NLE Fundamentals of Nursing & the Nursing Process — Vital Signs & Basic Physiologic MonitoringConcept Map

Concept

Temperature (Body Heat Regulation)

Sub Concepts

• Normal ranges by route (oral, rectal, axillary, tympanic)
• Pyrexia and hyperthermia classification
• Febrile response phases (chill, course, defervescence)
• Antipyretic management and nursing interventions
• Factors affecting temperature (age, circadian rhythm, exercise, hormones)

Relationship To Central

First vital sign; reflects hypothalamic regulation and metabolic status

Concept

Pulse (Heart Rate & Cardiac Output)

Sub Concepts

• Pulse sites and palpation techniques (radial, apical, carotid, femoral, dorsalis pedis)
• Normal ranges by age group (adult 60–100/min)
• Tachycardia and bradycardia classification
• Pulse characteristics: rate, rhythm, volume/amplitude grading
• Pulse deficit and clinical significance
• Digoxin monitoring rule (apical <60 = hold)
• Factors affecting pulse (age, exercise, fever, medications, position)

Relationship To Central

Second vital sign; indicator of cardiovascular function and oxygenation

Concept

Respiration (Gas Exchange & Ventilation)

Sub Concepts

• Rate, depth, rhythm assessment
• Normal ranges by age (adult 12–20/min)
• Tachypnea, bradypnea, apnea, dyspnea classification
• Abnormal breathing patterns (Cheyne-Stokes, Kussmaul)
• Discreet counting techniques
• Oxygen saturation (SpO₂) monitoring and interpretation
• Hypoxemia recognition (<90%)

Relationship To Central

Third vital sign; reflects respiratory function and oxygenation adequacy

Concept

Blood Pressure (Hemodynamic Status)

Sub Concepts

• Systolic and diastolic pressure components
• Normal ranges (systolic <120, diastolic <80)
• Hypertension and hypotension classification
• Orthostatic (postural) hypotension definition and measurement
• Accurate measurement techniques and proper positioning
• Cuff sizing errors and their impact
• Korotkoff sounds and auscultatory gap
• BP regulation mechanisms (baroreceptors, RAAS)

Relationship To Central

Fourth vital sign; indicator of perfusion, cardiac output, and vascular resistance

Concept

Pain — The Fifth Vital Sign

Sub Concepts

• Pain assessment frameworks (PQRST/OLDCARTS)
• Pain severity scales (0–10 numeric, Wong-Baker FACES, FLACC, behavioral scales)
• Acute vs. chronic pain classification
• Nociceptive vs. neuropathic pain types
• WHO analgesic ladder (non-opioids, weak opioids, strong opioids)
• Pharmacologic management (paracetamol, NSAIDs, opioids)
• Non-pharmacologic interventions (cutaneous stimulation, distraction, relaxation, imagery)
• Opioid monitoring and naloxone reversal

Relationship To Central

Fifth vital sign; subjective patient experience requiring assessment and management

Concept

Special Populations & Variations

Sub Concepts

• Infants and children (higher HR, RR; lower BP; assessment timing)
• Older adults (blunted fever response, wider pulse pressure, orthostatic risk)
• Comparison to patient baseline vs. population norms
• Context-dependent interpretation (activity, medication, disease state)

Relationship To Central

Vital signs must be interpreted within age, developmental, and clinical context

Concept

Documentation & Clinical Escalation

Sub Concepts

• Recording route/site for each vital sign
• Time-based documentation
• Trend identification (rising HR/RR with falling BP/SpO₂)
• Early warning recognition and escalation protocols
• Graphic flow sheet plotting for trend visibility
• Professional communication per RA 9173 standards

Relationship To Central

Accurate recording and timely reporting are patient-safety imperatives

Concept

Clinical Nursing Assessment (NCM Framework)

Sub Concepts

• Assessment phase of nursing process
• Data collection and baseline establishment
• Comparison against NANDA-I nursing diagnoses
• Maslow hierarchy prioritization (basic physiologic needs)
• Safety and infection control in vital sign measurement
• Delegation and supervision per RA 9173

Relationship To Central

Vital signs are foundation of NCM independent and collaborative functions

To

Pulse

From

Temperature

Strength

strong

Relationship

Fever increases metabolic rate and raises heart rate (~10 bpm per 1°C elevation)

To

Respiration

From

Temperature

Strength

strong

Relationship

Fever increases respiratory rate to meet increased oxygen demands

To

Blood Pressure

From

Pulse

Strength

strong

Relationship

Cardiac output (determined by HR × stroke volume) is a primary regulator of blood pressure

To

Oxygen Saturation

From

Respiration

Strength

strong

Relationship

Respiratory rate and depth directly affect gas exchange and blood oxygen levels

To

Pulse

From

Oxygen Saturation

Strength

strong

Relationship

Hypoxemia triggers compensatory tachycardia to increase oxygen delivery

To

Pulse

From

Blood Pressure

Strength

moderate

Relationship

Hypotension may trigger reflex tachycardia as a compensatory mechanism

To

Pulse

From

Pain

Strength

moderate

Relationship

Acute pain increases heart rate due to sympathetic nervous system activation

To

Blood Pressure

From

Pain

Strength

moderate

Relationship

Severe acute pain can elevate blood pressure through stress response

To

Respiration

From

Pain

Strength

moderate

Relationship

Acute pain can increase respiratory rate and cause splinting (shallow breathing)

To

Pain

From

Temperature

Strength

moderate

Relationship

Fever and inflammation often accompany pain; both warrant assessment

To

Nursing Process Assessment Phase

From

Vital Signs Assessment

Strength

strong

Relationship

Vital signs provide objective baseline data for the assessment phase and inform nursing diagnoses

To

Clinical Escalation

From

Vital Signs Trends

Strength

strong

Relationship

Trending vital signs (rising HR/RR with falling BP/SpO₂) indicate deterioration requiring immediate reporting

To

Temperature Management

From

Antipyretic Medications

Strength

strong

Relationship

Paracetamol is first-line; acts on hypothalamic set point to reduce fever

To

Apical Pulse Assessment

From

Digoxin Administration

Strength

strong

Relationship

Apical pulse <60 bpm is a contraindication to digoxin administration; must count 1 full minute

To

Pain Management

From

WHO Analgesic Ladder

Strength

strong

Relationship

Provides systematic approach to pain relief progression based on severity

To

Pharmacologic Analgesia

From

Non-pharmacologic Pain Management

Strength

strong

Relationship

Multimodal approach combining both reduces analgesic dose requirements and enhances effectiveness

To

Blood Pressure Accuracy

From

Cuff Size Selection

Strength

strong

Relationship

Cuff too small = falsely HIGH reading; cuff too large = falsely LOW reading

To

Fall Risk

From

Orthostatic Hypotension

Strength

strong

Relationship

Postural BP drop ≥20 mmHg systolic or ≥10 mmHg diastolic increases fall risk

To

Hypoxemia Intervention

From

SpO₂ <90%

Strength

strong

Relationship

SpO₂ <90% constitutes hypoxemia requiring oxygen therapy and immediate assessment

To

Vital Sign Interpretation

From

Special Populations

Strength

moderate

Relationship

Vital signs vary by age, development, and chronic conditions; interpret against patient baseline

To

Patient Safety

From

Documentation Accuracy

Strength

strong

Relationship

Recording route, site, time, and trends enables trend recognition and safe clinical decisions

To

Nursing Practice Accountability

From

RA 9173 Standards

Strength

strong

Relationship

Philippine nursing law mandates accurate vital sign assessment and timely reporting of abnormalities