Vital Signs: Temperature

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Questions and Answers

Which of the following factors can influence normal vital sign ranges?

  • Age
  • Exercise tolerance
  • Weight
  • All of the above (correct)

A patient has a body temperature of 38.5°C. According to the provided information, this condition is best described as which of the following?

  • Hypothermia
  • Pyrexia (correct)
  • Frostbite
  • Hyperpyrexia

Which of the following methods for assessing body temperature is considered the MOST accurate?

  • Rectal (correct)
  • Tympanic Membrane
  • Oral
  • Axillary

A patient's temperature was taken axillary and read as 36.0°C. What is the estimated core body temperature, considering the adjustment needed for axillary readings?

<p>36.5°C (D)</p> Signup and view all the answers

Which type of thermometer relies on sensing reflected infrared emissions to measure body temperature?

<p>Tympanic Thermometer (B)</p> Signup and view all the answers

A patient experiences alternating periods of fever and normal body temperature at regular intervals. This pattern is MOST consistent with which type of fever?

<p>Intermittent Fever (B)</p> Signup and view all the answers

What is the rationale behind placing a thermometer posteriorly into the sublingual pocket when taking an oral temperature?

<p>To ensure the thermometer is close to the sublingual artery. (D)</p> Signup and view all the answers

What physiological process does respiratory rate specifically measure?

<p>The number of breaths per minute (C)</p> Signup and view all the answers

A patient is breathing at a rate of 9 breaths per minute. Which term BEST describes this condition?

<p>Bradypnea (D)</p> Signup and view all the answers

What is the proper term for the act of breathing out?

<p>Expiration (B)</p> Signup and view all the answers

What does the character of arterial pulse reflect?

<p>Force, Rhythm, and Volume (C)</p> Signup and view all the answers

In pulse assessment, what does the term ‘equality’ refer to?

<p>The comparison of pulse characteristics on both sides of the body. (A)</p> Signup and view all the answers

When assessing the radial pulse, which fingers are recommended to palpate the artery, excluding the thumb?

<p>Index, Middle &amp; Ring finger (D)</p> Signup and view all the answers

When palpating the radial pulse, what is the purpose of keeping the ring finger proximal to the heart?

<p>To obliterate the back flow coming from the ulnar artery. (A)</p> Signup and view all the answers

When assessing the brachial artery pulse, where should the hand be placed relative to the patient's elbow?

<p>Cup your hand under the patient elbow (A)</p> Signup and view all the answers

Which of the following is a critical precaution to observe when assessing the carotid pulse?

<p>Never press both carotids at the same time (A)</p> Signup and view all the answers

When locating the dorsalis pedis artery, which anatomical landmark serves as a key reference point?

<p>Extensor tendon of the big toe (A)</p> Signup and view all the answers

Which of the following best describes the location for assessing the popliteal pulse?

<p>Behind the knee (C)</p> Signup and view all the answers

What is the accepted normal range for resting heart rate in healthy adults?

<p>60-100 beats per minute (C)</p> Signup and view all the answers

A patient presents with a sustained heart rate of 115 beats per minute. Based on the information, how should this condition be classified?

<p>Tachycardia (D)</p> Signup and view all the answers

In pulse assessment, what does the term ‘rhythm’ primarily evaluate?

<p>The regularity of the intervals between heartbeats. (B)</p> Signup and view all the answers

Which of the following qualities describes a pulse with a 'bounding' character?

<p>Strong (A)</p> Signup and view all the answers

Of the following options, which values represent the normal range for human adult body temperature?

<p>36.7 to 37.2°C (C)</p> Signup and view all the answers

Which of the following is considered a vital sign?

<p>Blood Pressure (D)</p> Signup and view all the answers

Which of the following alterations in body temperature refers to a core body temperature below the lower limit of normal?

<p>Hypothermia (C)</p> Signup and view all the answers

A patient’s body temperature reads 105°F. Estimate the Celsius temperature.

<p>40.5°C (B)</p> Signup and view all the answers

The displayed monitor indicates a respiratory rate of 22 RPM. Based on the reference, what is the correct term for this respiratory rate?

<p>Normal (D)</p> Signup and view all the answers

The body temperature of a patient alternates at regular intervals between periods of fever and periods of normal temperatures. Identify this type of fever.

<p>Intermittent fever (D)</p> Signup and view all the answers

If the radial artery is palpated to assess pulse, what should be kept proximal to the heart?

<p>Ring finger (B)</p> Signup and view all the answers

When placing the blood pressure cuff, what artery should be palpated?

<p>Brachial artery (C)</p> Signup and view all the answers

To locate the carotid artery, you should place your fingers at the level of the cricoid cartilage just inside which border?

<p>Medial (D)</p> Signup and view all the answers

To locate the dorsalis pedis artery, you should place your fingers just lateral to which tendon?

<p>extensor hallucis longus (B)</p> Signup and view all the answers

When counting the pulse rate of a patient with regular pulse, how long should you count?

<p>15 seconds (B)</p> Signup and view all the answers

If a patient heart rate is less than 60, the patient is experiencing:

<p>Bradycardia (C)</p> Signup and view all the answers

Which of the following is an observation for pulse rhythm?

<p>Regularly Regular (B)</p> Signup and view all the answers

What does the pulse volume measure?

<p>strength or amplitude (B)</p> Signup and view all the answers

What is the meaning of the pulse as derived from the Greek?

<p>Move To and Fro (D)</p> Signup and view all the answers

Which is a location for assessing body temperature known at common way?

<p>Oral (C)</p> Signup and view all the answers

Which is a location for assessing body temperature known at safest way?

<p>Axillary (B)</p> Signup and view all the answers

Which is a location for assessing body temperature known at most accurate way?

<p>Rectal (B)</p> Signup and view all the answers

A patient's body temperature is measured at 36.2°C. Considering the normal range, which factor could potentially explain this reading?

<p>Advanced age affecting thermoregulation (D)</p> Signup and view all the answers

A patient presents with a body temperature of 40°C (104°F). Considering the classifications of altered body temperatures, how would you best describe this condition?

<p>Pyrexia (B)</p> Signup and view all the answers

A patient consistently exhibits fluctuating body temperatures, with peaks occurring in the late afternoon and returning to normal by morning. Which type of fever pattern is MOST likely being displayed?

<p>Intermittent fever (A)</p> Signup and view all the answers

When assessing a patient's respiratory rate, you notice the rate is slightly irregular but falls within the normal range. What would be the MOST appropriate next step?

<p>Reassess the respiratory rate over a full minute. (A)</p> Signup and view all the answers

A patient's respiratory assessment reveals shallow breaths at a rate of 14 breaths per minute. How should this respiratory pattern be classified?

<p>Normal (B)</p> Signup and view all the answers

During an assessment, a patient inhales, expanding their chest, and then exhales forcefully. What physiological action is specifically represented by the exhalation phase?

<p>Expiration (C)</p> Signup and view all the answers

When evaluating a patient's radial pulse, you note that the artery walls feel thickened and less elastic than normal. What could this potentially indicate?

<p>Underlying cardiovascular condition (D)</p> Signup and view all the answers

While assessing the radial pulse, you find it difficult to palpate and note that it disappears with only slight pressure. How would you document the pulse volume?

<p>Weak (B)</p> Signup and view all the answers

You are preparing to assess the popliteal pulse on a patient. Which action would BEST facilitate accurate palpation of this pulse?

<p>Flexing the patient's knee slightly (A)</p> Signup and view all the answers

A patient's heart rate is assessed at 52 beats per minute. What term BEST describes this heart rate?

<p>Bradycardia (D)</p> Signup and view all the answers

Flashcards

What are vital signs?

Measurements of the body's fundamental functions, indicating overall health status.

List the vital signs

The five main vital signs monitored are: body temperature, pulse rate, respiratory rate, blood pressure, and oxygen saturation.

Normal body temperature range

The normal range for body temperature is between 36.7 to 37.2 degrees Celsius.

Pyrexia

A body temperature above the usual range. Also called hyperthermia or fever.

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Hyperpyrexia

A body temperature of 41C° (105°F) or higher.

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Hypothermia

A core body temperature below the lower limit of normal.

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Frostbite

Freezing of the body's surface areas, such fingers, toes and ear lobes.

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Electronic thermometer

A thermometer that displays the reading on a digital screen

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Glass (mercury) thermometer

A thermometer using mercury's expansion in glass to measure temperature.

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Paper thermometer

A thermometer using temperature-sensitive paper strips.

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Tympanic Membrane Thermometer

A thermometer that measures temperature at the eardrum.

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Non Contact Infrared Thermometers

A non-contact thermometer that uses infrared technology to measure body temperature.

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Oral temperature measurement

Measuring temperature with a thermometer placed in the sublingual pocket.

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Axillary temperature measurement

Measuring temperature with a thermometer placed in the armpit.

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Rectal temperature measurement

Measuring temperature with a thermometer placed in the rectum. Provides a very accurate core temperature reading.

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Tympanic Membrane Temperature

Measuring temperature using a probe placed in the external auditory canal.

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Intermittent Fever

Body temperature oscillates between fever level and normal level.

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Remittent Fever

A wide range of temperature fluctuations occurs over the 24 hour period, all of which are above normal.

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Contant Fever

Body temperature fluctuates minimally but always remains elevated.

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Relapsing Fever

Short febrile periods alternate with 1-2 days of normal temperature.

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Inspiration (inhalation)

The act of breathing in.

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Expiration (exhalation)

The act of breathing out.

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Respiratory Rate

The number of breaths per minute.

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Normal Respiratory Rate

The normal range of respiratory rate is between 12 and 20 breaths per minute.

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Bradypnea

A respiratory rate of 10 or fewer breaths per minute.

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Tachypnea

A respiratory rate greater than 24 breaths per minute.

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Apnea

Cessation of breathing.

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Arterial Pulse

A wave produced by cardiac systole traversing in the peripheral direction.

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Upper limb pulse sites

The pulse sites found in the upper limb are: brachial, radial, and ulnar.

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Radial Pulse

Pulse point located on the thumb side of the wrist.

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Radial Pulse Examination

The middle finger should be used to judge the parameters of pulse.

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Brachial Artery pulse

This pulse is felt just medial to the biceps tendon.

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Carotid Artery Pulse

The pulse area located in the lower third of the neck at the level of the cricoid cartilage.

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Lower limb pulse sites

The pulse sites found in the lower limb:

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Dorsalis Pedis pulse

Pulse measured on the dorsum of the foot just lateral to the extensor tendon of the big toe

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Posterior Tibial Artery

Artery posterior to the medial malleolus.

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Popliteal Pulse Location

Located behind the knee.

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Pulse Rate Comment

This is measured using rate(60-100), rythm, force, character, equality on both sides.

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Normal Adult Pulse Rate

Normal adult pulse rate is between 60 - 100 bpm.

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Tachycardia

A pulse rate in excess of 100 beats per minute in an adult.

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Bradycardia

A heart rate less than 60 beats per minute in an adult.

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Rhythm Examination

Observation of pulse and regularity.

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Pulse Volume

The measure of the strength or amplitude of force against the arterial wall.

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Study Notes

  • Vital signs are measurements of the body's basic functions.
  • Normal vital signs vary with age, sex, weight, exercise tolerance, and overall health.
  • The five main vital signs typically monitored are body temperature, pulse rate, respiratory rate, blood pressure, and oxygen saturation.

Temperature

  • A normal body temperature range is between 36.7 to 37.2 degrees Celsius.
  • Formula to convert Fahrenheit to Celsius: C= (Fahrenheit -32) × 5/9

Alterations in Body Temperature

  • Pyrexia, hyperthermia, or fever, indicates a body temperature above the usual range.
  • Hyperpyrexia is a very high temperature, such as 41°C (105°F).
  • Hypothermia indicates a core body temperature below the lower limit of normal.
  • Frostbite is freezing of the body's surface areas like earlobes, fingers, and toes when exposed to extremely low temperatures.

Types of Thermometers

  • Electronic (digital) thermometers are used to measure body temperature.
  • Glass (mercury) thermometers are also used to measure body temperature.
  • Paper thermometers can measure body temperature.
  • Tympanic membrane thermometers are used to measure body temperature.
  • Non-contact infrared thermometers are used to measure body temperature.

Sites for Assessing Body Temperature

  • Oral (common way): A reliable temperature reading is taken by placing the thermometer posteriorly into the sublingual pocket for 3-5 minutes, with a normal temperature reading of 37°C.
  • The sublingual artery is close to this landmark, so this location monitors changes in core body temperature.
  • Axillary (safe way): Temperature is measured at the axilla by placing the thermometer in the central position and adducting the arm close to the chest wall for 10 minutes.
  • The reading will be 36°C + 0.5°C
  • It is considered an unreliable site for estimating core body temperature because there are no main blood vessels around this area, and 0.5°C should be added to the actual reading.
  • Rectal (accurate reading): Rectal temperature is the most accurate method for measuring core temperature, with a reading of 37°C – 0.5°C taken in 2-3 minutes.
  • 0.5°C should be reduced to the actual reading.
  • Tympanic membrane: A tympanic thermometer senses reflected infrared emissions from the tympanic membrane through a probe placed in the external auditory canal, giving a quick reading.

Respiratory Rate

  • Inspiration (inhalation) means breathing in.
  • Expiration (exhalation) means breathing out.
  • Respiratory rate is the number of breaths per minute.
  • The normal range of the respiratory rate is 12-20 breaths per minute

Characters of Respiratory Rate

  • Bradypnea is a respiratory rate of 10 or fewer breaths per minute.
  • Tachypnea is a respiratory rate greater than 24 breaths per minute.
  • Apnea is the cessation of breathing.

Pulse

  • Pulse: A Greek word meaning "move to and fro".
  • Arterial pulse: A wave produced by cardiac systole traversing in the peripheral direction in the arterial tree.

Sites of Pulse Examination

  • Sites for pulse examination include UL (upper limb), neck, LL (lower limb), and apical pulse.

UL Pulse Sites

  • Brachial
  • Radial
  • Ulnar

How to Examine Radial Pulse

  • Palpate with 3 fingers – index, middle & ring.
  • Ring finger should be kept proximal to the heart.
  • Index finger should be distal from the heart to obliterate the back flow from the ulnar artery, giving light pressure to obliterate.
  • Rest all parameters of pulse are judged by the middle finger

Brachial Artery

  • Rest the patient's arm with elbow extended, palm up.
  • Use the thumb of the opposite hand.
  • Cup your hand under the patient’s elbow.
  • Feel the pulse just medial to the biceps tendon.

The Carotid Artery

  • Have the patient lie down with the head of the bed elevated 30 degrees.
  • Carotid pulsations may be visible just medial to the sternomastoid.
  • Place the left thumb on the right carotid artery in the lower third of the neck; Never press both carotids at the same time.

LL Pulsations

  • Femoral
  • Popliteal
  • Anterior Tibial
  • Posterior Tibial
  • Dorsalis Pedis

Comment on Pulse

  • Rate between 60-100.
  • Rhythm
  • Force, tension, volume
  • Character
  • Equality on both sides
  • Condition of arterial wall
  • Apex pulse ratio

Pulse Rate

  • Normal adult heart rate is 60-100 beats per minute.
  • To count, measure for 15 seconds and multiply this number by four to calculate heart rate per minute.

Pulse Tachycardia and Bradycardia

  • Tachycardia is a heart rate in excess of 100 beats per minute in an adult.
  • Bradycardia is a heart rate less than 60 beats per minute in an adult.

Rhythm Observation

  • Regularly regular indicates the pulse is measured at a regular interval.
  • Irregularly regular indicates any irregularity at regular intervals.
  • Irregularity is repeated irregularly at irregular intervals.

Pulse Volume

  • Pulse volume measures the strength or amplitude of force exerted by the ejected blood against the arterial wall with each contraction:
    • Weak (thready and usually rapid).
    • Normal (full, easily palpable).
    • Strong (bounding).

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