40 Questions
What is the primary reason for taking vital signs in patients?
To establish a baseline for future comparisons
Which of the following is NOT a component of vital signs?
Height
How often should vital signs be measured for an unstable or critical patient?
Every 5 minutes
Who is responsible for measuring vital signs in a hospital setting?
All of the above
Why is pain considered a vital sign?
Because it is what the patient tells us about their pain
How often should vital signs be measured for a post-operative patient in the recovery room?
Every 15-60 minutes
What is the recommended frequency for measuring vital signs on a rehabilitation floor?
Every shift
Who should take vital signs if administering medication to a patient?
Nurse
What is the primary purpose of taking a patient's vital signs?
To monitor and evaluate a patient for potential problems
What is the normal fluctuation in body temperature throughout the day?
Temperature is highest at 4pm and lowest at 6am
Which part of the hypothalamus controls heat production?
Posterior hypothalamus
What is the set point in temperature regulation?
A comfortable temperature that the brain sets for the body
Which method of heat loss involves the transfer of heat through direct contact?
Conduction
What is the term for the body's involuntary response to changes in body temperature?
Shivering
What is the term for the visible sweat that occurs when the body loses heat through evaporation?
Sensible perspiration
What is the effect of increased metabolism on heat production?
It increases heat production
What is a common result of decreased blood oxygen levels on heart rate?
Increased heart rate
Which medication can decrease the heart rate?
All of the above
What is the term for an abnormal or irregular heartbeat?
Arrhythmia
What is the normal rating of a pulse's fullness?
+2 (normal)
What is the effect of chronic pain on heart rate?
Variable effect on heart rate
What is the term for a pulse that is weak or difficult to feel?
Thready pulse
What is the term for a pulse that is strong and full?
Bounding pulse
What is the purpose of assessing peripheral pulses?
To evaluate blood flow to peripheral tissues
What is the primary reason for not treating fever if it's not over 102.2°F?
To avoid suppressing the body's natural defense mechanism
What is the term for the abnormal elevation of the body temperature above 37°C (98.6°F) due to disease?
Pyrexia
What is the primary cause of hypothermia?
Heat loss during prolonged exposure to cold
What is the temperature range that requires immediate medical attention?
Above 105°F
What is the primary purpose of the chill phase during fever?
To elevate the body temperature to a new set point
What is the term for the elevated body temperature related to the inability of the body to promote heat loss or reduce heat production?
Hyperthermia
What is the primary symptom of the fever phase during fever?
Flushed skin
What is the primary care approach during the fever phase?
Comfort, hydration, and prevention of shivering
During the flush or crisis phase, what is the primary reason for the drop in the hypothalamus set point?
Pyrogens are removed from the body
What is the primary cause of hypothermia?
Body's inability to produce heat
What is the normal pulse rate for adults?
60-100 bpm
What is the term for an abnormally elevated heart rate above 100 beats/min in adults?
Tachycardia
What is the primary factor that causes a decrease in pulse rate?
Sleep
What is the pulse rate generally?
Slowest at rest
What is the primary reason for the difference in pulse rates between infants and adults?
Age
What is the primary factor that causes an increase in the pulse rate, according to the text?
Acute pain
Study Notes
Vital Signs Module
- The learner will be able to discuss the taking of vital signs and apply the nursing process in case studies and discussions to plan care for a patient experiencing variations in vital signs.
- Importance of taking vital signs:
- Helps us know where a patient's baseline vital signs should be
- Helps us know if there are any drastic changes from the baseline vital signs
- Components of vital signs:
- Temperature
- Pulse
- Respiration
- Blood pressure
- Oxygen saturation
- Pain scale (when relevant to the patient being assessed)
Frequency of Vital-Sign Measurement
- Frequency based on patient stability:
- Unstable/critical patient: every 5 minutes
- Stable patient: every 4 to 8 hours
- Post-op patient: every 15-60 minutes in recovery, every 15 minutes the first half hour after surgery
- Rehab floor: every shift
- Psych floor: every day
- CNA/PCA can do vital signs, but nurse should do vital signs if administering medication
Nurse's Responsibility for Vital-Sign Measurement
- Assess vitals correctly and accurately for every patient in their care
- Obtain patient's usual baseline and compare to any drastic changes
- Report drastic changes to provider or charge nurse
- Vital signs are used to monitor and evaluate patients, determine diagnosis, treatment, and plan of care
Body Temperature
- Regulated by the hypothalamus
- Set point: comfortable temperature that the brain sets for the body
- Set point can be altered by infection, allergens, or inflamed tissues
- Methods of temperature control:
- Heat loss:
- Radiation
- Conduction
- Convection
- Evaporation
- Heat production:
- Metabolism
- Shivering
- Heat loss:
Temperature-Related Terms
- Pyrexia: abnormal elevation of body temperature above 37°C (98.6°F), also known as fever
- Hyperpyrexia: extreme abnormal elevation of body temperature, needs immediate medical attention
- Hyperthermia: elevated body temperature due to inability to promote heat loss or reduce heat production
- Hypothermia: heat loss during prolonged exposure to cold, overwhelms the body's ability to produce heat
Fever
- Fever helps the body fight disease by stimulating proteins called interferon
- Should not treat fever if it's not over 102.2°F (for adults) or 104°F (for children), unless rising quickly
- Fever can trigger seizures in children
Phases of Fever
- Chill Phase: body reacts to a new set point, ends when a new set point is reached
- Signs and symptoms: shivering, blood vessels constrict, absence of sweating
- Care: assessment, blankets, fluids, nourishment, oxygen
- Fever Phase: plateau, new set point reached
- Signs and symptoms: flushed skin, warm skin, weak, muscle aches, drowsy, restless
- Care: comfort, hydration, prevent shivering, limit physical activity, oral hygiene, environmental temp control
- Flush or Crisis Phase: set point overshot or pyrogens removed, hypothalamus set point drops
- Signs and symptoms: profuse diaphoresis, less shivering, flushed warm skin, fever "breaks"
- Care: fluids, light clothing, hypothermia blanket, medication, oral hygiene, environmental temp control
Pulse
- Physiology of the pulse:
- Blood coming from the heart with every ventricular contraction
- Your heart has 4 chambers, left ventricle ejects blood to aorta, right ventricle ejects blood to pulmonary system
- Pulse rate: number of pulsations felt in a beat
- Normal pulse rates:
- Infants: 80-180 bpm
- Adults: 60-100 bpm
- Factors that increase pulse rate:
- Pain
- Stress
- Fear
- Anger
- Anxiety
- Exercise
- Decreased BP
- Increased temperature
- Low oxygen
- Medication (e.g., vasoconstrictor medications)
- Factors that decrease pulse rate:
- Heart conditioned by long-term exercise
- Hypothermia
- Chronic pain
- Negative chronotropic drugs (e.g., digitalis, beta-adrenergic and calcium channel blockers)
- Lying down
- Characteristics of pulse:
- Pulse rhythm: regular, irregular, dysrhythmia, arrhythmia
- Pulse quality or amplitude: descriptions of fullness of pulse (0, +1, +2, +3)
Learn about the importance of taking vital signs, its components, and how to apply the nursing process to plan care for patients with varying vital signs. Understand the role of vital signs in determining a patient's baseline and identifying drastic changes.
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