Fundamentals of Nursing

• RN’s responsibility is to delegate when stable
• RN’s responsibility

  1. Review, analyze, interpret, and report

  2. Assess accuracy of the equipment

  3. Know the usual ranges

  4. Frequency depending on doctor’s orders and institution’s policy
• Acceptable ranges for adults

  • Temperature: 36 C to 38 C (96.8 F to 100.4 F), Average oral/tympamic: 37 C (98.6 F), Average rectal: 37.5 C (99.5 F), Axillary temperature: 36.5 C (97.7 F)
  • Pulse: 60 to 100 beats per minute, Strong and regular pulses
  • Blood pressure: Normal 90/60 mmHg or 120/80 mmHg, Systolic < 120 mmHg, Diastolic < 80 mmHg, Pulse pressure: 30 to 50 mmHg
  • Respiration: 12 to 20 breaths per minute, Deep and regular
  • Oxygen saturation: SPO2 95% to 100%
• When to measure vital signs

  Learn when to B.A.S.S.H someone: Before, during, after blood products transfusion, medication administration, nursing interventions, admission, status changes, symptoms that are non-specific, hospital routine schedule
• Equipment for vital signs taking

  • Sphygmomanometer
  • Wristwatch with second hand
  • Stethoscope
  • Thermometer
  • Pulse oximeter
  • Focus and attention
• General preparation

  W.I.P.E before and after all nursing procedures: Wash hands before and after procedure, Identify and inform the patients regarding the procedures, Provide privacy and position patients correctly
• General steps

  Check doctor’s orders for any special orders, Wash hands, Prepare materials, Identify the patient, Provide privacy, Explain procedure to the patient, Perform taking the temperature, pulse rate, respiratory rate, and blood pressure, Wash hands, Dispose all disposables accordingly, Document reading and patient’s response to procedure
• Body Temperature

  • Heat produced – heat lost = body temperature
  • Core temperature: Temperature of the deep tissues, Relatively constant
  • Surface temperature: Skin, subcutaneous tissue, and fats, Changes in response to the environment
  • Normal body temperature range: 36.5 C to 37.5 C, Average body temperature: 37 C
• Factors affecting body temperature

  • Age
  • Environment
  • Stress
  • Exercise
  • Hormone level
  • Circadian rhythm
• Thermoregulation

  1. Skin receptors sense warm or cold stimuli and sends signals to the hypothalamus

  2. Hypothalamus: Detects signals from receptors, Sends signals to effectors to regulate body temperature, Senses minor changes in body, Anterior – controls heat loss, Posterior – controls heat production
• Low body temperature


  Vasoconstriction preserves heat by limiting blood flow
• High body temperature

  Heat loss
• Receptors

  1. Sends signals to effectors to regulate body temperature

  2. Senses minor changes in body
• Receptors

  • Anterior - controls heat loss
  • Posterior - controls heat production
• Low Body Temperature


  • Vasoconstriction - Preserves heat by limiting blood flow
  • Heat Loss: Sweating, Vasodilation
  • Compensate: Shivering, Muscle contraction
  • Increase blood flow to surface to promote heat loss
• Hypothalamus regulates body temperature
• Medulla oblongata controls the vital signs
• Pons controls the pacing of your breathing
• Mechanisms of Heat Loss

  1. Sweating

  2. Vasodilation of blood vessels - Widening

  3. Inhibition of heat production
• Heat Conservation Mechanisms

  Vasoconstriction of blood vessels - Narrowing, Reduces blood flow to the skin and extremities to reduce heat loss, Heat production is stimulated through voluntary muscle contraction and muscle shivering
• Vital Signs

  • Fundamentals of Nursing Practice | PROF. Espina | BS Nursing 2nd SEM 2022-2023 YSABELLA ANGELES
• Heat Production is a by-product of metabolism
• Basal metabolic rate (BMR) - Heat produced by the body, Thyroid levels: Absence of thyroid hormones reduces BMR in half
• Muscular activity and physical exercise contribute to heat production
• Shivering occurs when vasoconstriction fails, it is an involuntary response to temperature differences in the body
• Non-shivering thermogenesis occurs in neonates as they cannot shiver
• Heat loss mechanisms include Radiation, Conduction, Convection, and Evaporation
• Fever (pyrexia) is a result of an immune response, while Hyperthermia is an elevated body temperature resulting from inability to lose heat or halt heat production
• Phases of Fever: Cold/chill phase, Plateau phase, Fever abatement/flush phase
• Types of Fever

  • Sustained - Constant elevated body temperature above 38 C
  • Intermittent - Temperature spikes and returns
  • Remittent - Temperature spikes and does not return
  • Relapsing - Returns to normal for a day but recurs
• Afebrile means not feverish, Febrile means showing symptoms of fever
• Hypothermic Condition: Heat stroke - Prolonged exposure to heat, Body temperature at 40 C, Signs and symptoms include Hot, dry skin, Confusion, Delirium, Excess thirst, Nausea, Visual dis
• Afebrile = not feverish
• Febrile = showing symptoms of fever
• Hypothermic condition


  When the temperature drops below the usual range of body temperature
• Heat stroke

  1. Prolonged exposure to heat

  2. Body temperature at 40 C

  3. Signs and symptoms: Hot, dry skin, Confusion, Delirium, Excess thirst, Nausea, Visual disturbance, Does not sweat
• Heat exhaustion

  1. Profuse sweating / diaphoresis

  2. Results in electrolyte or water loss

  3. Signs and symptoms: Paleness, Dizziness, Nausea and vomiting, Fainting, Moderately increased temp
• Hypothermia


  1. When the temperature drops below the usual range of body temperature

  2. Mechanism: Heat loss during prolonged exposure to cold, Inability to produce heat

  3. Signs and symptoms: Decreased HR, RR, and BP, Cyanotic, Cardiac dysrhythmias, Decreased level of consciousness

  4. Management: Decrease or remove exposure to cold, Promote heat, Assess core temperature
• Where to measure body temperature

  • Oral
  • Axillary
  • Tympanic
  • Rectal
• Types of thermometers

  • Digital thermometer
  • Tympanic thermometer
  • Rectal thermometer
  • Chemical dot thermometer