1.

Vital Signs - Temperature, pulse, respirations, and blood pressure; and pain in some agencies
2. Vital signs reflect... - changes in function that otherwise might not be observed
3. Two kinds of body temperature - core temperature and surface temperature
4. core temperature - the amount of heat in the deep tissues and structures of the body, such as the abdominal
and pelvic cavities remains relatively constant
5. surface temperature - Temperature of the skin, subcutaneous tissue, and fat. Rises and falls in response to the
environment.
6. factors affecting heat production
 basal metabolic rate
 muscle activity
 thyroxine output
 epinephrine, norepinephrine, and sympathetic stimulation/stress response
 fever
7. Heat is lost from the body through... - radiation, conduction, convection, evaporation
8. Radiation - transfer of heat from the surface of one object to the surface of another without direct contact
between the two
9. Conduction - transfer of heat from one molecule to a molecule of lower temperature cannot take place without
contact
10. Convection - dispersion of heat by air currents
11. Evaporation - continuous vaporization of moisture from the respiratory tract and from the mucosa of the mouth
and from the skin
12. insensible water loss - the loss of water not noticeable by a person, such as through evaporation from the skin
and exhalation from the lungs during breathing accounts for about 10% of basal heat loss
13. Insensible heat loss - Heat loss that accompanies the Insensible water loss. (caused by evaporation)
14. Three main parts of body temperature regulation
 sensors in the periphery
 integrator in the hypothalamus
 effector system that adjusts production and loss of heat
15. physiological processes to increase body temperature
 shivering to increase heat production
 sweating inhibited to decrease heat loss
 vasoconstriction to decrease heat loss
16. __________________ is the center that controls core temperature - hypothalamic integrator
17. Factors affecting body temperature:
 Age
 2 Diurnal Variations ( circadian rhythms)
 Exercise
 Hormones
 Stress
 Environment
18. Normal Temperature Range for Adults - between 36ºC and 37.5ºC (96.8ºF to 99.5ºF)
19. Pyrexia - a body temperature above the normal range, fever
20. Febrile - feverish
21. Afebrile - without fever
22. four common types of fever
 Intermittent
 Remittent
 Relapsing
 Constant
23. Intermittent fever - a body temperature that alternates at regular intervals between periods of fever and
periods of normal or subnormal temperatures
24. Remittent fever - Wide range of temperature fluctuations occur over a 24 hour period; all of which are above
normal.

1
25. Relapsing fever - Short febrile periods of a few days are interspersed with periods of 1 or 2 days of normal
temperature
26. Constant fever - Body temperature fluctuates minimally but always remains above normal.
27. Fever spike - a temperature that rises to fever level rapidly following a normal temperature and then returns to
normal within a few hours
28. Phases of Fever
29. Onset (cold or chill phase)
30. Course (plateau phase)
31. Defervescence (fever abatement/flush phase)
32. Clinical Manifestations of fever onset –
 -increased heart rate
 -increased respiratory rate and depth
 -shivering
 -pallid, cold skin
 -complaints of feeling cold
 -cyanotic nail beds
 -"gooseflesh" appearance of the skin
 -cessation of sweating
33. Clinical manifestations of fever course –
 -absence of chills
 -skin that feels warm
 -photosensitivity
 -glassy-eyed appearance
 -increased pulse and respiratory rate
 -increased thirst
 -mild to severe dehydration
 -drowsiness, restlessness, delirium, or convulsion
 -herpetic lesions of the mouth
 -loss of appetite
 -weakness and aching muscles
34. Clinical Manifestation of Defervescence –
 -flushed and warm skin
 -sweating
 -decreased shivering
 -possible dehydration
35. Clinical Manifestations of Hypothermia –
 -Decreased body temp, pulse, respirations
 -severe shivering (initially)
 -feelings of cold and chills
 -pale, cool, waxy skin
 -frostbite (discolored, blistered nose, fingers, toes)
 -hypotension
 -decreased urinary output
 -lack of muscle coordination
 -disorientation
 -drowsiness progressing to coma
36. Advantages and disadvantages of oral temperature –
 A: accessible and convenient
 D: can break if bitten; inaccurate if client has ingested cold or hot food or fluid or smoked; could injure
mouth following oral surgery
37. Advantages and disadvantages of rectal temperature
 A: reliable measurement
 D: inconvenient and unpleasant; difficult for patients who cannot turn to the side; could injure the rectum;
presence of stool may interfere wit thermometer placement
2
38. Advantages and disadvantages of axillary temperature
 A: safe and noninvasive
 D: the thermometer may need to be left in place a long time to obtain an accurate measurement
39. Advantages and disadvantages of tympanic membrane temperature
 A: readily accessible; reflects the core temperature; very fast
 D: can be uncomfortable and involves risk of injuring the membrane if the probe is inserted too far;
repeated measurements may vary, right and left may differ; presence of cerumen may affect the reading;
have been shown to be imprecise
40. Advantages and disadvantages of temporal artery temperature
 A: safe and noninvasive; very fast
 D: requires electronic equipment or that may be expensive or unavailable; variation in technique needed if
the client has perspiration on the forehead; have been shown to be inconsistent
41. Types of oral thermometers - Basal & hypothermia
42. Temperature Scales - C= (Fahrenheit temperature-32) x 5/9
43. F= (Celcius temperature x 95) + 32
44. Pulse wave represents... - stroke volume output/amount of blood that enters the arteries with each ventricular
contraction
45. Cardiac Output - volume of blood pumped into the arteries by the heart
46. Cardiac output = - result of the stroke volume (SV) times heart rate (HR) per minute
47. Healthy resting adult's cardiac output - about 5 liters per minute
48. peripheral pulse - pulse located away from the heart
49. apical pulse - a central pulse located at the apex of the heart
50. point of maximum impulse - apical pulse
51. Factors Affecting Pulse - age, sex, exercise, fever, medications, hypovolemia/dehydration, stress, position,
pathology
52. Pulse Sites
 -temporal
 -carotid
 -apical
 -brachial
 -radial
 -femoral
 -popliteal
 -dorsalis pedis
 -posterior tibial
53. Nurse collects what data when assessing the pulse? - rate, rhythm, volume, arterial wall elasticity, and the
presence or absence of bilateral equality
54. dysrhythmia/arrhythmia - a pulse with an irregular rhythm should be reassessed with apical pulse
55. healthy, normal artery - straight, smooth, soft, and pliable
56. Using the thumb - using the thumb is contraindicated because the nurse's thumb has a pulse that could be
mistaken for that of the client
57. when to use apical pulse
 for patients with irregular heart rate
 patients with bradycardia or tachycardia
 patients with a faint radial pulse
 patients taking cardiac medications
 infants and young children
 pulse deficit - discrepancy between apical and radial pulse
 length of apical pulse - 1 full minute
58. Two types of breathing - costal (thoracic) breathing and diaphragmatic (abdominal ) breathing
59. Before assessing a client's respirations, a nurse should be aware of... –
 -the client's normal breathing pattern
 -the influence of the client's health problems on respirations
 -any meds or therapies that might affect respirations
3
  -the relationship of the client's respirations to cardiac function
60. Factors that increase respiration –
 -exercise
 -stress
 -increased environmental temperature
 -lowered oxygen concentration
61. Factors that decrease respiration –
 -decreased environmental temperature
 -certain medications
 -increased intracranial pressure
62. Systolic blood pressure - the pressure of the blood as a result of contraction of the ventricles;the pressure of the
height of the blood wave
63. Diastolic blood pressure - pressure when the ventricles are at rest
64. pulse pressure - difference between systolic and diastolic pressure
65. Normal pulse pressure - 40 mmHg
66. Mean Arterial Pressure (MAP) - pressure actually delivered to the body's organs
67. Hematocrit - proportion of red blood cells to the blood plasma
68. factors influencing blood pressure - Age, exercise, race, stress, sex, medications, obesity, diurnal variations,
medical conditions, temperature
69. primary hypertension - denotes high blood pressure from an unidentified cause; also called essential
hypertension
70. secondary hypertension - an elevated blood pressure of a known cause
71. orthostatic hypotension - low blood pressure that occurs upon standing up
72. BP Cuff Width - should wrap at least 40% of the circumference of the arm
73. BP Cuff Length - should cover at least 2/3 of the limb
74. Oxygen Saturation Value - the percent of all hemoglobin binding sites that are occupied by oxygen
75. Factors affeting SaO2 Readings –
 -hemoglobin level
 -circulation
 -activity
 -carbon monoxide poisoning