Podcast
Questions and Answers
What are the primary aspects to document regarding a patient's condition?
What are the primary aspects to document regarding a patient's condition?
Which of the following should be reported as abnormal findings?
Which of the following should be reported as abnormal findings?
What does oxygen saturation measure?
What does oxygen saturation measure?
What is the normal range for body temperature in degrees Fahrenheit?
What is the normal range for body temperature in degrees Fahrenheit?
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How is a significant rate of respiration typically characterized?
How is a significant rate of respiration typically characterized?
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What is the formula to convert Celsius to Fahrenheit?
What is the formula to convert Celsius to Fahrenheit?
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What is the equivalent temperature in Celsius for 103°F?
What is the equivalent temperature in Celsius for 103°F?
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Which of the following describes the abdominal cavity?
Which of the following describes the abdominal cavity?
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Which of the following accurately represents a characteristic of surface temperature?
Which of the following accurately represents a characteristic of surface temperature?
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What is the relationship between Celsius and Fahrenheit when converting temperatures?
What is the relationship between Celsius and Fahrenheit when converting temperatures?
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What is the recommended duration for leaving a mercury-in-glass thermometer in the axilla?
What is the recommended duration for leaving a mercury-in-glass thermometer in the axilla?
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When performing a rectal temperature assessment, how deep should the thermometer be inserted?
When performing a rectal temperature assessment, how deep should the thermometer be inserted?
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What should the client be instructed to do while taking a rectal temperature?
What should the client be instructed to do while taking a rectal temperature?
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What is an important aftercare step for the client after a temperature assessment?
What is an important aftercare step for the client after a temperature assessment?
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What is the correct method for exposing the axilla prior to taking an axillary temperature?
What is the correct method for exposing the axilla prior to taking an axillary temperature?
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What primarily controls the exchange of gases in respiration?
What primarily controls the exchange of gases in respiration?
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Which factors can influence the rate of respiration?
Which factors can influence the rate of respiration?
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What is the role of chemoreceptors in respiration?
What is the role of chemoreceptors in respiration?
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Where are the main respiratory centers located in the brain?
Where are the main respiratory centers located in the brain?
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How does exercise affect respiration?
How does exercise affect respiration?
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What site is least likely to provide an accurate pulse oximetry reading in the presence of impaired circulation?
What site is least likely to provide an accurate pulse oximetry reading in the presence of impaired circulation?
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What is the recommended frequency for changing the location of adhesive sensors?
What is the recommended frequency for changing the location of adhesive sensors?
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Which of the following factors is essential for obtaining an accurate pulse oximetry reading?
Which of the following factors is essential for obtaining an accurate pulse oximetry reading?
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What should a nurse do to enhance the accuracy of pulse oximetry readings?
What should a nurse do to enhance the accuracy of pulse oximetry readings?
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Which type of probe selection is crucial for obtaining accurate readings in pulse oximetry?
Which type of probe selection is crucial for obtaining accurate readings in pulse oximetry?
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Which factor does NOT likely influence body temperature?
Which factor does NOT likely influence body temperature?
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What is the primary purpose of assessing respiratory rate?
What is the primary purpose of assessing respiratory rate?
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Which technique is best for measuring oxygen saturation accurately?
Which technique is best for measuring oxygen saturation accurately?
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How can external temperature affect respiration rates?
How can external temperature affect respiration rates?
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Which symptom may indicate an abnormal decrease in oxygen saturation?
Which symptom may indicate an abnormal decrease in oxygen saturation?
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Study Notes
Vital Signs
- Vital signs include temperature, respiration, and oxygen saturation.
- Learning outcomes of the lecture and practical session include describing normal ranges, identifying factors affecting these vitals, and demonstrating the skills to assess and document them. Students also learn to recognize and report abnormal findings.
- Body temperature is a balance of heat produced (metabolism, muscular activity, thyroxine and epinephrine) and heat lost (skin, lungs, body wastes).
- Core temperature refers to deep tissue temperature (e.g., abdominal and pelvic cavity).
- Surface temperature refers to the temperature of skin and subcutaneous tissue.
- Temperature scales include Celsius (°C) and Fahrenheit (°F). Conversion: F = (1.8 x C) + 32.
- Factors affecting body temperature include age, circadian rhythms (physical, mental, behavioural changes over a 24-hour cycle), exercise, hormones (pregnant/ovulation, slight increase), stress (slight increase), and environment.
- Normal body temperature range is 35°C - 37.5°C. A temperature of 38°C or higher often indicates an infection.
- Fever has stages: prodromal (non-specific symptoms like headache, fatigue, malaise, muscle aches), chill (onset of fever with increased heart and respiratory rate, shivering, pale/cold skin), plateau (absence of chills, warm skin, feeling thirsty/dry mouth, mild/severe dehydration, malaise/weakness/muscle aches, loss of appetite), and flush (shivering, flushed skin, diaphoresis (sweating), thirsty/dry mouth, possible dehydration).
Types of Thermometers
- Non-invasive thermometers include mercury-in-glass thermometers, electronic thermometers, infrared (tympanic) thermometers, and temporal artery thermometers.
- Invasive thermometer: Pulmonary artery catheter (gold standard for measuring core body temperature).
Taking Body Temperature
- Common sites for taking body temperature include oral, tympanic, axillary, and rectal.
- Oral temperature is measured in the posterior sublingual pocket with the mouth closed.
- Tympanic temperature is measured in the ear canal. For adults, placing the thermometer tip upward in the ear canal; and downwards in children less than 3 years of age.
- Axillary temperature is taken in the armpit with the arm held tightly across the chest.
- Rectal temperature is taken 1.5-3.5 cm from the anus, varying with age and size.
Assessing Body Temperature
- Steps for assessing body temperature include verifying client identity, selecting the appropriate measurement site, and ensuring client cooperation.
- Consider factors like hot/cold drinks, presence of cerumen/extreme environmental temperatures, moisture, and stool presence.
- Prepare the thermometer, equipment (e.g., gloves, lubricant, pads, tray, rubbish bag), and the environment.
- Position the client appropriately (e.g., reclining, side-lying) based on the selected site.
- Explain the procedure clearly and gain the client's cooperation.
Assessing Respiration
- Respiration involves the exchange of oxygen and carbon dioxide between the atmosphere and the body, controlled by respiratory centers in the medulla oblongata and pons, and chemoreceptors in the medulla, carotid, and aortic bodies. They respond to changes in the concentration of O2, CO2, and H+.
- Factors that can affect respiration include Age, Gender, Exercise, Medications (eg. morphine), Stress, Altitudes, Diseases, and Body Position (sitting or lying down).
- Common assessment aspects involve characteristics such as Rate, Depth, Rhythm, Quality, and Sound.
- Different respiration patterns include but are not limited to Eupnea, Bradypnea, Tachypnea, and Hyperpnea.
- Methods to assess respiration include visual and tactile observation.
- Equipment for measuring respiration includes a watch (with a second hand).
- Necessary steps to assess respiration include minimizing client awareness, counting for one full minute, and observing chest/abdominal movement, depth, rhythm, and quality of breathing.
Pulse Oximetry
- Pulse oximetry is a non-invasive method for measuring arterial blood oxygen saturation (SaO2), it does so by determining the percentage of oxygenated hemoglobin in pulsatile arterial blood flow.
- Pulse oximetry is used for detecting hypoxemia and assessing the patient's tolerance to oxygen therapy.
- Device details include a probe with two light-emitting diodes (red and infrared) and a photodetector.
- Normal SpO2 range is 95-100%, 90-95% may be acceptable in some patients, but less than 85% is certainly abnormal, and less than 70% is life-threatening.
- Factors that can affect pulse oximetry readings include factors like hemoglobin level, presence of carbon monoxide, inadequate blood perfusion or circulation in the area probed, shivering or excessive movements, and proper probe placement.
Documentation
- Documenting vital signs (temperature, respiration, pulse oximetry) is done using a blue/black pen.
- Documentation should be done immediately in a client's progress sheet indicating rate, depth, rhythm, quality of the assessment.
- The documentation of vital signs should be precise, clearly indicate site of measurement (oral (O), tympanic (T), axillary (A), rectal (R)), and be presented graphically (e.g., using temperature charts).
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Description
This quiz covers the essential aspects of vital signs, including temperature, respiration, and oxygen saturation. Students will learn to identify normal ranges and factors affecting these vital signs, along with the proper assessment and documentation skills. Explore the concepts of core and surface temperature and their measurement scales.
