Vital signs
- are body temperature, pulse, respiration, and blood
pressure.
 Oxygen saturation- is also commonly measured
at the same time as the traditional vital signs.
- Vital signs should be looked at in total, are checked
to monitor the functions of the body.
- Monitoring the client’s vital signs should not be an
automatic or routine procedure. It should be a
thoughtful and scientific assessment.
- Vital signs should be evaluated with reference to
client’s present and prior health status, their usual
vital signs results and accepted normal standards.
BODY TEMPERATURE
- Reflects the balance between the heat produced and
the heat lost from the body and measured in heat
units called degrees.
- There are two kinds of body temperature:
1. Core temperature- is the temperature of the deep
tissues of the body such as abdominal cavity and
pelvic.
2. Surface temperature- is the temperature of the skin.
 Heat balance- when the amount of heat
produced by the body equals the amount of heat
lost.
5 Factors that affect the body’s heat production:
1. Basal metabolic rate (BMR)- is the rate of energy
utilization in the body that requires to maintain
essential activities such as breathing Metabolic rates
decrease with age. The younger the person, the higher
the BMR.
2. Muscle activity- including shivering, increases the
metabolic rate.
3. Thyroxine output- increased thyroxine output
increases the rate of cellular metabolism throughout
the body.
4. Epinephrine, norepinephrine, and sympathetic
stimulation/stress response- these hormones
immediately increase the rate of cellular metabolism
in many body tissues.
5. Fever- increases the cellular the cellular metabolic
rate and thus increases the body’s temperature
further.
Heat
- Is lost from the body through radiation, conduction,
convention, and evaporation.
 Radiation- is the transfer of the heat from the
surface of one object to the surface of another
without contact between the two objects.
 Conduction- is the transfer of the heat from one
molecule of a lower molecule.
 Convection- is the dispersion of heat by air
currents.
 Evaporation- is continuous vaporization of
moisture from the respiratory tract and from
mucosa of the mouth and the skin.
Insensible water loss- continuous and unnoticed
water loss.
Insensible heat loss- accompanying heat loss.
REGULATION OF BODY TEMPERATURE
- The system that regulates body temperature has three
parts:
 Sensors in the periphery
 In the core, an integrator in the hypothalamus
 An effector system that adjusts the production
and loss of heat.
- Most sensors or sensory receptors are in the skin.
 Hypothalamic integrator- is the center that
controls the core temperature.
FACTORS AFFECTING BODY TEMPERATURE
- Nurses should be aware of the of the factors that can
affect a client’s body temperature so they can
recognize normal temperature variations and
understand the significance of body temperature
measurement that deviate from normal.
1. Age
2. Diurnal variations
3. Exercise
4. Hormones
5. Stress
6. Environment
ALTERATIONS IN BODY TEMPERATURE
- The normal range for adults is considered to be
between 36 degrees and 37.5 c (96.8 f to 99.5 f)
 There are two primary alternations in body
temperature:
1. Pyrexia hyperthermia (fever)- a body temperature
above the usual range.
 Hyperpyrexia- a very high fever, such as 41c  (105.8
f)
 Febrile- the client who has a fever 
 Afebrile- the one who does not have a fever.
FOUR TYPES OF FEVERS:
1. Intermittent fever- the body temperature alternates
at regular intervals between periods of fever and
periods of normal or subnormal temperature.
Example is the disease malaria.
 2. Remittent fever- such as with a cold or influenza, a  Cardiac output- is the volume of the blood pumped
wide range of temperature fluctuations more than 2 into the arteries by the heart and equals the result of
degree happens over a 24-hour period, all of which the stroke volume times the heart rate per minute.
above normal.   Peripheral pulse- is a pulse located from the heart.
3. Relapsing fever- a short febrile periods of a few days Example: foot or wrist. 
are interspersed with periods of 1 to 2 days of normal  Apical pulse- is central pulse that is located at the
temperature.  apex of the heart. It is also referred to as the point of
4. Constant fever- the body temperature fluctuates maximal pulse (PMI)
minimally but always remains above normal. This
can happen with thyroid fever.  FACTORS AFFECTING PULSE:
 fever spike- a temperature that rises to fever level 1. Age
rapidly following a normal temperature and then 2. Sex 
returns to normal within a few hours.  3. Exercise
 bacterial blood infections often cause fever spikes.  4. Fever
 In some conditions, an elevated temperature is not a 5. Medications
true fever. There are 2 examples, the heat 6. Hyvolemia/ dehydration
exhaustion and heat stroke. 7. Stress
 heat exhaustion- is a result of excessive heat and 8. Position
dehydration. Signs of heat exhaustion includes pales 9. Pathology
beds, dizziness, nausea, vomiting, fainting, and a
moderately increased of temperature. 
 Heat stroke- generally have been exercising in hoy
weather, have warm, flushed skin and often do not
sweat. 

HYPOTHERMIA 
 is a core body temperature below the lower limit of
normal. 
 The three physiological mechanisms of hypothermia
are:
1. Excessive heat loss
2. Inadequate heat production to counteract heat loss PULSE SITE
3. Imparted hypothalamic thermoregulation.  - a pulse may be measured in nine lines:
 hypothermia may be induced or accidental.  1. Temporal
2. Carotid
ASSESSING BODY TEMPERATURE  3. Apical
 the most common sites for measuring body 4. Brachial
temperature are: 5. Radial
 oral 6. Femoral 
 Rectal  7. Popliteal 
8. Posterior tibial
 Ancillary
9. Dorsalis pedis
 Tympanic membrane 
 Skin or temporal artery

TYPES OF THERMOMETERS 
 electronic thermometer 
 Chemical disposable thermometer 
 Temperature sensitive tape 
 Infrared thermometer 
 Temporal artery thermometer 

PULSE
 is a wave of blood created by contraction of the left
ventricle of the heart. 
 compliance- of the arteries is their ability to contract
and expand. when a person’s arteries lose their
distensibility, as can happen with age, greater
pressure is required to pump the blood into the
arteries. 

Assessing the Pulse

 - A pulse is commonly assessed by palpation (feeling)
or auscultation (hearing).
- . The middle three fingertips are used for palpating all
pulse sites except the apex of the heart. A stethoscope
is used for assessing apical pulses
- A pulse is normally palpated by applying moderate
pressure with the three middle fingers of the hand.
- The nurse should also be aware of the following
 Any medication that could affect the heart rate.
 Whether the client has been physically active. If so,
wait 10 to 15 minutes until the client has rested and
the pulse has slowed to its usual rate.
 TACHYCARDIA- . An excessively fast heart rate
(e.g., over 100 beats/min in an adult)
 BRADYCARDIA-. A heart rate in an adult of less
than 60 beats/min
 pulse rhythm- is the pattern of the beats and the
intervals between the beats. Equal time elapses
between beats of a normal pulse
 dysrhythmia or arrhythmia- A pulse with an
irregular rhythm is referred
- When a dysrhythmia is detected, the apical pulse
should be assessed. An electrocardiogram (ECG) is
necessary to define the dysrhythmia further.
 Pulse volume- also called the pulse strength or
amplitude, refers to the force of blood with each beat.
Usually, the pulse volume is the same with each beat.
APICAL-RADIAL PULSE ASSESSMENT
- An apical-radial pulse may need to be assessed for
clients with certain cardiovascular disorders.
Normally
- the apical and radial rates are identical. An apical
pulse rate greater than a radial pulse rate can indicate
that the thrust of the blood from the heart is too weak
for the wave to be felt at the peripheral pulse site, or
it can indicate that vascular disease is preventing
impulses from being transmitted.
 Pulse deficit- any discrepancy between the two-pulse
rate.
RESPIRATIONS
 Respiration- is the act of breathing. Inhalation or
inspiration refers to the intake of air into the lungs.
 Exhalation or expiration- refers to breathing out or
the movement of gases from the lungs to the
atmosphere
 . Ventilation- is also used to refer to the movement
of air in and out of the lungs
There are two types of breathing:
1. Coastal breathing(thoracic)
2. Diaphragmatic breathing (abdominal)
 Bradypnea- abnormally slow respirations
 Tachypnea or polypnea- abnormally fast respirations.
 Apnea- is the absence of breathing.
 Tidal volume- during the normal inspiration and
expiration, an adult takes in about 500Ml of air.
 Hyperventilation- refers to very deep, rapid
respirations.
 Hypoventilation- refers to very shallow respirations.
 Respiratory rhythm- refers to the regularity of the
expirations and the inspirations.
 Respiratory quality or character- refers to those
aspects of breathing that are different from normal,
effortless breathing
BLOOD PRESSURE
 Arterial blood pressure- is a measure of the pressure
exerted by the blood as it flows through the arteries.
Because the blood moves in waves, there are two
blood pressure measurements.
 systolic pressure- is the pressure of the blood as a
result of contraction of the ventricles, that is, the
pressure of the height of the blood wave.
 diastolic pressure- is the pressure when the ventricles
are at rest.
 Pulse pressure- The difference between the diastolic
and the systolic pressures
- A normal pulse pressure is about 40 mmHg but can
be as high as 100 mmHg during exercise.
Determinants of Blood Pressure
- Arterial blood pressure the result of several factors:
the pumping action of the heart, the peripheral
vascular resistance (the resistance supplied by the
blood vessels through which the blood flows), and
the blood volume and viscosity.
PUMPING ACTION OF THE HEART COMPONENTS OF COMMUNICATION:
1. SENDER: a party that sends the message
- When the pumping action of the heart is weak, less
blood is pumped into arteries (lower cardiac output),
2. CHANNEL: must be selected, it is the manner by
and the blood pressure decreases which a message is sent
- May include speaking, writing, etc.
PERIPHERAL VASCULAR RESISTANCE 3. RECEIVER: must be able to decode the message
- Peripheral resistance can increase blood pressure. which means mentally processing the message into
The diastolic pressure especially is affected. understanding
4. FEEDBACK (response): a message that the receiver
BLOOD VOLUME returns to the sender
- When the blood volume decreases (for example, as a
result of a hemorrhage or dehydration), the blood MODES OF COMMUNICATION:
pressure decreases because of decreased fluid in the 1. VERBAL/ ORAL: spoken or written
arteries. a. Simplicity: use of commonly understood words,
brevity, and completeness.
BLOOD VISCOSITY
b. Clarity and Brevity: clarity is saying precisely
- Blood pressure is higher when the blood is highly what is meant. Brevity is the fewest words used.
viscous (thick), that is, when the proportion of red i. Simple and clear
blood cells to the blood plasma is high. This c. Timing and Relevance: the timing needs to be
proportion referred as hematocrit. appropriate to ensure that words are heard.
FACTORS AFFECTING BLOOD PRESSURE d. Adaptability: it is important for the nurse to then
modify his or her tone of speech and express
1. Age concern by facial expression while moving
2. Exercise toward the client.
3. Stress e. Credibility: nurses should convey confidence and
4. Race
certainty in what they are saying while being able
5. Sex
6. Medications
to acknowledge their limitations.
7. Obesity 2. NON-VERBAL: gestures, facial expressions, and
8. Diurnal variations touch
9. Medical conditions a. Personal Appearance: clothing and etc.
10. Temperature b. Posture and Gait
c. Facial Expression
d. Facial Expression
e. Gestures
3. WRITTEN COMMUNICATION:
HYPERTENSION

- A blood pressure that is persistently above normal. FACTORS AFFECTING COMMUNICATION:

1. Status/ role
HYPOTENSION
2. Cultural Differences
- is a blood pressure that is below normal 3. Choice of Communication Channel
4. Length of Communication
Orthostatic hypotension
5. Use of Language
- is a blood pressure that decreases when the client sits 6. Disabilities
or stands. 7. Known or Unknown Receiver

THERAPEUTIC COMMUNICATION:
COMMUNICATION SKILLS: - Involves the use of techniques such as silence,
COMMUNICATION: the process of conveying offering self, restating, reflecting, and seeking
information between 2 or more people. clarification
COMMUNICATE: to share - It requires the components of empathy, positive
regard, positive sense of self
 - It is healing and bringing about positive change
through open communication
- Rapport is an understanding between two or more
people
NURSE-CLIENT RELATIONSHIP:
- The nurse and the client work together to assist
the client to grow and solve his problems
PHASES OF THE HELPING RELATIONSHIP:
1. PRE-INTERACTION PHASE
o Similar to the planning stage before an
interview—nurses have information before
the face to face
o The nurse recognizes her own feelings
o Focus on the plan for information to be
discussed
2. INTRODUCTORY PHASE:
o Set the tone for the rest of the relationship
o Closely observe each other and form
judgments about each other’s behavior
o Opening relationships, clarifying the
problem, building trust
3. WORKING PHASE:
o The client and nurse begin to see each other
as unique individuals
o Begin to explore thoughts and feelings
o Begin to take action to meet goals
o Nurse helps clients with long- and short-
term goals
o The nurses reinforce successes and helps the
client to deal realistically with failure
4. TERMINATION PHASE
o Nurse and client accept feelings of ending
the relationship
o The client has developed independence and
has no feelings of anxiety or dependence
NON-THERAPEUTIC COMMUNICATION
TECHNIQUES:
- It involves the use of barriers such as giving
reassurance, rejecting, giving approval or
disapproval, agreeing, giving advice.
- Overloading, value judgment
Critical thinking
- is the process of intentional higher level thinking
to define a client’s problem, examine the
evidence-based practice in caring for the client,
and make choices in the delivery of care.
Clinical reasoning
- is the cognitive process that uses thinking
strategies to gather and analyze client
information, evaluate the relevance of the
information, and decide on possible nursing
actions to improve the client’s physiological and
psychosocial outcomes.
Creativity
- is thinking that results in the development of
new ideas and products. Creativity in problem
solving and decision making is the ability to
develop and implement new and better
solutions for health care outcomes. Creativity is
required when the nurse encounters a new
situation or a client situation in which traditional
interventions are not effective.
The use of creativity provides the nurse with the ability
to:
- Generate many ideas rapidly.
- Be ly flexible and natural; that is, able to change
viewpoints or directions in thinking rapidly and
easily.
- Create original solutions to problems.
- Be independent and self confident, even when
under pressure.
- Demonstrate individuality
Critical analysis
- is the application of a set of questions to a
particular situation or idea to determine
essential information
The nursing process
- is a systematic, rational method of planning and
providing individualized nursing care. Its
purposes are to identify a client’s health status
and actual or potential health care problems or
needs, to establish plans to meet the identified
needs, and to deliver specific nursing
interventions to meet those needs
six phases of the nursing process: assessment,
diagnosis, outcomes identification, planning,
implementation, and evaluation
The nursing process is a systematic, rational method of
planning and providing nursing care. Its purpose is to
identify a client’s health care status, and actual or
potential health problems, to establish plans to meet
the identified needs, and to deliver specific nursing
interventions to address those needs. The nursing
process is cyclical; that is, its components follow a
logical sequence, but more than one component may
be involved at one time
Assessing
- is the systematic and continuous collection,
organization, validation, and documentation of
data
Data collection
- is the process of gathering information about a
client’s health status. Data collection must be
both systematic and continuous.
database
- contains all the information about a client; it
includes the nursing health history (Box 11–1),
physical assessment, primary care provider’s
history and physical examination, results of
laboratory and diagnostic tests, and material
contributed by other health personnel
Subjective data, also referred to as symptoms or covert
data, are apparent only to the person affected and can
be described or verified only by that person.
Objective data, also referred to as signs or overt data,
are detectable by an observer or can be measured or
tested against an accepted standard.
CLIENT The best source of data is usually the client,
unless the client is too ill, young, or confused to
communicate clearly
Family members or significant others can be secondary
sources of data if the client cannot speak for
themselves, is a poor historian, or is a young child
Client records include information documented by
various health care professionals. Client records also
contain data regarding the client’s occupation, religion,
and marital status.
Diagnosing is the second phase of the nursing process.
In this phase, nurses use critical thinking skills to
interpret assessment data and identify client strengths
and problems. Diagnosing is a pivotal step in the nursing
process
The term diagnosing refers to the reasoning process,
whereas the term diagnosis is a statement or
conclusion regarding the nature of a phenomenon. The
standardized NANDA names for the diagnoses are called
diagnostic labels; and the client’s problem statement,
consisting of the diagnostic label plus etiology (causal
relationship between a problem and its related or risk
factors), is called a nursing diagnosis.
Qualifiers are words that have been added to some
NANDA labels to give additional meaning to the
diagnostic statement
Planning is a deliberative, systematic phase of the
nursing process that involves decision making and
problem solving. In planning, the nurse refers to the
client’s assessment data and diagnostic statements for
direction in formulating client goals and designing the
nursing interventions required to prevent, reduce, or
eliminate the client’s health problems
Discharge planning, the process of anticipating and
planning for needs after discharge, is a crucial part of a
comprehensive health care plan and should be
addressed in each client’s care plan
rationale is the evidence-based principle given as the
reason for selecting a particular nursing intervention.
y, implementing consists of doing and documenting the
activities that are the specific nursing actions needed to
carry out the interventions
evaluating is a planned, ongoing, purposeful activity in
which clients and health care professionals determine
(a) the client’s progress toward achievement of goals/
outcomes and (b) the effectiveness of the nursing care
plan. Evaluation is an important aspect of the nursing
process because conclusions drawn from the evaluation
determine whether the nursing interventions should be
terminated, continued, or changed
Normal body temperature can range from
97.8 degrees F (or Fahrenheit, equivalent to 36.5
degrees C, or Celsius) to 99 degrees F (37.2 degrees C)
for a healthy adult.