Vital Signs and Their Assessment

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Questions and Answers

What does tachypnea indicate in relation to metabolic activity?

Slower breathing rates caused by stress

Decreased oxygen requirement due to low metabolic rate

Increased oxygen requirement due to elevated body temperature (correct)

Consistent breathing patterns regardless of activity level

Which of the following describes orthopnea?

Fast and shallow breathing indicating anxiety

Normal breathing pattern observed in adults

Difficulty breathing while lying flat (correct)

Periods of no breathing lasting over 6 minutes

What can be the consequence of apnea lasting longer than 4 to 6 minutes?

Potential brain damage and death (correct)

Immediate recovery of normal breathing patterns

Increased respiratory rate as a compensatory mechanism

Complete resolution of respiratory issues

What characterizes bradypnea?

Slow breathing due to depression of the respiratory center Signup and view all the answers

At what temperature does a newborn typically maintain?

36.8°C Signup and view all the answers

Which group of individuals is more sensitive to changes in environmental temperature?

Very young and very old Signup and view all the answers

What physiological change in women can cause fluctuations in body temperature?

Hormonal changes Signup and view all the answers

What is the term for fever that alternates between periods of fever and normal or subnormal temperature?

Intermittent fever Signup and view all the answers

Why is rectal temperature measurement considered the most accurate?

It is an internal measurement. Signup and view all the answers

What is a contraindication for taking an oral temperature?

Patient has just eaten hot food Signup and view all the answers

In what scenario would axillary temperature measurement be used?

When both oral and rectal sites are contraindicated Signup and view all the answers

What happens during inspiration in the respiratory process?

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

Which measurement site has the average normal temperature set at 36.5°C?

Axillary Signup and view all the answers

What regulates body temperature?

Hypothalamus Signup and view all the answers

At what temperature range is a normal body temperature maintained?

36.4°C - 37.3°C Signup and view all the answers

Which thermometer type provides a reading in less than 2 seconds?

Tympanic thermometer Signup and view all the answers

Which of the following is not a method to measure body temperature?

Electrocardiogram Signup and view all the answers

What physiological factor can lead to fluctuations in body temperature?

Circadian rhythms Signup and view all the answers

How frequently should vital signs be checked for a stable patient?

Every 4 hours Signup and view all the answers

What is considered the fifth vital sign?

Pain Signup and view all the answers

Which thermometer type utilizes disposable covers to minimize cross-infection?

Electronic thermometer Signup and view all the answers

Study Notes

Vital Signs

Vital signs include temperature, pulse, respiration, and blood pressure.
Pain is sometimes considered a fifth vital sign.
Changes in vital signs can indicate changes in health.

Frequency of Vital Sign Assessments

Stable patients typically have vital signs checked every 4 hours.
Unstable patients, those taking medications affecting cardiovascular or respiratory function, or those who've had surgery, require more frequent vital sign checks.

Assessing Body Temperature

Body temperature is the heat of the body, measured in degrees.
Regulated by the thermoregulatory center in the hypothalamus, which receives signals from thermal receptors in the skin.
These receptors either produce or conserve body heat, keeping temperature within a 36.4°C–37.3°C range.
Heat is lost when body heat is transferred to the skin surface via circulating blood.
Deep body temperature remains fairly constant, but surface temperatures vary with environmental factors.
Body temperature balance maintains homeostasis.
Fluctuations in temperature affect fluid balance.

Types of Thermometers

Electronic thermometers: Measure temperature in 25–50 seconds. Suitable for oral, rectal, and axillary sites. They often have disposable covers to minimize cross-contamination.
Tympanic thermometers: Use infrared sensors to measure temperature from the eardrum in under 2 seconds. Disposable covers are often used.
Glass thermometers: Contain mercury, which expands with heat and contracts with cold.
Temperature-sensitive patch/tape: Applied to forehead or abdomen, color changes indicate temperature. A thermometer is needed to confirm.
Automated monitoring devices: Used in healthcare settings to measure temperature, pulse, and blood pressure.

Factors Affecting Body Temperature

Circadian rhythms: Body temperature is typically 0.6°C lower in the early morning than late afternoon.
Age: Very young and very old are more sensitive to environmental temperature changes.
Gender: Women tend to have more fluctuations in temperature due to hormonal changes, such as a rise in progesterone around ovulation.
Stress: Stress increases epinephrine and norepinephrine production, increasing metabolic rate and temperature.
Environmental temperature: Body responds to environmental temperature changes by adjusting clothing to control heat loss or retention.

Terms & Definitions for Types of Fever

Intermittent: Temperature alternates regularly between fever, normal, or subnormal.
Constant: Temperature stays elevated with minimal fluctuations (less than 2°C).
Relapsing: Temperature returns to normal for at least a day before recurring.
Crisis: Temperature returns to normal suddenly.
Lysis: Temperature returns to normal gradually.

Areas to Measure Temperature From

Oral Temperature

Patient must be able to close their mouth.
Placed under the tongue and left for 3 minutes.
Contraindications include unconsciousness, seizures, infants/young people with oral cavity diseases, and recent consumption of hot/cold food/fluids or smoking. Wait 15-30 minutes after consumption.

Rectal Temperature

Most accurate method, as it measures internal temperature.
Lubricate the thermometer.
Insert and leave for 1 minute.
Contraindications include rectal surgery, diarrhea, rectal diseases, and cardiac surgery (as the thermometer may slow the heart rate).

Axillary Temperature

Used when oral and rectal temperature measurements are contraindicated.
Some hospitals use it with newborns to prevent rectal wall perforation.

Average Normal Temperatures for Healthy Adults

Oral: 37°C
Rectal: 37.5°C
Axillary: 36.5°C

Assessing Respirations

Respiration: Movement of air into and out of the lungs.
Inspiration: Inhalation (breathing in).
Expiration: Exhalation (breathing out).
External respiration: Exchange of O2 and CO2 between alveoli and circulating blood.
Internal respiration: Exchange of O2 and CO2 between circulating blood and cells in tissues.

Factors Affecting Respiration

Exercise, respiratory/cardiovascular disease, medications, trauma, infection, pain, and anxiety impact respiration.
Eupnea: Normal breathing rate, typically 16–20 breaths per minute. Consistent relationship to heart rate (one breath equals roughly four heart beats).
Tachypnea: Rapid breathing, often due to elevated body temperature (pyrexia) or increased metabolic demands. A temperature rise of every 0.6°C correlates to roughly 4 more breaths per minute.
Bradypnea: Slow breathing due to depression in the respiratory center or certain medications (e.g., morphine).
Respiratory depth: Varies from shallow to deep.
- Apnea: Absence of breathing. Apnea lasting longer than 4-6 minutes can lead to serious brain damage or death.
- Dyspnea: Difficulty breathing, often rapid and shallow.
- Orthopnea: Difficulty breathing when lying flat, but breathing is easier when upright.

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Description

This quiz covers vital signs including temperature, pulse, respiration, and blood pressure. It explains the significance of these metrics in health monitoring, the frequency of assessments for different patient conditions, and details on how body temperature is regulated. Test your knowledge on this essential nursing topic!