NOTES OF FOUNDATION FOR NURSING STUDENTS IN YEAR ONE

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!