Elizabeth A. Bruderle
College of Nursing
Last Updated: Thursday, February 13, 2003
Independent nursing function
Nurse has ultimate responsibility for accuracy:
Temperature, Pulse, Respirations, Blood Pressure (T. P. R., BP) are assessed and interpreted together.
Nurse must consider patient's normal pattern in relation to standard values/range.
When to assess? determined by routine, physician’s orders, and/or nurse’s clinical judgment.
On admission: baseline data
Beginning of each shift
Change in patient's status
Before/after invasive procedures
Before/after certain medications
Before/after nursing interventions
Definition: Heat of body measured in degrees; indicates relationship between heat production and heat loss.
Core body temperature
Normal adult range: 96.6-99.3; afebrile
Heat Production: metabolism, muscle activity, hormones, pyrexia
Heat Loss: radiation, conduction, convection, evaporation
Regulation: Skin & Central Nervous System (Hypothalamus)
Factors Affecting Temperature: age, circadian rhythm, stress, gender, environmental extremes
Assessing Body Temperature: Site and Method must be consistent; be sure to record site selected.
Methods: glass, electronic, temperature sensitive tape, automated monitoring
Sites: Selection based on nurse's assessment of patient
Oral, Rectal, Axillary, Tympanic Membrane (ear)
Definition: Wave of blood that can be palpated at major arteries. Produced by contraction of left ventricle.
Cardiac Output: Amount of blood pumped per minute.
Stroke Volume: Amount of blood pumped into aorta with each ventricular contraction, approx. 70cc.
CO = SV x Beats per Minute
What is your Cardiac Output?
Regulation of Pulse: Involuntary
Autonomic Nervous System (ANS)
Sympathetic & Parasympathetic
Sinoatrial node (SA): Pacemaker
Factors Affecting Pulse: age, gender, exercise, fever, medications, hemorrhage, stress, pain, position change
Rate (beats/min.): Bradycardia, Tachycardia
Rhythm (pattern of beats): Sinus Rhythm versus Dysrhythmia
Volume/strength/amplitude: scale 0-+4
Alternative assessment techniques:
Stethoscope for apical pulse at apex of heart: AHR
Definition: Process through which oxygen is inhaled and carbon dioxide is exhaled.
CNS control: Cerebral Cortex (voluntary); Brainstem (involuntary)
Mechanical and Chemical Factors: Muscle activity and Blood gas levels
Critical Factor: Level of carbon dioxide in arterial blood
Factors Affecting Respirations: age, exercise, stress, fever, medications, pulmonary diseases
Rate: apnea, bradypnea, tachypnea,
Depth: deep, shallow
Rhythm/pattern: regular, irregular
Quality: quiet, labored
Definition: Measure of pressure/force exerted by the blood as it moves through the arteries; moves in waves consistent with the pumping action of the heart.
Terms: Korotkoff sounds, systolic, diastolic, pulse pressure, hypertension, hypotension, orthostatic hypotension
Hemodynamic factors Circulating blood volume Cardiac output Peripheral resistance Blood viscosity
Factors that affect blood pressure:
age, sex, race, obesity, exercise, stress, pain, circadian rhythm, cardiovascular/renal disease
Assessing Blood Pressure
Too small: False high reading (pressure not transmitted evenly to artery).
Too large: False low reading (pressure directed to a large surface area)