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The Biological Basis of Clinical
Observations
Fully updated for its fourth edition, The Biological Basis of Clinical Observations provides
readers with the understanding needed to perform clinical observations, make accurate
judgements about the patient’s condition and make good decisions concerning patient
care.
This essential textbook supports safe and effective clinical practice by explaining the
techniques involved in making clinical observations, alongside the biological knowledge
which gives them meaning. For each topic, it explains the pathological basis for
variations in observed results, focusing on relevant anatomy and physiology, genetics
and pharmacology, and the basic principles of care. A greatly expanded chapter on
pharmacology reects the increased importance of this subject in the nursing curriculum.
Topics discussed include:
• temperature
• cardiovascular observations
• respiratory observations
• urinary and bowel observations
• neurological observations
• nutrition
• uid balance
• skin
• pharmacology
• pregnancy.
The Biological Basis of Clinical Observations is a unique text which integrates explanations
of essential procedures with the biological knowledge that underpins practice. It is
essential reading for all nursing and healthcare students preparing for clinical practice.
William T. Blows was formerly a nurse tutor and lecturer at City University of London, UK
where he taught biology to nurses.
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The Biological Basis of Clinical
Observations
Fourth Edition
William T. Blows
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Designed cover image: Getty Images
Fourth edition published 2024
by Routledge
4 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN
and by Routledge
605 Third Avenue, New York, NY 10158
Routledge is an imprint of the Taylor & Francis Group, an informa business
© 2024 William T. Blows
The right of William T. Blows to be identied as author of this work has been asserted
in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act
1988.
All rights reserved. No part of this book may be reprinted or reproduced or utilised in
any form or by any electronic, mechanical, or other means, now known or hereafter
invented, including photocopying and recording, or in any information storage or
retrieval system, without permission in writing from the publishers.
Trademark notice: Product or corporate names may be trademarks or registered
trademarks, and are used only for identication and explanation without intent to
infringe.
First edition published by Routledge 2001 as The Biological Basis of
Nursing: Clinical Observations
Third edition published by Routledge 2018
British Library Cataloguing-in-Publication Data
A catalogue record for this book is available from the British Library
ISBN: 978-1-032-48446-4 (hbk)
ISBN: 978-1-032-48440-2 (pbk)
ISBN: 978-1-003-38911-8 (ebk)
DOI: 10.4324/9781003389118
Typeset in Optima
by Apex CoVantage, LLC
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Contents
List of gures vii
List of plates xiii
List of tables xiv
Preface to the fourth edition xvi
Acknowledgment xviii
1 Temperature 1
2 Cardiovascular observations (I): the pulse and
electrocardiogram (ECG)
23
3 Cardiovascular observations (II): blood pressure 42
4 Cardiovascular observations (III): blood tests 65
5 Respiratory observations 97
6 Fluid and electrolyte balance 121
7 Nutrition 135
8 Elimination (I): urinary observations 155
9 Elimination (II): digestive observations 180
10 Skin 197
11 Neurological observations (I): consciousness 219
12 Neurological observations (II): pain 247
13 Neurological observations (III): eyes 268
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vi Contents
14 Neurological observations (IV): movement 287
15 Pharmacology and drug side effects, interactions and allergies 311
16 Physiological changes occurring in pregnancy 336
Index 346
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Figures
1.1 The adenosine triphosphate (ATP) molecule 2
1.2 A. Glucose molecule (C H O ). B. Pyruvate molecule (C H O ) 3
6 12 6 3 3 3
1.3 The Krebs (citric acid or tricarboxylic acid) cycle 4
1.4 Electron transport chain 5
1.5 The mitochondrion 5
1.6 The conversion from adenosine diphosphate (ADP) and inorganic
phosphate (Pi) to form an ATP molecule 6
1.7 The E-shaped triglyceride molecule 6
1.8 The entry of fatty acids into the Krebs (citric acid) cycle 7
1.9 The Krebs urea cycle in liver cells (hepatocytes) 8
1.10 Temperature prole in a cold and in a warm environment 9
1.11 The homeostatic mechanism begins with a stimulus affecting a receptor
at the start of the afferent pathway 11
1.12 The Kelvin (°K), Celsius (centigrade, °C) and Fahrenheit (°F) temperature
scales 12
1.13 Tempadot thermometer reading 13
1.14 The mechanism for fever 15
1.15 The mechanism of antipyretic (anti-inammatory) drugs 18
2.1 Cross section through the heart (viewed anteriorly) 24
2.2 Double circulation of the blood from the heart 25
2.3 The cardiac conduction system 25
2.4 Arterial pulse sites on the body 27
2.5 Pedal (foot) pulses 28
2.6 ECG lead positions I, II, III (forming the Einthoven triangle) and sites for
leads V1 to V6 across the chest 31
2.7 The Einthoven triangle showing leads I, II and III, aVR, aVL and aVF 32
2.8 The cardiac axis 32
2.9 Normal and abnormal ECG tracings 33
2.10 Antiarrhythmic Class I sodium channel drugs 37
2.11 Antiarrhythmic Class III potassium channel blocking drugs 38
2.12 Action of digoxin in cardiac muscle cells 39
3.1 Blood pressure values through the circulatory system 43
3.2 The left ventricle and the aorta during the cardiac cycle 44
3.3 The vasomotor centre (VMC) and the local factors inuencing the
peripheral resistance (PR) 45
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viii Figures
3.4 The effect of the baroreceptors on the VMC 46
3.5 The factors affecting the VMC 46
3.6 The renin-angiotensin-aldosterone cycle 47
3.7 Factors contributing to the mean arterial pressure (MAP) 48
3.8 Right arm with sphygmomanometer cuff in place 50
3.9 Korotkoff phases and sounds set against the blood pressure column (left)
with the pressure differences between the phases shown (right) 52
3.10 The action of beta-blocker drugs 60
4.1 Proportions of protein in blood 67
4.2 The C-peptide incorporated as part of the proinsulin molecule prior to
its separation 69
4.3 The troponin complex in muscle 70
4.4 Vitamin D synthesis pathways from the skin (via pre-vitamin D
3
) and
oral intake (via vitamin D
2
) 73
4.5 The cholesterol cycle 75
4.6 Thyroid hormone circulation and feedback 84
4.7 Blood clotting mechanism via the intrinsic (caused by internal damage
to blood vessels) and extrinsic (caused by external injury to tissues)
pathways. 86
4.8 Blood cells derived from bone marrow stem cells 90
5.1 The respiratory tract includes the nasal and oral cavities, the pharynx
and larynx (voice box) and the trachea which divides at the lower end
into left and right bronchi, one for each lung 98
5.2 Microscopic view of the lung showing an alveolus containing air, with
walls of type I and type II cells, a pulmonary capillary containing blood
and interstitial uid between the capillary and the alveolus 99
5.3 The lungs and the pleural membrane 100
5.4 Inspiration and expiration 101
5.5 Breathing volumes at rest and during exercise 102
5.6 Tracheostomy 103
5.7 The respiratory centre of the brainstem and irregular forms of breathing 105
5.8 The blood gas tensions in arterial and venous blood compared with the
gas tensions of the lungs and tissues 107
5.9 The oxygen saturation curve 113
5.10 The Apgar score 115
5.11 The bronchodilator drugs 118
6.1 The water molecule (H
2
O) 122
6.2 The three body water compartments 123
6.3 Water passes from input (oral) to output (excretion) through the three
body compartments 123
6.4 Osmosis 124
6.5 The formation and return of tissue uid 124
6.6 Fluid balance 125
6.7 The 24-hour uid balance chart 126
6.8 The relative concentrations and values of the major electrolytes are
shown in the three body compartments 131
7.1 (A) Kwashiorkor (protein deciency). (B) Marasmus (energy deciency)
in children 136
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Figures ix
7.2 The amino acid molecule with an amino group (NH
2
), a carboxyl
group (COOH) and a variable radical (R) 137
7.3 Mild kwashiorkor in hospital patients due to protein lack and stress 138
7.4 The triglyceride molecule consists of three fatty acids attached to a
glycerol backbone 139
7.5 Unsaturated fatty acids showing omega (ω) 3 and 6 139
7.6 Disaccharides 140
7.7 Two of the major pathways for regulating food intake 149
8.1 The renal system consists of a left and right kidney with ureters, the
urinary bladder within the bony pelvis below and a single urethra 156
8.2 The kidney in cross section 157
8.3 The renal nephron 158
8.4 The glomerulus and Bowman’s capsule 159
8.5 The proximal convoluted tubule, between the Bowman’s capsule
and the loop of Henle, reabsorbs water, urea, sodium and other
substances 159
8.6 The events taking place through the loop of Henle, including the
sodium concentration gradient 160
8.7 The distal convoluted tubule 161
8.8 Mr Wet physiology 162
8.9 Mr Dry physiology 163
8.10 The effect of insulin on glucose 165
8.11 Mechanism of the large urine loss (diuresis) in uncontrolled diabetes 166
8.12 Mechanism of sodium and hydrogen loss 171
8.13 The natural history of bilirubin 172
8.14 The pH scale 173
9.1 The digestive system begins at the mouth 181
9.2 Physiology of defecation 182
9.3 Colonic stoma sites 188
9.4 Stimulation of the vomit centre is often via the chemoreceptor trigger
zone, which itself is stimulated by motion or drugs 189
9.5 Vestibular stimulation of the cerebellum 190
9.6 Vagus innervation of the digestive tract 190
9.7 Bowel distortions that occur mostly in children 193
9.8 Oesophageal varices caused by portal hypertension 194
10.1 Section through the epidermis 198
10.2 Section through the skin showing the epidermis, dermis and
hypodermis 200
10.3 The factors affecting wound healing 207
10.4 The stages of wound healing 208
10.5 Different types of wound healing 209
10.6 Sites where pressure can cause open sores 210
10.7 Classication of burns 211
10.8 The ‘rule of nines’ area of burn estimator 212
10.9 Human leukocyte antigen (HLA) gene cluster PSORS1 (locus 6p21) in
skin cells as a cause of psoriasis 215
11.1 Left side block diagram of the brain areas in connectivity of
consciousness 220
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