GNRS 555 Midterm Study Guide - Complete
With Solutions
Save
Terms in this set (215)
Measuring vitals is my responsibility
Select right equiptment
Know pt's baseline
Use organized systemic approach
Control environmental factors
What are the general
Analyze results based on medical history and
guidelines for measuring
current illness
and documenting vital
Always double check abnormal vitals
signs?
Take appropriate nursing actions
Notify MD of abnormal findings
Document findings accurately
Take vital before med administration
Do not delegate unstable pts to CNAs
At change of shift
When to take vitals Before med administration
Per hospital policy
Temp: 36-38
Pulse: 60-100 BPM
Acceptable ranges of
Respiration: 12-20 breaths/min
vital signs (baseline) for
O2 sat (greater than or equal to 95)
adults
BP 120/80
Pain
Easily accessible
Comfortable for pt
Advantages of oral Provides accurate surface temp reading
temperature Reflects rapid change in core temp
Reliable route to measure temp in pts who are
intubated
, Causes delay in measurement if pt recently ingested
hot/cold fluids, smoked, receiving O2 by mask/nasal
cannula
Disadvantages of oral
Not for pts who have oral surgery, trauma, hx of
temperature
epilepsy, or shaking chills
Not for infants, small children, or confused pts
Risk of body fluid exposure
Easily accessible site
Found to be most accurate method in critically ill
pts
Minimal pt repositioning required
Obtained w/o disturbing, waking, or repositioning
Tympanic membrane
pts
advantages
Used for pts with tachypnea w/o affecting breathing
Sensitive to core temp changes
Very rapid measurement
Unaffected by oral intake of fluids or smoking
Not influenced by environmental temps
, More variability of measurement than w/ other core
temp devices
Requires removal of hearing aids before
measurement
Requires disposable sensor cover with only one size
available
Otitis media and cerumen impaction distorts
readings
Not used in patients who have had surgery of the
ear or tympanic membrane
TM disadvantages Does not accurately measure core temperature
changes during and after exercise
Does not obtain continuous measurement
Affected by ambient temperature devices such as
incubators, radiant warmers, and facial fans
Use in infants older than 6 months (Seattle Children's
Hospital, 2019) and children under 3 years of age;
use care to position device correctly because
anatomy of ear canal makes it difficult to position.
Inaccuracies reported caused by incorrect
positioning of handheld unit
Argued to be more reliable when oral temperature
Rectal temp advantages
is difficult or impossible to obtain
Lags behind core temperature during rapid
temperature changes
Not for patients with diarrhea, rectal disorders, or
bleeding tendencies or those who had rectal
surgery
Rectal Temp Requires positioning and is often source of patient
Disadvantages embarrassment and anxiety
Risk of body fluid exposure and injury to rectal
lining
Requires lubrication
Not for routine vital signs in newborns
Readings influenced by impacted stool
, Inexpensive
Skin temperature Provides continuous reading
advantages Safe and noninvasive
Used for neonates
Measurement lags behind other sites during
temperature changes, especially during
hyperthermia
Skin temperature
Adhesion impaired by diaphoresis or sweat
disadvantages
Reading affected by environmental temperature
Cannot be used for patients with allergy to
adhesives
Easy to access without position change
Very rapid measurement
Comfortable with no risk of injury to patient or nurse
Eliminates need to disrobe or be unbundled
Temporal artery
Comfortable for patient
advantages
Used in premature infants, newborns, and children
(Reynolds et al., 2014)
Reflects rapid change in core temperature
Sensor cover not required
Inaccurate with head covering or hair on forehead
Temporal artery
Affected by skin moisture such as diaphoresis or
disadvantages
sweating
Safe and inexpensive
Axillary advantages
Reliable in stable term and preterm infants
Long measurement time
Requires continuous positioning
Measurement lags behind core temperature during
rapid temperature changes
Not recommended for detecting fever
Axillary disadvantages
Requires exposure of thorax that can result in
temperature loss, especially in newborns
Affected by exposure to environment, including
time to place the thermometer
Underestimates core temperature
With Solutions
Save
Terms in this set (215)
Measuring vitals is my responsibility
Select right equiptment
Know pt's baseline
Use organized systemic approach
Control environmental factors
What are the general
Analyze results based on medical history and
guidelines for measuring
current illness
and documenting vital
Always double check abnormal vitals
signs?
Take appropriate nursing actions
Notify MD of abnormal findings
Document findings accurately
Take vital before med administration
Do not delegate unstable pts to CNAs
At change of shift
When to take vitals Before med administration
Per hospital policy
Temp: 36-38
Pulse: 60-100 BPM
Acceptable ranges of
Respiration: 12-20 breaths/min
vital signs (baseline) for
O2 sat (greater than or equal to 95)
adults
BP 120/80
Pain
Easily accessible
Comfortable for pt
Advantages of oral Provides accurate surface temp reading
temperature Reflects rapid change in core temp
Reliable route to measure temp in pts who are
intubated
, Causes delay in measurement if pt recently ingested
hot/cold fluids, smoked, receiving O2 by mask/nasal
cannula
Disadvantages of oral
Not for pts who have oral surgery, trauma, hx of
temperature
epilepsy, or shaking chills
Not for infants, small children, or confused pts
Risk of body fluid exposure
Easily accessible site
Found to be most accurate method in critically ill
pts
Minimal pt repositioning required
Obtained w/o disturbing, waking, or repositioning
Tympanic membrane
pts
advantages
Used for pts with tachypnea w/o affecting breathing
Sensitive to core temp changes
Very rapid measurement
Unaffected by oral intake of fluids or smoking
Not influenced by environmental temps
, More variability of measurement than w/ other core
temp devices
Requires removal of hearing aids before
measurement
Requires disposable sensor cover with only one size
available
Otitis media and cerumen impaction distorts
readings
Not used in patients who have had surgery of the
ear or tympanic membrane
TM disadvantages Does not accurately measure core temperature
changes during and after exercise
Does not obtain continuous measurement
Affected by ambient temperature devices such as
incubators, radiant warmers, and facial fans
Use in infants older than 6 months (Seattle Children's
Hospital, 2019) and children under 3 years of age;
use care to position device correctly because
anatomy of ear canal makes it difficult to position.
Inaccuracies reported caused by incorrect
positioning of handheld unit
Argued to be more reliable when oral temperature
Rectal temp advantages
is difficult or impossible to obtain
Lags behind core temperature during rapid
temperature changes
Not for patients with diarrhea, rectal disorders, or
bleeding tendencies or those who had rectal
surgery
Rectal Temp Requires positioning and is often source of patient
Disadvantages embarrassment and anxiety
Risk of body fluid exposure and injury to rectal
lining
Requires lubrication
Not for routine vital signs in newborns
Readings influenced by impacted stool
, Inexpensive
Skin temperature Provides continuous reading
advantages Safe and noninvasive
Used for neonates
Measurement lags behind other sites during
temperature changes, especially during
hyperthermia
Skin temperature
Adhesion impaired by diaphoresis or sweat
disadvantages
Reading affected by environmental temperature
Cannot be used for patients with allergy to
adhesives
Easy to access without position change
Very rapid measurement
Comfortable with no risk of injury to patient or nurse
Eliminates need to disrobe or be unbundled
Temporal artery
Comfortable for patient
advantages
Used in premature infants, newborns, and children
(Reynolds et al., 2014)
Reflects rapid change in core temperature
Sensor cover not required
Inaccurate with head covering or hair on forehead
Temporal artery
Affected by skin moisture such as diaphoresis or
disadvantages
sweating
Safe and inexpensive
Axillary advantages
Reliable in stable term and preterm infants
Long measurement time
Requires continuous positioning
Measurement lags behind core temperature during
rapid temperature changes
Not recommended for detecting fever
Axillary disadvantages
Requires exposure of thorax that can result in
temperature loss, especially in newborns
Affected by exposure to environment, including
time to place the thermometer
Underestimates core temperature
