FUNDAMENTALS OF NURSING RETURN a.

Lysis -gradual decline

DEMONSTATION b. Crisis/flush – sudden decline
indicating hypothalamic px
VITAL SIGNS
METHODS OF TEMPERATURE TAKING: TYPES OF
Temperature – balance between heat produced and THERMOMETER
heat lost measured in units called degrees. 1. Mercury in glass
1. Core temperature – temperature of the deep 2. Electronic
tissues such as the abdominal & pelvic 3. Chemical disposable
cavities thus, remaining relatively constant 4. Temperature-sensitive tape
(37 degrees). 5. Infrared (bang-bang0
2. Surface temperature – temperature of the
skin, subcutaneous tissue & fat which rises ROUTES OF TEMPERATURE TAKING
and falls in response to the environment. 1. Oral – 3-5 minutes
o Accessible and convenient
PROCESSES INVOLVED IN HEAT LOSS o Not used after oral surgery, after
a. Radiation – transfer of heat without contact eating or drinking, mouth breathers
between the objects. 2. Rectal – 2-3 minutes
b. Conduction – transfer of heat requiring o Reliable and accurate
difference between 2 surfaces. o Inconvenient and unpleasant, not
c. Convection – dissipation of heat by air used in patients with cardiac
currents. problems
d. Evaporation – continuous vaporization of 3. Axillary – 5-10 minutes
moisture from skin, oral mucosa & o Safe and non-invasive, least accurate
respiratory tract leading to insensible water o Measure surface temperature
loss thereby, insensible heat loss. 4. Tympanic – 2-3 seconds
o Readily accessible, very fast and
REGULATION OF BODY TEMPERATURE
reflects core temperature
a. Sensors in the skin & in the core – skin has
o Presence of cerumen can affect
more receptors for cold than warmth.
reading
b. Integrator in the hypothalamus
c. Effector systems that adjust production and
loss of heat NORMAL TEMPERATURE: 36.5-37.5 ℃
 Axillary: 36.5℃
Note:  Oral: 37℃
 Temperature vary according to route  Anal: 37.5℃
o Axillary is usually 1° ↓ than oral
o Rectal is usually 1° ↑ than oral. TEMPERATURE SCALES
 Variations among persons: 3-6 ℃ 9
1. ℃⎯℉ conversion  (℃ x ) + 32
 Normal range: 36.8-37.5 ℃ (in other 5
references 36.5- 37.5 ℃ or 36.5-37.7 ℃) 5
2. ℉⎯℃ conversion  (℉ - 32) +
9
ALTERATION IN BODY TEMPERATURE
 Pyrexia/hyperthermia/fever – body PATTERNS OF FEVER
temperature above normal range 1. Sustained – constant above 38℃ (100.4℉)
 Hyperpyrexia – very high fever of 41 ℃ & with little fluctuation
above 2. Intermittent – fever spikes interspersed with
 Hypothermia – subnormal core body usual temperature levels
temperature 3. Remittent – fever spikes and falls without a
return to normal temperature levels
STAGES OF CLINICAL SIGNS OF FEVER 4. Relapsing – periods of febrile episodes with
1. Cold or chill stage – onset of fever acceptable temperature values
2. Febrile stage
3. Defervescence – fever abatement of decline of PULSE RATE
fever
  Wave of blood created by contraction of the
left ventricle of the heat and is transmitted
into different pulse sites.
 Cardiac Output = stroke volume x heart rate
per minute (CO = SV x HR)
KINDS OF PULSE SITES
1. Peripheral pulse – pulse located away from
the heart
2. Apical pulse – central pulse that is located at
the apex of the heart
o 5th ICS left MCL, also the PMI (pt. of
maximal impulse)
METHODS OF ASSESSMENT
a. By Palpation – use of 3 fingers
b. Use of stethoscope – preferably diaphragm
PULSE: LIFESPAN CONSIDERATIONS
FACTORS AFFECTING PULSE RATE
1. Age
2. Gender
3. Stress & muscular activity
4. Fever
5. Medications – digitalis & beta blockers ↓ PR,
epinephrine & atropine sulfate ↑ increase PR
6. Hemorrhage – loss about 500 ml blood and
PARTS OF STETHOSCOPE
more (drop in PR)
7. ↑ PR as compensatory mechanism
8. Position changes – in sitting or standing
position, ↓ venous return to the heart due to
pull of gravity thus, ↑ PR
CHARACTERISTICS OF A PULSE RATE
 Rate – speed counted as beats per minute
 Normal findings
o 60-100 bpm
 Abnormal findings
o Tachycardia – PR ↑100 bpm
o Bradycardia – PR ↓60 bpm
 Rhythm – pattern & interval of beats which
can either be
o Regular: patterns & intervals are
similar throughout the entire minute
o Dysrhythmia: irregular rhythm
 Volume or amplitude – strength of the pulse
o Full or bounding pulse – pulsations
can be observed, can or cannot be
obliterated by strong pressure
o Normal pulse: detected readily;
obliterated by strong force
o Weak, thread or feeble pulse hardly
be felt, obliterated by slight pressure
o 0 – no pulse
o +1 – weak and thread
o +2 – normal
o +3 – strong and full
o +4 - bounding pulse
 Arterial wall elasticity – feels straight,
smooth, soft and pliable
 Bilateral equality – presence or absence
head for high pitch sounds
a. Apical-radial pulse assessment –
normally identical
b. Pulse deficit – discrepancy between
apical and radial pulse
1. INFANTS – newborns may have heart
murmurs that are not pathological
2. CHILDREN – the apex of the heart is normally
located in the 4th intercostal space in young
children; 5th intercostal space in children 7
years old and older
3. ELDERS – often have decrease peripheral
circulation

THE ACT OF BREATHING: RESPIRATION
 Ventilation – movement of gases into and out
of the lung
 Diffusion – movement of oxygen and carbon
monoxide between alveoli and RBCs.
 Perfusion – distribution of RBCs to and from
the pulmonary capillaries.
TYPES OF BREATHING
1. Costal (thoracic) breathing – involves the
external intercostal muscles and other
accessory muscles, such as the
sternocleidomastoid muscles. Can
observed by movement of the chest upward
and outward
2. Diaphragmatic (abdominal) breathing –
involves the contraction and relaxation of the
diaphragm. Observed by the movement of the
abdomen, which occurs as a result of the
diaphragm’s contraction and downward
movement
INHALATION
 Diaphragm contracts (flattens)
 Ribs move ↑ and outward
 Sternum moves outward
 Enlarging the size of the thorax
EXHALATION
 Diaphragm relaxes
 Ribs move ↓ and inward
 Sternum moves inward
 Decreasing the size of the thorax
RESPIRATORY CONTROL MECHANISMS
 Respiratory centers
o Medulla oblongata
o Pons
 Chemoreceptors
o Medulla
o Carotid and aortic bodies
 Both respond to O2, CO2, H+ in arterial blood
FACTORS AFFECTING RESPIRATIONS
 INCREASED RESPIRATIONS
o Exercise (increases metabolism)
o Stress (readies the body for "fight or
flight") = SNS
o Increased environmental temperature
o Lowered oxygen concentration at
increased altitudes.
 DECREASED RESPIRATIONS
o ↓ environmental temperature
o Certain medications (e.g., narcotics)
o Increased intracranial pressure
RESPIRATIONS: LIFESPAN CONSIDERATIONS
1. INFANTS - some newborns display “periodic
breathing”
2. CHILDREN – diaphragmatic breathers
3. ELDERS – anatomic and physiologic changes
causes respiratory system to be less efficient
ASSESSMENT OF VENTILATION
 Easy to assess
o Respiratory rate: breaths/minute
o Ventilatory depth: deep, normal,
be shallow
o Ventilatory rhythm: regular/irregular
o Quality: effort, sounds
 Diffusion and perfusion
 Arterial oxygen saturation – measure of
effectiveness
ALTERATIONS IN BREATHING PATTERN
1. RATE
 Bradypnea – slow
 Tachypnea – fast (more than 20)
 Hyperpnea – labored respiration normally
occurring during exercise
 Apnea – absence of breathing (PAUSE)
 Hypoventilation — shallow respirations
 Hyperventilation — fast, deep respirations
 Cheyne-Stokes respiration - Breaths that
gradually become faster and deeper than
normal, then slower, and alternate with
periods of apnea
 Ataxic breathing or Biot’s Respiration –
Rapid, deep breathing with abrupt pauses
between each breath; equal depth to each
breath
2. EFFORT
 Kussmaul’s respiration – Rapid, deep
breathing without pauses; in adults, more
than 20 breaths/minute; breathing usually
sounds labored with deep breaths that
resemble sighs
 Dyspnea – difficulty in breathing
  Orthopnea – ability to breathe only in upright, 5. Last sound heard before period of silence
sitting or standing position. (diastolic)

BENEFITS OF MEASURING BP
1. Detects new problems
2. Hypertension patients can provide the
pattern about his BP to the doctor
3. Serves as self-monitoring to adherence to
therapy
DISADVANTAGES
1. Improper use leads to inaccurate readings
2. Unnecessary alarms the patient
3. Inappropriate adjustment through
medications
4. If the bp cuff is small compared to the arm’s
circumference of the patient, the BP will be
inaccurately low
5. If the bp cuff is big compared to the arm’s
circumference of the patient, the BP will be
inaccurately high

ARTRIAL BLOOD PRESSURE

 Force exerted on the walls of an artery by
pulsing blood under pressure from the heart
o Systolic = max peak pressure during
ventricular contraction
o Diastolic = minimal pressure during
ventricular relaxation (present all the
time)
 Pulse pressure = difference between systolic
and diastolic pressure
 Measured in mmHg
 Recorded as fraction = 120/80
 Systolic = 120; Diastolic = 80
 Pulse pressure – difference between systolic
and diastolic

PHYSIOLOGY OF ARTERIAL BLOOD PRESSURE

 Cardiac output
 Peripheral resistance
 Blood volume
 Viscosity
 Elasticity
BLOOD PRESSURE
FACTORS AFFECTING ARTERIAL BLOOD PRESSURE
Korotkoff’s sound (the sound you hear while 1. Age. Older people have higher blood pressure
conducting BP check) due to decreased elasticity of blood vessels
2. Exercise. Physical activity increases the
PHASES cardiac output and hence the blood pressure.
1. 1st faint, clear, tapping, pumping sound 3. Stress. Stimulation of the sympathetic
(systolic) nervous system increases the blood pressure
2. Whooshing, swishing sound reading;
3. Pumping sound, softer, more intense 4. Race. African Americans over 35 years tend to
4. Muffled, soft blowing sound have higher blood pressures than European
Americans of the same age
 5. Sex. After puberty, females usually have lower
blood pressures than males of the same age;
this difference is thought to be due to
hormonal variations. After menopause,
women generally have higher blood
pressures than before.
6. Medications. Many medications, including
caffeine, may increase or decrease the blood
pressure.
7. Obesity. Both childhood and adult obesity
predispose to hypertension.
8. Diurnal variations. Pressure is usually lowest
early in the morning, when the metabolic rate
is lowest, then rises throughout the day and
peaks in the late afternoon or early evening.
9. Medical conditions. Any condition affecting
the cardiac output, blood volume, blood
viscosity, and/or compliance of the arteries
has a direct effect on the blood pressure. HYPERTENSION VS HYPOTENSION
(polycythemia vera -x high rbcs)
Hypertension
 More common than hypotension
 Thickening of walls
 Loss of elasticity
 Family history
 Risk factors

Hypotension
Measuring BP
 Systolic <90mmHg
 Direct (invasive monitoring)
 Dilation of arteries
 Indirect (auscultatory & palpatory)
 Loss of blood volume
 Sites (upper arm – brachial artery; thigh –
 Decrease of blood flow to vital organs
popliteal artery)
 Orthostatic/postural
Types of BP Taking
MEASUREMENT OF BP
Invasive – insertion of catheter in the body
Non-invasive – use of sphygmomanometer, cuff and  Equipment
stethoscope (palpatory or circulatory)  Auscultation
 Children
BP CUFF SIZE GUIDELINES  Ultrasonic stethoscope
 Lower extremity
 Electronic blood pressure

TPR Charting – activity paper 

RR/T = black or blue ballpen

PR = red ballpen

Morning (5 AM) = black

Afternoon (5PM) = blue
Evening (9PM) = red

SHIFTINGS (chart)

11PM-7AM  1 am to 5 am
7AM- 3PM  5am to 9am 2. Contusion – injuries resulting from a
1PM- 5 PM 3 pm to 11 pm forceful blow to the skin and soft tissue,
5PM-6PM  3 pm to 11 pm however leaving the outer layer of skin
intact
3. Abrasion – superficial layer of tissue is
removed, skin is scrapped along a hard
surface
4. Incision – clean cut or surgical, skin, soft
tissues and muscle may be severed
5. Laceration – jagged edges (claws, barbed
wires)
6. Puncture – small entry, may have some
internal damage and can become infected
7. Tear/avulsion – skin and soft tissue partially
or completely torn away
8. Open or close wounds

Depth (except pressure ulcers and burns)

- Partial thickness – conned to skin, heal by
regeneration
WOUND CARE - Full thickness – involving epidermis, dermis,
subcutaneous, and possibly muscle and
Wounds - disruption in the continuity and bone – require connective tissue repair
regulatory of the tissue cells - Superficial – involving the 2 outer layers
Wound healing - restoration of the disruption in (dermis and epidermis) your wound usually
the continuity of the skin heals faster
- Deep – involving more layer (muscle) the
Layers of the Skin healer is longer here
 Epidermis: stratum corneum, stratum Likelihood and Degree of Contamination
lucidum, stratum granulosum, stratum 1. Clean – closed wounds where respiratory
spinosum, melanocyte, stratum basale (minimal inflammation, uninfected)
 Dermis: papillae, papillary region, reticular 2. Clean contaminated – surgical wounds in
region which respiratory (no infection)
3. Contaminated – open fresh accidental
Skin – outer covering of the body that has special wounds and surgical wounds involving
functions such as protection from germs, major break in surgical wounds or large
regulation of body temperature and help us to feel spillage in GT (with inflammation)
4. Infected – containing dead tissue (within
Causes of wounds clinical infection)
- Surgery
- Burns Signs of infection
- Injury Infected wound
- Loss of sensation - Thick green or yellow drainage
- Poor circulation - Foul odor
- Redness or warmth around wound
Classification - Redness of surrounding area
- Swelling
Types of Wounds
1. Pressure ulcers Widespread infection
 - Fever or chills
- Weakness
- Contusion or difficulty concentrating
- Rapid heartbeat
- Swelling
ASSESSMENT
Measurement, appearance, pain, exudate
Materials that escape from blood vessels during
inflammatory phase
1. Serous – chiefly serum, watery with few
cells
2. Purulent – thick due to presence of pus,
with leukocytes, liquefied dead tissue
debris, dead or living bacteria
3. Sanguineous – large amount of RBCs
4. Drainage – approximate the amount of
describing the saturation of dressing
a. Minimal – strains on dressing
(scantly soaked) (one fourth to three
fourths)
b. Moderate – saturates dressing
without leakage (one half to two
thirds)
c. Heavy – overflows the dressing
History – a detailed thoroughly history is essential
for assessing the extent of injury for organizing
appropriate wound management
When? The longer the wound has been present,
the more likely an infection will occur after closure
Where? What are the potential contaminants
(saliva, pus? soil)
How? Must possess any potential damage to
deeper structure
Wound bleeding
Arteries – spurning, pulsating, bright red
Veins – steady, slow flow, dark red
Capillaries, slow even flow
Phases of Wound Bleeding
1. Inflammatory phase (3-6 days)
- Vascular and cellular responses are
immediately initiated if the skin is cut or
injured
- Vasoconstriction temporarily occurs
until platelets clot to control bleeding
and close the wound
- edema, redness, warm to touch, pain
happens are blood vessels dilate
pouring the antibodies, leukocytes and
RCBs in the site of injuries
- vasodilation is caused by serotonin,
histamine and prostaglandin
2. Proliferative phase (3-4 days after injury to
day 21)
- Collagen synthesis  capillaries grow 
fibrin deposition  tissue becomes
translucent and red color or pink
(granulation tissue)
- Epithelization
- Fibroblasts multiply and new budding
capillaries combine forming a
granulation tissue
- The new capillaries will now nourish the
multiplying fibroblasts or connective
tissues
3. Maturity phase (day 21 to 1-2 years)
- Remodeling: collagen accumulation
within orderly structure
- From the start of collagen synthesis,
collagen fibers undergo a process of lysis
and regeneration. The collagen fibers
become more organized, aligning more
closely to each other and increasing
tensile strength
- Scar tissue is formed from the collagen
growth if the collagen growth exceeds
the lysis, a keloid is formed
Types of Wound Healing
1. Primary intention healing
a. Wounds have minimum tissue loss,
and wound edges are properly
approximated (surgical incision)
2. Secondary intention healing
a. Wounds are left to heal
spontaneously. The wound fills with
granulation tissue and when it heal
it produces a deeper and wider scar
because of great tissue loss (acne)
3. Tertiary intention healing
 a. Occurs when there is a delayed Deep wounds
surgical closure of an infected - Control bleeding and elevate bleeding
wound part
- Clean the wound as best as possible
Factors Affecting Wound Healing - Apply a sterile or clean dressing
- Size, how deep, reason care Specific wounds
- Pressure, age, circulation, medications, - Hematoma
activity, nutrition, infection o rest, ice packs (immobile),
- Immobility, and inactivity compression bandage (cold
- Inadequate nutrition: weight loss, compress) and elevate
muscle atrophy, loss of subcutaneous - Abrasion/incision/laceration
tissue  reduce padding o cleanse wound thoroughly with
- Fecal and urinary inconsistence  sterile gauze soaked in sterile water
moisture-maceration or cooled boiled water
- Decreased mental status o Apply a non-adherent dressing
- Diminished sensation - Tear/avulsion
- Excessive body heat o return skin to original position
- Presence of chronic conditions o apply pressure to wound using
- Tissue perfusion addressing and a pad to control any
- Advanced age: loss of lean body mass, bleeding: bandage
thin epidermis, decreased elasticity of - embedded object
skin, increased dryness of skin, o do not remove foreign object
decreased perception and blood flow o control the bleeding and place a ring
- Poor lifting and transfer techniques
- Incorrect positioning Steps
- Hard support surfaces 1. Assess dressing and assess wound integrity
- Incorrect application of pressure 2. Ensure asepsis during dressing changes
relieving devices 3. Reinforce initial dressing when bleeding is
noted and change dressings promptly when
Pressure Ulcer saturated with drainage
- Pressure ulcer, decubitus ulcer, bed sore 4. Minimize strain on the incision change
- Any lesion caused by unrelieved a. Use appropriate tape, bandages,
pressure  damage in underlying tissue binders
- Painogenesis, pressure intensity, b. Splint chest and abdominal incisions
pressure duration, tissue tolerance when coughing, changing positions
and movement
Stages of Pressure Ulcers c. Instruct patient to avoid touching
1. Intact skin with nonblanchable redness the incision or dressing to avoid and
2. Partial thickness skin loss involving minimize wound injury or
epidermis, dermis or both contamination
3. Full thickness tissue loss with visible fat d. Assess patient’s nutritional intake
4. Full thickness tissue loss with exported and degree at hygiene or assistance
bone, muscle or tendon needed to support healing
e. Instruct the patient and significant
Wound Assessment other to report immediately
- Clean the wound thoroughly with gauze following signs of infection like
soak in saline or cooled, boiled water redness marked swelling,
- Apply a non-stick dressing tenderness, increased warmth
 around the site and presence of
discharges
f. Reinforce the value of taking
prescribed prophylactic medications
such as antibiotics and analgesics
Dressing
Purpose
- To protect the wound from mechanical
injury and other microorganisms
- To splint or immobilize the wound
- To absorb drainage
- To prevent contamination from bodily
discharges
- To debride the wound
- To inhibit the growth and kill
microorganisms using dressings with
antimicrobial properties
- To provide moisture and a physiologic
environment conductive for healing
- To provide mental and physical comfort
to the patient
- Aid in hemostasis
- Protect from seeing the wound
- Promote normal insulation at wound
surface
absorbed into the dressing allowing
wound debridement
Wet-to-wet
- It keeps our wound moist, this dressing
will be changed often
- Sterile saline or antimicrobial agent are
used to saturate the dressing which are
packed on the wound. It provides an
optimum environment for wound
healing, better removal at exudates and
patient comfort but increased infection
can occur when the wound become
moderated and the linens may become
damp
Rules
- Dressings should always extend well
beyond edges and wear gloves
- Place directly on wound
- If bleeding strikes, apply another
dressing
- If there is only one sterile dressing, use
it to cover the wound
- Wash hand, try not to talk, sneeze over
the wound

Types and Application

1. Sterile dressing
2. Gauze
3. Adhesive

Dry-to-dry
- To aid in the management of a wound
with minimal drainage
- To protect wound from injury, prevent
introduction of bacteria, reduce
discomfort and assist with healing
- May adhere to the wound surface when
it dries causing pain and disruption at
granulation tissue during removal
Wet-to-dry
- To mechanically debride a wound
- Gauze is saturated with normal saline
and is packed into the wound and
covered by a dry dressing. As drying
occurs, debris and necrotic tissue are