient/unpleasant.
Axillary: safe/non-invasive, longer time for accurate reading.
Tympanic Membrane: accessible/fast, discomfort, involves risk, cerumen interference.

Types of Thermometers

Mercury-in-glass
Electronic
Chemical disposable
Temperature-sensitive tape
Infrared

Temperature Scales

Fahrenheit and Celsius
Conversion formulas provided.

Pulse

A pressure wave created by the left ventricle's contraction.
Compliance: ability of the artery to expand and contract.
Cardiac output: blood pumped per minute.
Stroke volume: blood ejected per heartbeat.
Heart rate (pulse) x Stroke volume= Cardiac Output
Apical pulse: central pulse at the apex of the heart.
Peripheral pulse: location away from the heart (e.g., radial, carotid, femoral).
Normal heart rate: 60 -100 beats/minute (adults).

Factors Affecting the Pulse

Age: decreases with age.
Gender: slightly lower in males after puberty.
Exercise: increases with activity.
Fever: increases.
Hypovolemia: loss of blood volume.
Stress: sympathetic nervous system stimulation.

Assessing the Pulse

Rate: 60–100 beats/minute, bradycardia (below 60), tachycardia (above 100).
Rhythm: regular or irregular, arrhythmia.
Volume: strength/amplitude (absent to bounding).
Elasticity: smooth, soft, and pliable.

Apical-Radial Pulse

Assessing both apical and radial pulse rates simultaneously, to detect differences.
Often done in clients with cardiovascular issues.
Normally apical and radial rates are the same.
Pulse deficit: any discrepancy between apical and radial rates.

Respirations

Act of breathing.
External respiration: gas exchange between alveoli and pulmonary blood.
Internal respiration: gas exchange between circulating blood and body tissues.
Inhalation (inspiration).
Exhalation (expiration).

Mechanisms of Respiration

Processes driving inhalation and exhalation (diaphragm, thoracic cavity movement).

Assessing Respirations

Do not announce the intent to assess rate.
Normal respiratory rate: 14-24 breaths/minute.
Eupnea: normal rate and depth.
Bradypnea: abnormally slow breathing.
Tachypnea: abnormally fast breathing.
Apnea: cessation of breathing.
Hyperventilation: very deep breathing
Hypoventilation: shallow breathing
Dyspnea: difficulty breathing
Orthopnea: difficulty breathing unless sitting or standing

Blood Pressure

Force exerted by blood in arteries.
Systolic: pressure during ventricular contraction.
Diastolic: pressure during ventricular relaxation.
Pulse pressure: difference between systolic and diastolic.
(Normal value) 120/80 mmHg (adults).

Factors Affecting Blood Pressure

Age: increases in early life then decreases with age.
Exercise: increases blood pressure.
Stress: sympathetic stimulation increases blood pressure.
Gender: females have slightly lower blood pressure.
Obesity: higher blood pressure.
Diurnal variation: lowest blood pressure in the early morning.

Abnormalities in Blood Pressure

Hypertension: persistently elevated above 140/90 mmHg.
Primary hypertension: unknown cause.
Secondary hypertension: known cause.
Hypotension: persistently below 100/60 mmHg.
Orthostatic hypotension: drops in pressure when sitting or standing.

Sphygmomanometers

Devices used to measure Blood Pressure and various types

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Description

This quiz focuses on the fundamental concepts of vital signs in nursing, including body temperature, pulse, respiration, and blood pressure. It covers the roles of various factors affecting heat production and loss, essential for understanding patient assessments in nursing practice.