This document provides information on assessing and monitoring vital signs including temperature, pulse, respiration, and blood pressure. It defines key terms and describes normal ranges. Factors that can influence each vital sign are discussed. The document outlines proper technique for taking vital signs and common errors to avoid. Nursing interventions for abnormalities such as fever are also reviewed.

1. UNIT 5
BASIC NURSING CARE
(TPR & BP)

2. Learning outcomes
On completion of this lesson, the
student nurse should be able to:
Define: core temperature, surface
temperature, pyrexia &
hypothermia
Identify times to assess vital
signs
Describe factors influencing the
body temperature

3. Identify four ways in which the
body loses heat
Identify factors that can
contribute to pyrexia
Describe the signs of fever
Describe nursing intervention for
clients with pyrexia

4. Define: Pulse, Tachycardia,
Bradycardia; Dysrhythmia and Pulsus
regularis
Identify nine common areas where
the pulse is easily palpable and state
different purposes for their use
Describe factors which influence the
pulse rate

5. Define respiration, inspiration,
expiration; bradypnea, tachypnea,
apnea and eupnoea
Describe factors that influence
respiratory rate, rhythm and volume
Identify breathing sounds that
indicate problems with breathing

6. Differentiate between Systolic and
Diastolic Blood Pressure
Define hypertension and Hypotension
Describe the factors affecting Blood
Pressure

7. Identify actions that will give an
erroneous reading when measuring
blood pressure
Identify situations in which the
Blood Pressure cannot be measured
on a client’s arm or thigh.

8. Vital signs
Vital signs reflect the body’s
physiologic status and provide
information critical to evaluating
homeostatic balance.
Are the clearest indicator of overall
health status.
Vital signs include: T (temperature),
PR (Pulse Rate)/ HR (Heart rate), RR
(Respiratory Rate), and BP (Blood
Pressure)

9. Times to assess vital signs
On admission – to obtain baseline date
When a client has a change in health
status or reports symptoms such as
chest pain or fainting
According to a nursing or medical
order
Before and after the administration
of certain medications that could
affect HR or BP

10. Before and after surgery or an
invasive diagnostic procedures
Before and after any nursing
intervention that could affect the vital
signs. E.g. Ambulation
According to hospital /other health
institution policy.

11. Body temperature
Is a balance between heat produced
and heat lost
The body continually produces heat as
a by-product of metabolism.
When the amount of heat produced by
the body equals the amount of heat
lost, the person is in heat balance
Normal body temperature is 36°C-
37.5°C

13. Terminologies
Core temperature
is the temperature of the deep
tissues of the body, such as the
abdominal cavity and pelvic cavity.
It remains relatively constant.

14. Surface temperature
The temperature of the skin, the
subcutaneous tissue and fat
Gives a good estimation of core
temperature
It rises and falls in response to the
environment.
Measured non-invasively

15. Hypothermia
A core body temperature below the
lower limit of normal
The three physiological mechanisms of
hypothermia are:
Excessive heat loss,
Inadequate heat production to
counteract heat loss,
Impaired hypothalamic
thermoregulation

16. Hyperthermia or pyrexia
Elevated body temperature
It can be related to an internal or
external source

17. Hyperpyrexia
An extremely high temperature
above 41 ⁰C
The client who has a fever is referred
to as febrile; the one who does not is
afebrile

18. Factors influencing the body
temperature
Age-Children and elderly
Exercises- Hard or strenuous
exercises can increase the body
temperature to as high as 38.3°C to
40°C measured rectally
Environment- If the environment
temperature is higher than that of the
body, heat is absorbed from the
environment

19. Hormones- Temperature rises during
ovulation and decrease of the onset of
menstruation
Increase during pregnancy especially
during the first three months
Stress- Stimulation of the
sympathetic nervous system can
increase the production of epinephrine
and norepinephrine, thereby increasing
metabolic activity and heat production

20. Intake of food- Some food increases
the basal metabolic rate, with
consequent heart production

21. Four ways in which the body
loses heat
Convection- when the body heat
warms surrounding air which rises
and is replaced by cooler air
Radiation- Emission of the heart
from the body in the form of
electromagnetic waves, without
direct contact with another surface

22. Evaporation- heat loss occurring
during a conversion of liquid to
vapour
Conduction-transfer of heat from
one molecule to another by direct
contact

23. Factors that can contribute to
pyrexia
Very strenuous muscular activity
Exposure to intense heat
Dehydration
Any form of tissue destruction
Brain lesions
Diseases

24. Signs of pyrexia
Sweating
Chills and shivering
Headache
Muscle aches
Irritability
General body weakness

25. Describe nursing intervention for
clients with pyrexia
Nursing diagnosis
Pyrexia as evidenced by body
temperature above the normal range
Goals and outcome
Patient to maintain temp within
normal range 36 ⁰C- 37.5 ⁰C

26. Nursing Interventions
Remove excess clothing
Perform tepid sponge to allow
evaporative cooling
Encourage patient to drink more fluids
Adjust and monitor environmental
temperature if applicable
Reduce physical activity to limit heat
production
Ensure physical comfort e.g. keep
linens dry

27. Pulse
It is a wave of blood created by
contraction of the left ventricle
Number of times the heart beats in
one minute
Pulse is easier to locate in arteries
close to skin that can be pressed
against bone

28. Characteristic of the pulse
Rate – number of beats/min
Tachycardia - fast heart rate (>100
bpm)
Bradycardia – slow heart rate (< 60
bpm)

29. Rhythm – regularity of pulse
The rhythm of a normal pulse is
regular and the interval between
successive beats is even
Dysrhythmia/Arrythymia-Refers to
an irregular pulse
Pulsus regularis-Refers to a pulse
with a regular interval

30. Strength – Refers to the force with
which the blood is palpable with every
heartbeat over a peripheral arterial
wall.
Weak or thready
Bounding or full
Strong

31. Sites of measurement the pulse
Temporal: used when other pulses
points are not accessible.
Carotid: used in cases of cardiac arrest
and to determine circulation to the brain
Apical: routinely used for infant and
children < 3 years, also used in adults to
check for discrepancies with peripheral
pulses and in patient with cardiac
conditions
Brachial: used when taking blood
pressure, also used during cardiac arrest
of infants

32. Radial: readily available and routinely
used
Femoral: used during cardiac arrest and
to check circulation to the legs
Popliteal: used to determine blood
pressure in legs and to check circulation
to the legs
Posterior tibial: to determine
circulation to the feet
Dorsalis Pedis: to determine circulation
to the feet

36. Factors that influence pulse
Age -as age increase the pulse gradually
decreases
Sex- pulse rate of women is an average
of 6-8 b/m faster than that of men
Emotions- Stress increases the
sympathetic nervous system (SNS)
stimulation which increases the rate and
force of heart beat
Pain- Surface pain accelerates the heart
rate while deep and intense pain slows
the heart rate

37. Exercises- Heart rate accelerated
during physical activity to supply the
greater demand for oxygen in the
muscle cells
Heat- Prolong exposure to external
and an increase in internal body heat,
accelerates the heart rate
Medication- SNS stimulants
accelerate pulse rate, SNS
depressants reduce pulse rate

38. Respiration
Is the act of breathing, includes
intake of O2 and the output of
CO2
is the mechanism the body uses to
exchange gases between the
atmosphere and the blood of the
cells.
Respiration rate- is the frequency
of breathing that is recorded as
the number of breaths per minute.

39. Qualities of normal respirations
12-20 respirations per minute
Quiet
Effortless
Regular

40. Terminologies related to
respiration
Inspiration (or inhalation): is the
intake of air to the lung.
Expiration (or exhalation) is the
discharge of breathing out the lung
Tachypnoea- Rapid respiration rate of
more than 20 b/m
Bradypnea: slow breathing below 12
breath per minute with normal depth
and rhythm

41. Eupnea- normal breathing rate and
depth
Apnea- temporary cessation of
breathing
Hypoventilation- Refers to superficial
ventilation
Hyperventilation- Refers to deep,
rapid breathing

42. Dyspnoea- difficulty in breathing
Hypoxia- low levels of oxygen in the
body tissues
Cyanosis- bluish discolouration of the
skin, nail beds and mucous membranes,
indicating reduced levels of oxygen

43. Assessment of respiration
Rate- number of breaths per minute,
normal range is 12- 20 bpm in adults
Respiratory rhythm- Is the regularity
of expiration and inspiration
Respiration depth (Character)-
Refers to the volume of air breathed in
and out. Recorded as shallow, deep or
labored
Respiration sounds

44. Breathing sounds that indicate
problems with breathing
Noisy breathing- can be a result of
excess fluids in the respiratory organs
or other obstructions to the airflow
Stridor- harsh, high-pitched sound
heard on inspiration when there is
some obstruction in the respiratory
tract

45. Wheezing- is a continuous, high–
pitched sound, made by the air moving
through a partially obstructed airway
Crackles- fines crackling sounds heard
on inspiration when the respiratory
tract is wet
Gurgles- are coarse wheezing or
whistling sounds heard mostly on
expiration when the air moves through
mucous or obstructed airways

46. Factors which influencing
respiration
Age- influences both the rate and depth
Emotions-hyperventilation occurs during
anxiety and hypoventilation can occur
during depression
Exercises- increase both the depth and
speed during and after exercises
Medication- SNS depressants reduce
breathing rate and depth
Voluntary influence- respiration rate,
rhythm and volume can be changed
voluntarily

47. Pain- depresses or increases the
respiration rate, rhythm and depth
Body position- supine position can
cause superficial respiration
Sex- men usually have a greater lung
capacity than women of the same age

48. Blood pressure
Blood pressure (BP) is the pressure
exerted by blood against the wall of
blood vessels
It includes arterial, venous and
capillary pressures

50. There are two types of blood
pressure
Systolic pressure: is the pressure of
the blood as a result of contraction
of the ventricle
Diastolic blood pressure: is the
pressure when the ventricles are at
rest.

51. The difference between the systolic
and diastolic pressure is called pulse
pressure
A normal pulse pressure is about 40
mmHg.
Blood pressure is measured in mmHg
and recorded as a fraction. Ideal BP
for adults is 120/80mmHg
Normal ranges are systolic 90-
139mmHg and diastolic 60-89mmHg

52. Mean arterial pressure (MAP)
MAP is the average arterial pressure
throughout one cardiac cycle, systole,
and diastole
The normal range is 70 to 110 mmHg
MAP= SBP+ 2*(DBP)
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53. An elevated blood pressure of
140/90 mmHg and above is called
hypertension; an abnormal lowering
of blood pressure below 90/60
mmHg is called hypotension

54. Factors affecting blood
pressure
Age- Blood pressure varies with age
Elasticity of the blood vessel walls
decreases with age
Physical activity- increase cardiac
output
Emotions- stimulates the SNS causing
an increase in cardiac output, with
consequent rise in blood pressure

55. Pain- Pain increases/decreases blood
pressure due SNS
stimulation/parasympathetic reaction
Body size- varies in direct
proportion to the body size, common
in obese persons

56. Body position- arterial pressure is
slightly higher in a standing than s lying
position
Race- higher blood pressure in
Afrikaners, Americans, Europeans and
Blacks
lower in certain races such Orientals,
Khoisan and Asians

57. Common blood pressure
measurement mistakes
Wrong cuff size.
Cuff positioning.
Incorrect patient positioning (back
must be supported, feet on a flat
surface and legs uncrossed)

58. Talking ( patient must not talk or
actively listen during the
procedure)
Patient preparation (e.g. ensure the
bladder is empty as it can raise a
blood pressure measurement by 10-
15mmHg)

59. Have a nice day!