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What is hypothermia? –
A condition where body temperature falls below the normal range typically below 35°C.
What is hyperthermia? –
A condition where the body temperature rises above the normal range due to failed thermoregulation.
What is pyrexia? –
Another term for fever an elevation in body temperature often due to infection.
What controls body temperature? –
The hypothalamus: anterior controls heat loss posterior controls heat production.
What is the normal core temperature range?
– Typically between 36°C to 38°C.
How is body temperature regulated? –
Through the balance of heat production (from metabolism shivering) and heat loss (via radiation
What factors increase heat production? –
Metabolism muscle activity (shivering)
What is radiation (heat loss)? –
Transfer of heat without direct contact between objects.
What is conduction (heat loss)? –
Transfer of heat through direct contact with solids liquids
What is convection (heat loss)?
– Transfer of heat by air or fluid movement.
What is evaporation (heat loss)?
e.g. – Loss of heat when liquid turns into vapor
What are normal temperatures by age? – Newborn: 36.8°C
– Newborn: 36.8°C 1–3 yrs: 37.7°C
Factors influencing body temperature –
Age, infection
Why should nurses assess temperature regularly? –
To establish a baseline detect trends
When to recheck temperature after antipyretics? –
30 minutes after administration and every 4 hours until stable.
Sites for measuring temperature –
tympanic, Oral, rectum, axilla
How does site affect temperature reading? –
Rectal is ~0.5°C higher than oral; axillary is ~0.5°C lower.
Why assess respiration? –
Early changes in respiratory rate can indicate client deterioration.
What are the 3 processes of respiration? –
diffusion Ventilation perfusion
What is ventilation? –
The mechanical movement of air into and out of the lungs.
What is diffusion? –
Exchange of oxygen and carbon dioxide between alveoli and blood.
What is perfusion? –
The transport of blood to and from pulmonary capillaries.
What changes during inspiration? –
Diaphragm contracts chest expands
What changes during expiration? –
Diaphragm relaxes chest returns to resting state
Normal respiratory rate for newborn –
30–60 breaths per minute.
Normal respiratory rate for infant (6 months) –
30–50 breaths per minute.
Normal respiratory rate for toddler (2 years) –
25–32 breaths per minute
Normal respiratory rate for child – .
20–30 breaths per minute
Normal respiratory rate for adolescent –
16–20 breaths per minute.
Normal respiratory rate for adult –
12–20 breaths per minute.
What is apnoea? –
Absence of breathing.
What is bradypnoea? –
Abnormally slow breathing.
What is tachypnoea? –
Abnormally fast breathing.
What is orthopnoea? –
Difficulty breathing when lying flat.
What is dyspnoea? –
Difficulty or labored breathing.
What does SpO₂ measure? –
The peripheral oxygen saturation or the amount of oxygenated hemoglobin via a pulse oximeter.
What is SaO₂? –
Arterial oxygen saturation measured via arterial blood sample.
What is a normal SpO₂ reading? –
Typically between 95–100%.
Why use a pulse oximeter? –
It's a non-invasive method to assess oxygen saturation.
What does a 90% SpO₂ mean? –
90% of hemoglobin binding sites have oxygen attached.
What is systolic blood pressure? –
The highest pressure recorded when the left ventricle contracts and pushes blood into the aorta.
What is diastolic blood pressure? –
The minimum pressure in the arteries when the ventricles relax (the heart is at rest).
Why is understanding blood pressure important for nurses? –
It helps identify acute or chronic health problems and plan appropriate interventions.
What is blood pressure a measure of? –
The force of blood against the arterial walls as the heart pumps.
What do the systolic and diastolic numbers represent? –
Systolic = pressure during heart contraction; Diastolic = pressure during heart relaxation.
What are the main factors maintaining blood pressure? –
Cardiac output, peripheral resistance, blood volume, blood viscosity, and elasticity of blood vessels.
What is cardiac output? –
The amount of blood the heart pumps per minute.
What is peripheral resistance? –
The resistance blood encounters as it flows through vessels.
What is blood viscosity? –
The thickness of the blood.
What is vessel elasticity? –
The ability of blood vessels to stretch and return to normal shape.
What causes high blood pressure (hypertension)? –
Obesity, smoking, stress, inactivity, high salt intake, excessive alcohol, genetics.
What causes low blood pressure (hypotension)? –
Dehydration, medications, illness, temperature, recent meals, blood loss, age, genetic factors.
How does temperature affect blood pressure? –
Warm temperatures may lower blood pressure.
How does exercise affect blood pressure? –
It raises BP during activity but lowers resting BP over time.
What are Korotkoff's sounds? –
Sounds heard while measuring BP: indicate changes in blood flow.
What is Phase I of Korotkoff's sounds? –
First faint tapping sounds (systolic pressure).
What is Phase V of Korotkoff's sounds? –
Last sound heard before silence (diastolic pressure).
How is blood pressure measured directly? –
Invasively, using an arterial cannula (only in ICU).
How is blood pressure measured indirectly? –
Non-invasively using a stethoscope and sphygmomanometer.
What is a normal adult blood pressure? –
Systolic <120 mmHg and Diastolic <80 mmHg.
Henry's BP is 188/96. What action should the nurse take? –
Educate him about hypertension, suggest lifestyle changes, and refer for further assessment.
What lifestyle changes can help lower blood pressure? –
Exercise, reduce salt, quit smoking, limit alcohol, manage stress, maintain a healthy weight.
What is pulse rate? –
The palpable beating of blood against artery walls, indicating circulatory status.
What affects pulse quality? –
Heart strength, blood volume, and arterial condition.
What does a strong, regular pulse indicate? –
Effective heart pumping and healthy circulation.
What does a weak or hard-to-find pulse suggest? –
Poor heart function or circulation issues.
What factors influence pulse rate? –
Exercise, fever, pain, medications, age, metabolism, posture, haemorrhage.
Where is the most common site to check adult pulse? –
Radial artery (wrist). nearest thumb
When should you assess a client's pulse? –
After surgery, during pain, with heart conditions, after meds, or during IV fluid infusion.
What does decreased fluid volume do to pulse? –
Increases heart rate to compensate for lower blood volume.
How does stress affect pulse rate? –
Increases pulse due to sympathetic nervous system stimulation.
What is the point of maximal impulse (PMI)? –
Located at the 5th intercostal space, mid-clavicular line – used for apical pulse.
Why measure the apical pulse? –
More accurate when peripheral pulses are difficult to detect or in children under 2.
How to measure apical pulse? –
Use a stethoscope, listen at the PMI, and count once beats are clearly heard.