NURSU 461 VS PPT EXAM WITH CORRECT
SOLUTION
VS provide data to determine - ANSWER patients state of health i.e. establish a baseline
on the patient, and also provide data to allow us to monitor a patient's condition; they
guide our clinical decision making.
VS allows us to - ANSWER identify problems and evaluate response to our interventions.
The basis for clinical decision making and problem solving!!!
interpretation of VS guidelines - ANSWER -Evaluate the reading (acceptable
range/parameters)
-Correlate w/ client's medical history, therapies, prescribed medications, & symptoms
-Consider environmental factors that may affect vital signs and control for these
Know your pts - ANSWER medical history, therapies and prescribed medicines
some what cause predictable changes in VS - ANSWER illnesses & treatments; athlete,
atrial fib; bradycardic secondary to beta blocker, tachycardic secondary to synthroid;
copd
environmental factors - ANSWER warm humid room may cause elevation in
temperature; loud/overstimulation may cause elevation in HR/BP
use VS to determine - ANSWER indications for medications
record & report - ANSWER VS appropriately
abnormal VS good practice - ANSWER repeat the vital sign to ensure it is indeed outside
of normal parameters first. Then must communicate significant changes in vital signs to
provider!
when should VS be taken? - ANSWER •As part of a complete physical assessment
•Or as part of ongoing monitoring of condition
-Based on the provider's (MD, DO, NP, PA) order set
-Established minimum frequency
-PRN
when VS are taken inpatient, used to - ANSWER establish a baseline and to provide
ongoing monitoring of a patients condition. The provider writing the orders on this
,patient will decide the minimum frequency of VS for each patient; this will be in your
order set in the EMR. You should collaborate regarding this especially if the patient's
status changes. This could be less frequently in a stable patient i.e. Q4h or very
frequently in a recent post-surgical patient i.e. Q10min or a patient with a recent change
in condition. You can always assess more frequently as a nurse if you feel it's necessary.
thermoregulation - ANSWER balancing act between heat lost and heat produced (heat
produced - heat lost = body temp)
balancing act with thermoregulaltion keeps us - ANSWER within optimal range of
36-38*C (96.8-100.4 *F). This is when our tissues and cells function best. Various
mechanisms play a role in keeping this balancing act going. Hypothalamus regulates a
set point and senses minor changes in that set point. This triggers impulses to facilitate
heat conservation/production (vasoconstriction, muscle contraction i.e. shivering) or
heat loss (sweating, vasodilation, redistribution of blood to surface vessels)
radiation - ANSWER body to object without direct contact
conduction - ANSWER body to surface via direct contact
convection - ANSWER dispersion of heart via air currents
evaporation - ANSWER dispersion of heat through water vapor (perspiration)
diaphoresis - ANSWER visible perspiration on skin
factors that affect body temp - ANSWER •Age
•Exercise
•Hormone level
•Circadian rhythm
•Emotional Stress
•Environment
•Illness/Injury
newborns & heat loss - ANSWER lose heat rapidly (large surface-mass ratio)
older adults & heat loss - ANSWER -less subcutaneous fat, lower body temp, longer time
to register temperature change
hormones & heat - ANSWER temp increase with ovulation (think of those trying to get
pregnant—they monitor this)
temp alterations due to - ANSWER excessive heat production or loss, minimal heat
production or loss
, fever or pyrexia - ANSWER >100.4
FUO - ANSWER fever of unknown origin
phases of fever - ANSWER pyrogens such as (bacteria/viruses) trigger immune system,
the immune system's function is actually enhanced with mild temp elevations up to 102.2
(increased wbc production, harder for virus to replicate) , therefore the hypothalamus
raises its set point to help the immune system function. So lets say the hypothalamus
moves the set point from 98.6 to 101; there is a brief time where the body is trying to
stimulate heat production to reach that set point, and is in fact below the set point, so
the individual actually feelscold/chills. Once the body actually achieves the set point
temp, the chills resolve. Remove the pyrogens (antibiotics to rid of bacteria), set point
drops to normal again.
hyperthermia - ANSWER no change in hypothalamic set point, just an overload of the
body's regulatory system with heat (heat exhaustion, heat stroke)
malignant hyperthermia - ANSWER drug induced heat production that is uncontrolled
(i.e. certain anesthetics)
temp too low - ANSWER warm environmental temperature, heated O2, warming
blankets (bear hugger), warmed fluids oral or IV, cover head (monitor cardiac status,
have emergency equipment ready)
temp too high - ANSWER cool environmental temperature 70-80*, cooling blankets,
obtain cultures (wound, urine, blood, sputum as indicated), provide antipyretics
(acetaminophen, ibuprofen, aspirin—no aspirin in children!!), administer ordered
antibiotics (after obtaining specimens for culture), oral hygiene, fluids/rest/prevent
shivering (decreases energy expenditure), monitor WBC/SedRates/Electrolytes
hypothermia ranges - ANSWER •Mild—93.2-96.8°
•Moderate—86-93.2°
•Severe--< 86°
causes of hypothermia - ANSWER -↓metabolism
-↓ mental functioning
-↓ pulse, respirations, BP
-Cardiac arrest if untreated
core temp in hypothermia - ANSWER assessment of core temperature is critical in these
patients (core versus surface)
Also see hypothermia used as a therapeutic measure in certain conditions...
ICU core body temps - ANSWER -pulmonary artery catheter, indwelling urinary catheter
SOLUTION
VS provide data to determine - ANSWER patients state of health i.e. establish a baseline
on the patient, and also provide data to allow us to monitor a patient's condition; they
guide our clinical decision making.
VS allows us to - ANSWER identify problems and evaluate response to our interventions.
The basis for clinical decision making and problem solving!!!
interpretation of VS guidelines - ANSWER -Evaluate the reading (acceptable
range/parameters)
-Correlate w/ client's medical history, therapies, prescribed medications, & symptoms
-Consider environmental factors that may affect vital signs and control for these
Know your pts - ANSWER medical history, therapies and prescribed medicines
some what cause predictable changes in VS - ANSWER illnesses & treatments; athlete,
atrial fib; bradycardic secondary to beta blocker, tachycardic secondary to synthroid;
copd
environmental factors - ANSWER warm humid room may cause elevation in
temperature; loud/overstimulation may cause elevation in HR/BP
use VS to determine - ANSWER indications for medications
record & report - ANSWER VS appropriately
abnormal VS good practice - ANSWER repeat the vital sign to ensure it is indeed outside
of normal parameters first. Then must communicate significant changes in vital signs to
provider!
when should VS be taken? - ANSWER •As part of a complete physical assessment
•Or as part of ongoing monitoring of condition
-Based on the provider's (MD, DO, NP, PA) order set
-Established minimum frequency
-PRN
when VS are taken inpatient, used to - ANSWER establish a baseline and to provide
ongoing monitoring of a patients condition. The provider writing the orders on this
,patient will decide the minimum frequency of VS for each patient; this will be in your
order set in the EMR. You should collaborate regarding this especially if the patient's
status changes. This could be less frequently in a stable patient i.e. Q4h or very
frequently in a recent post-surgical patient i.e. Q10min or a patient with a recent change
in condition. You can always assess more frequently as a nurse if you feel it's necessary.
thermoregulation - ANSWER balancing act between heat lost and heat produced (heat
produced - heat lost = body temp)
balancing act with thermoregulaltion keeps us - ANSWER within optimal range of
36-38*C (96.8-100.4 *F). This is when our tissues and cells function best. Various
mechanisms play a role in keeping this balancing act going. Hypothalamus regulates a
set point and senses minor changes in that set point. This triggers impulses to facilitate
heat conservation/production (vasoconstriction, muscle contraction i.e. shivering) or
heat loss (sweating, vasodilation, redistribution of blood to surface vessels)
radiation - ANSWER body to object without direct contact
conduction - ANSWER body to surface via direct contact
convection - ANSWER dispersion of heart via air currents
evaporation - ANSWER dispersion of heat through water vapor (perspiration)
diaphoresis - ANSWER visible perspiration on skin
factors that affect body temp - ANSWER •Age
•Exercise
•Hormone level
•Circadian rhythm
•Emotional Stress
•Environment
•Illness/Injury
newborns & heat loss - ANSWER lose heat rapidly (large surface-mass ratio)
older adults & heat loss - ANSWER -less subcutaneous fat, lower body temp, longer time
to register temperature change
hormones & heat - ANSWER temp increase with ovulation (think of those trying to get
pregnant—they monitor this)
temp alterations due to - ANSWER excessive heat production or loss, minimal heat
production or loss
, fever or pyrexia - ANSWER >100.4
FUO - ANSWER fever of unknown origin
phases of fever - ANSWER pyrogens such as (bacteria/viruses) trigger immune system,
the immune system's function is actually enhanced with mild temp elevations up to 102.2
(increased wbc production, harder for virus to replicate) , therefore the hypothalamus
raises its set point to help the immune system function. So lets say the hypothalamus
moves the set point from 98.6 to 101; there is a brief time where the body is trying to
stimulate heat production to reach that set point, and is in fact below the set point, so
the individual actually feelscold/chills. Once the body actually achieves the set point
temp, the chills resolve. Remove the pyrogens (antibiotics to rid of bacteria), set point
drops to normal again.
hyperthermia - ANSWER no change in hypothalamic set point, just an overload of the
body's regulatory system with heat (heat exhaustion, heat stroke)
malignant hyperthermia - ANSWER drug induced heat production that is uncontrolled
(i.e. certain anesthetics)
temp too low - ANSWER warm environmental temperature, heated O2, warming
blankets (bear hugger), warmed fluids oral or IV, cover head (monitor cardiac status,
have emergency equipment ready)
temp too high - ANSWER cool environmental temperature 70-80*, cooling blankets,
obtain cultures (wound, urine, blood, sputum as indicated), provide antipyretics
(acetaminophen, ibuprofen, aspirin—no aspirin in children!!), administer ordered
antibiotics (after obtaining specimens for culture), oral hygiene, fluids/rest/prevent
shivering (decreases energy expenditure), monitor WBC/SedRates/Electrolytes
hypothermia ranges - ANSWER •Mild—93.2-96.8°
•Moderate—86-93.2°
•Severe--< 86°
causes of hypothermia - ANSWER -↓metabolism
-↓ mental functioning
-↓ pulse, respirations, BP
-Cardiac arrest if untreated
core temp in hypothermia - ANSWER assessment of core temperature is critical in these
patients (core versus surface)
Also see hypothermia used as a therapeutic measure in certain conditions...
ICU core body temps - ANSWER -pulmonary artery catheter, indwelling urinary catheter
