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What does orthopnea refer to?
What does orthopnea refer to?
What is arterial blood pressure a measure of?
What is arterial blood pressure a measure of?
Which position is typically associated with the difficulty of orthopnea?
Which position is typically associated with the difficulty of orthopnea?
Arterial blood pressure plays a significant role in assessing which of the following?
Arterial blood pressure plays a significant role in assessing which of the following?
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Which scenario best describes a potential condition associated with orthopnea?
Which scenario best describes a potential condition associated with orthopnea?
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What is the equivalent Fahrenheit temperature for a Celsius measurement of 100?
What is the equivalent Fahrenheit temperature for a Celsius measurement of 100?
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Which equation correctly relates Celsius and Fahrenheit temperatures?
Which equation correctly relates Celsius and Fahrenheit temperatures?
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What physiological event causes the pulse?
What physiological event causes the pulse?
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What is the primary process described by internal respiration?
What is the primary process described by internal respiration?
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If the temperature in Fahrenheit is 32°F, what would be the Celsius temperature?
If the temperature in Fahrenheit is 32°F, what would be the Celsius temperature?
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During inhalation, which of the following statements is true?
During inhalation, which of the following statements is true?
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When converting 104°F to Celsius, what would be the result?
When converting 104°F to Celsius, what would be the result?
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Which of the following best describes exhalation?
Which of the following best describes exhalation?
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What is the relationship between internal respiration and external respiration?
What is the relationship between internal respiration and external respiration?
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What occurs during the process of internal respiration?
What occurs during the process of internal respiration?
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What is systolic blood pressure primarily a result of?
What is systolic blood pressure primarily a result of?
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During which phase is diastolic blood pressure measured?
During which phase is diastolic blood pressure measured?
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Which of the following best describes diastolic blood pressure?
Which of the following best describes diastolic blood pressure?
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What happens to systolic blood pressure during ventricular contraction?
What happens to systolic blood pressure during ventricular contraction?
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How do systolic and diastolic pressures relate to heart function?
How do systolic and diastolic pressures relate to heart function?
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What effect does fever have on cellular metabolism?
What effect does fever have on cellular metabolism?
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Which of the following is NOT a method by which heat is lost from the body?
Which of the following is NOT a method by which heat is lost from the body?
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During a fever, what physiological change occurs in body temperature regulation?
During a fever, what physiological change occurs in body temperature regulation?
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In thermoregulation, what role does vaporization play?
In thermoregulation, what role does vaporization play?
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Which of the following statements about heat loss mechanisms is accurate?
Which of the following statements about heat loss mechanisms is accurate?
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What is one of the clinical signs indicating a patient is experiencing fever?
What is one of the clinical signs indicating a patient is experiencing fever?
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Which of the following symptoms is characteristic of Stage II of fever?
Which of the following symptoms is characteristic of Stage II of fever?
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What symptom suggests potential dehydration during fever?
What symptom suggests potential dehydration during fever?
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Which of the following is a general symptom of malaise during fever?
Which of the following is a general symptom of malaise during fever?
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What is a common response to the decreased sensation of shivering in a fever state?
What is a common response to the decreased sensation of shivering in a fever state?
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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.
