Transcript vital signs2

General Survey
Initial Observations
Speech
Mood
Vital
Signs and Client’s
patterns and symptoms physical
and
signs
voice
of distress appearance behavior
intonations
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Height and
weight
1
• Vital signs
Vital signs are physical signs that indicate an individual is alive, such as
heart beat, breathing rate, temperature, and blood pressure. These
signs may be observed, measured, and monitored to assess an
individual's level of physical functioning. Normal vital signs change with
age, sex, weight, exercise tolerance, and condition.
Vital signs (temperature, pulse, respiratory rate and blood pressure) are
the first measurements obtained as a part of a nurses’ routine
assessment. Vital signs provide baseline data and can indicate changes
in physiological function. So, nurses must be skilled in the process to
obtain, interpret and communicate accurate vital signs.
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2
• Getting Started: The examination room should be quiet, warm
and well lit. After you have finished interviewing the patient,
provide them with a gown (a.k.a. "Johnny") and leave the room
(or draw a separating curtain) while they change. Instruct them
to remove all of their clothing (except for briefs) and put on the
gown so that the opening is in the rear. Occasionally, patient's
will end up using them as ponchos, capes or in other creative
ways. While this may make for a more attractive ensemble it
will also, unfortunately, interfere with your ability to perform an
examination! Prior to measuring vital signs, the patient should
have had the opportunity to sit for approximately five minutes
so that the values are not affected by the exertion required to
walk to the exam room. All measurements are made while the
patient is seated.
• Observation: Before diving in, take a minute or so to look at
the patient in their entirety, making your observations. Does the
patient seem anxious, in pain, upset? What about their dress
and hygiene? Remember, the exam begins as soon as you lay
eyes on the patient.
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3
Normal ranges for the average healthy adult:
• The sequence for recording vital sign measurements in the nurses’
notes is T-P-R and BP.
•
Temperature: (T), 97.8 - 99.1 degrees Fahrenheit / average 98.6 degrees Fahrenheit
•
Pulse: (P) 60 - 80 beats per minute (at rest)
•
Breathing: (R) 12 - 18 respirations (breaths) per minute
•
Blood Pressure: (BP).
Systolic: less than 120 mm of mercury (mm Hg)
Diastolic: less than 80 mm Hg
a.
b.
a.
b.
Examples of how to record TPR on a worksheet or notepad are:
Ms. Jones - room 314A - TPR 992 - 72 - 18.
Mr. Fever - room 206B - TPR 1008 - 84 - 22 shallow
Examples of how to record BP and pulse on a worksheet are:
Mr. Brown - - BP 132/84, P-76.
Ms. Skip A. Beat - BP 146/82/70, P-84.
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4
Factors Influencing Vital Signs
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Age
Gender
Heredity
Race
Lifestyle
Environment
Medications
Pain
Exercise
Anxiety and Stress
Postural Changes
Diurnal (daily) Variations
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5
AGING CHANGES
• Normal body temperature does not change significantly with aging.
Temperature regulation, however, is more difficult.
• Because of changes in the heart, the resting heart rate may become
slightly slower. It takes longer for the pulse to speed up when
exercising, and longer to slow back down after exercise. The
maximum heart rate reached with exercise is lowered.
• Blood vessels become less elastic. The average blood pressure
increases from 120/70 mm Hg to about 150/90 mm Hg and may
remain slightly high even if treated. The blood vessels also respond
more slowly to a change in body position.
• Although lung function decreases slightly, changes are usually only
in the reserve function. The rate of breathing usually does not
change.
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Variations by age
Children and infants have respiratory and heart rates that are faster
than those of adults as shown in the following table:
Age
Newborn
Normal heart rate Normal
(beats per
respiratory rate
minute)
(breaths per
minute)
120-160
30-50
0-5 months
6-12 months
1-3 years
3-5 years
6-10 years
11-14 years
14+ years
90-140
80-140
80-130
80-120
70-110
60-105
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25-40
20-30
20-30
20-30
15-30
12-20
12-20
7
EFFECT OF CHANGES
•
•
•
•
•
Loss of subcutaneous fat makes it harder to maintain body heat. Many older
people find that they need to wear layers of clothing in order to feel warm.
Likewise, skin changes include the reduced ability to sweat. Therefore,
older people find it more difficult to tell when they are becoming overheated.
There may be decreased tolerance to exercise. Some elderly people have a
reduced response to decreased oxygen or increased carbon dioxide levels
(the rate and depth of breathing does not increase as it should).
Many older people find that they become dizzy if they stand up too
suddenly. This is caused by a drop in blood pressure when they stand called
orthostatic hypotension.
Medications that are used to treat common disorders in the elderly may also
have a profound effect on the vital signs.
For example, digitalis (used for heart failure) and certain blood pressure
medications called beta blockers may cause the pulse to slow. Pain
medications can slow breathing. Diuretics can cause low blood pressure
and aggravate orthostatic hypotension ( (postural hypotension)
– Sudden drop in systolic pressure when client moves from a lying to a
sitting to a standing position
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COMMON PROBLEMS
• Older people are at greater risk for overheating (hyperthermia or heat
stroke). They are also at risk for dangerous drops in body temperature
(hypothermia).
• Fever is an important sign of illness in the elderly. Many times, fever is the
only symptom for several days. Any fever that is not explained by a known
illness should be investigated by a health care provider.
• Often, older people are unable to create a higher temperature with
infection so very low temperatures and checking the other vital signs plays
an important role in following these people for signs of infection.
• Heart rate and rhythm problems are fairly common in the elderly.
Excessively slow pulse (bradycardia) and arrhythmias such as atrial
fibrillation are common.
• High blood pressure (hypertension) and a drop in blood pressure when
changing body position (orthostatic hypotension) are common blood
pressure problems. High blood pressure should always be discussed with
your health care provider.
• Breathing problems are seldom normal. Although exercise tolerance may
decrease slightly, even a very elderly person should be able to breathe
without effort under usual circumstances.
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Thermoregulation
• Thermoregulation
– The heat of the body is measured in units called degrees.
– The core internal temperature of 98.6 degrees Fahrenheit (F)
does not vary more than 1.4 degrees F.
– Core internal temperature is higher than the skin and external
temperature.
– What is the formula to change Celsius to
Fahrenheit and back?
– A calculator helps here. To convert Fahrenheit to
Celsius, subtract 32 degrees and divide by 1.8. To
convert Celsius to Fahrenheit, multiply by 1.8 and add
32 degrees.
– NOW YOU KNOW!
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Temperature: This is generally obtained using an oral
thermometer that provides a digital reading when the
sensor is placed under the patient's tongue. As most exam
rooms do not have thermometers, it is not necessary to
repeat this measurement unless, of course, the recorded
value seems discordant with the patient's clinical condition
(e.g. they feel hot but reportedly have no fever or vice
versa). Depending on the bias of a particular institution,
temperature is measured in either Celcius or Farenheit,
with a fever defined as greater than 38-38.5 C or 101-101.5
F. Rectal temperatures, which most closely reflect internal
or core values, are approximately 1 degree F higher than
those obtained orally.
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orally
Temperature can be taken by mouth using either the classic glass
thermometer, or the more modern digital thermometers that use an
electronic probe to measure body temperature.
rectally
Temperatures taken rectally (using a glass or digital thermometer) tend
to be 0.5 to 0.7° F higher than when taken by mouth.
axillary
Temperatures can be taken under the arm using a glass or digital
thermometer. Temperatures taken by this route tend to be 0.3 to 0.4° F
lower than those temperatures taken by mouth.
by ear
A special thermometer can quickly measure the temperature of the ear
drum, which reflects the body's core temperature (the temperature of
the internal organs).
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Oral temperatures are contraindicated for clients who have
mouth injuries/surgery, who are confused, infants and young
children, comatose, have a history of seizures, are
intubated, or are short of breath and must breath through
the mouth or who are receiving 02 via mask. If they just
drank or ate something, wait 20-30 minutes before you take
an oral temperature.
Rectal temperatures are contraindicated in restless clients,
those who have rectal pathology or recent rectal surgery
and in some agencies those who have a history of seizures
or with myocardial infarctions (MI's). Rectal stimulation may
stimulate the vagus nerve and interfere with heart rate or
rhythm.
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Assessing Body Temperature
• The electronic thermometer consists
• Thermometers
of a battery-powered display unit,
(temperature
thin wire cord, and a temperature
sensitive probe. The probe must be
measurement)
covered with a disposable sheath
• Purpose: To assess the
before use. The probes are colorfunctional status of the
coded for proper use
body’s tissues and
• Glass or electronic
thermometers are
used.
• Temperature Sites
– Oral (blue or white
colored probe)
– Axillary
– Rectal(red)
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Hypothermia is total body cooling, a bodily response which occurs when the
right conditions are present such as wind exposure, wet conditions, where the
body becomes very cold, coupled with total exhaustion. Individuals usually
shiver for a period of time, then lose consciousness. Core body temperature can
then drop to life-threatening levels. Patients may appear clinically dead, but
area able to be resuscitated if handled very carefully and properly warmed. The
knowledge that these individuals can be treated if they receive quick attention is
of critical concern to those spending time in the out of doors, where these
potential conditions could develop. Cold, blue, stiff patients with no palpable
pulse are always to be treated as if they can be resuscitated, especially if
hypothermia appears to be the major cause. Although it may seem surprising, it
is not uncommon for individuals in Florida to become hypothermic when
swimming in the ocean, as hypothermia can occur any time a situation is
involved where core body temperature decreases. Hypothermia can occur
outside of a cold environment. The very young and very old are more
susceptible to hypothermic conditions. A person in their 6th to 7th decade of life
down in Florida, for example, could while swimming in the ocean drop their core
body temperature to a level that could potentially induce hypothermia.
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Common signs and symptoms of depressed body temperature including the
following:
94° Fahrenheit or less
Stumbling or wide gait
Slurred speech
Shivering
Faraway gaze
Hypothermia is suspected when you see an exhausted individual who is
cold, wet, with a depressed body temperature.
•
IF A PERSON IS UNCONSCIOUS, GREAT CARE MUST BE TAKEN NOT
TO JOSTLE THE INDIVIDUAL. EVEN IF YOU ARE TAKING OFF WET
CLOTHES AND REPLACING THEM WITH DRY ONES, IT IS IMPERATIVE
THAT YOU ARE VERY GENTLE. IT HAS BEEN DOCUMENTED OVER
AND OVER THAT AN INDIVIDUAL WITH SEVERE HYPOTHERMIA CAN
EASILY DEVELOP LIFE-THREATENING HEART ARRHYTHMIAS AND DIE
IF PROPER PRECAUTIONS ARE NOT TAKEN AND JOSTLING AND
.
QUICK MOVEMENTS OCCUR
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•In a severely hypothermic individual, DO NOT MOVE THE
PATIENT. BE VERY GENTLE. The following are priorities:
Stop the individual's temperature from dropping and slowly increase. It
is important to maximize a safe warming rate. There are many ways to
do this. There are external and internal ways to heat. In an outdoor
situation, externally warming is obviously the most practical. Some
other creative ways would be building a fire, use sleeping bags, tarps
and tents to redirect the warm air towards the victim's body. This should
be done slowly. Heating pads, if available, or simply laying next to the
victim, using another's body warmth to warm the victim is beneficial in
terms of re-warming and increasing temperature
Remove wet clothing as gently as possible, without jostling the torso
In the initial stages of hypothermia, exercising is not the best way to
increasing temperature since you are burning up sugar and eventually
this could be counterproductive.
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Pre-hospital treatment:
•
•
•
•
•
•
Replace wet clothes if possible
Increase insulation
Try creative vapor barrier
External heat, if possible
Heated air is good for the patient to breath in
Warm drinks - sugar added or some type of
sweetener added
• NO ALCOHOL
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Severe hypothermia:
• No rough handling
• Change wet clothes to dry. Cut the clothes if
necessary. Don't jostle the torso
• Maximize your insulation
• External heat is a must
• No drinks at this point in severe hypothermia
• Transport as gentle and as soon as possible to a
treatment facility
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Respiration- is the act of breathing.
Respiratory Rate: Respirations are recorded as breaths per minute. They
should be counted for at least 30 seconds as the total number of breaths in a
15 second period is rather small and any miscounting can result in rather
large errors when multiplied by 4. Try to do this as surreptitiously as possible
so that the patient does not consciously alter their rate of breathing. This can
be done by observing the rise and fall of the patient's hospital gown while
you appear to be taking their pulse. Normal is between 12 and 20. In
general, this measurement offers no relevant information for the routine
examination. However, particularly in the setting of cardio-pulmonary illness,
it can be a very reliable marker of disease activity.
Assessing Respirations A stethoscope is used to auscultate
breath sounds throughout the respiratory system. Rate is
counted by number of breaths taken per minute. Observation of
thoracic and abdominal movements includes:
Depth, rhythm, and symmetry
Costal (thoracic) breathing
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Diaphragmatic breathing
Assessing Respiratory Function
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Assessing Respirations
• Sites
– Observation of chest wall expansion and
bilateral symmetrical movement of the thorax
– Placement of back of hand next to client’s
nose and mouth to feel expired air
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Hemodynamic Regulation
Assessing Pulse
•
Pulse: This can be measured at any place where there is a large artery, though for
the sake of convenience it is generally done by palpating the radial impulse. You
may find it helpful to feel both radial arteries simultaneously, doubling the sensory
input and helping to insure the accuracy of your measurements. Place the tips of
your index and middle fingers just proximal to the patients wrist on the thumb side,
orienting them so that they are both over the length of the vessel.
•
assessment of pulse rate at the following sites:
1. temporal
2. carotid
3. apical
4. brachial
5. radial
6. femoral
7. popliteal
8. dorsal pedis
9. posterior tibial
The most accessible peripheral sites are the radial and carotid sites.
•
–
•
•
•
The carotid site should always be used to assess the pulse in a cardiac
emergency.
A peripheral pulse is palpated by placing the first two fingers on the pulse
point with moderate pressure.
A Doppler ultrasound stethoscope is used on superficial pulse points.
A stethoscope is used to auscultate the heart’s rate and rhythm.
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Taking your carotid pulse
•
Assessment of arterial pulses include the
presence and strength of the pulse and a
bilateral comparison. Never palpate both
carotid pulses at the same time because
occlusion could cause compromised
circulation to the brain.
• The carotid arteries take
oxygenated blood from
the heart to the brain. The
pulse from the carotids
may be felt on either side
of thefront of the neck just
below the angle of the
jaw. This rhythmic "beat"
is caused by varying
volumes of blood being
pushed out of the heart
toward the extremities.
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Radial pulse
•
Arteries carry oxygenated
blood away from the heart to
the tissues of the body; veins
carry blood depleted of oxygen
from the same tissues back to
the heart. The arteries are the
vessels with the "pulse", a
rhythmic pushing of the blood
in the heart followed by a
refilling of the heart chamber.
To determine heart rate, one
feels the beats at a pulse point
like the inside of the wrist for 10
seconds, and multiplies this
numbers by six. This is the perminute total.
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Technique for Measuring the Radial Pulse
• The pictures below demonstrate the location of the radial artery
(surface anatomy on the left, gross anatomy on the right).
•
•
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An apical pulse is the heartbeat at the apex of the heart. The apex of
the heart is located in left fifth intercostal space on the midclavicular
line. The stethoscope is placed just below the left nipple between the
fifth and six ribs.
•
•
•
•
•
•
•
•
•
•
•
•
Carotid Pulse
A common location for taking the pulse is the neck. There are two large arteries near
the front of the throat which supply the head with blood. These arteries are called the
carotid arteries.
One artery is located in a groove on the right side of the larynx and the other artery is
located in a groove on the left side of the larynx. The artery on the casualty's left side
is the left carotid artery and the artery on the casualty's right side is the right carotid
artery. Either artery can be used to take the casualty's carotid pulse.
To locate the artery, place the middle and index fingers on the casualty's larynx,
which is usually called the Adam's apple.
Move the fingers to the side until you feel the groove created by the muscles next to
the trachea.
Press on the groove until you feel the pulse.
Question:Why don't you use your thumb when taking a casualty's pulse?
Response:The thumb has a pulse of its own. You may be taking your pulse instead of
the casualty's pulse.
Radial Pulse
Another common location for taking the pulse is the wrist. When taking the pulse at
the wrist, gently press the radial artery against the bones of the wrist. The radial pulse
is taken on the inside of the wrist near the base of the thumb. Do not use the back of
the wrist. Either wrist can be used to take the casualty's radial pulse.
Question:When would you need to take a casualty's radial pulse?
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Response:You have applied aCopyright
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arm and want to check the
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below the
splint. of Thomson
Posterior Tibial Pulse
A less common location for taking the pulse is the ankle. When taking the
pulse at the ankle, gently press the posterior tibial artery against the
bones of the ankle. The pulse is taken on the inside of the ankle behind
the large ankle bone. The pulse can be found using either ankle.
Question:When would you need to take a casualty's posterior tibial
pulse?
Response:You have applied a splint to a fractured leg and want to check
the casualty's blood circulation below the splint.
Other Pulse Sites
The temporal pulse is felt at the temple near the ear.
The brachial pulse is felt on the inside of the elbow.
The femoral pulse is felt in the groin area.
The groin areas are located on each side of the body in the folds where
the abdomen joins the legs. The pubic area lies between the two groin
areas.
The popliteal pulse is felt behind the knee.
The dorsalis pedis pulse is felt on top of the foot.
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•
Frequently, you can see transmitted pulsations on careful visual inspection
of this region, which may help in locating this artery. Upper extremity
peripheral vascular disease is relatively uncommon, so the radial artery
should be readily palpable in most patients. Push lightly at first, adding
pressure if there is a lot of subcutaneous fat or you are unable to detect a
pulse. If you push too hard, you might occlude the vessel and mistake your
own pulse for that of the patient. During palpation, note the following:
Pulse Characteristics
•
Quantity: Measure the rate of the pulse (recorded in beats per minute).
Count for 30 seconds and multiply by 2 (or 15 seconds x 4). If the rate is
particularly slow or fast, it is probably best to measure for a full 60 seconds
in order to minimize the impact of any error in recording over shorter periods
of time. Normal is between 60 and 100.
Pulse rate (bradycardia, tachycardia)
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Regularity: Is the time between beats constant? In the normal setting, the heart
rate should appear metronomic. Irregular rhythms, however, are quite common.
If the pattern is entirely chaotic with no discernable pattern, it is referred to as
irregularly irregular and likely represents atrial fibrillation. Extra beats can also
be added into the normal pattern, in which case the rhythm is described as
regularly irregular. This may occur, for example, when impulses originating from
the ventricle are interposed at regular junctures on the normal rhythm. If the
pulse is irregular, it's a good idea to verify the rate by listening over the heart
(see cardiac exam section). This is because certain rhythm disturbances do not
allow adequate ventricular filling with each beat. The resultant systole may
generate a rather small stroke volume whose impulse is not palpable in the
periphery.
Pulse rhythm (dysrhythmias)
Volume: Does the pulse volume (i.e. the subjective sense of fullness) feel
normal? This reflects changes in stroke volume. In the setting of hypovolemia,
for example, the pulse volume is relatively low (aka weak or thready). There
may even be beat to beat variation in the volume, occurring occasionally with
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medications.
A pulse rate below 60 may also occur in a soldier who is physically fit.
A pulse rate of less than 50 beats per minute is called bradycardia.
pulse deficit
The absence of palpable pulse waves in a peripheral artery for one or
more heart beats, as is often seen in atrial fibrillation, the number of
such missing pulse waves (usually expressed as heart rate minus pulse
rate per minute).
if pulse is irregular, do an apical/radial pulse assessment to detect a
pulse deficit. Count apical pulse while colleague counts radial pulse.
Begin apical pulse count out loud to simultaneously assess pulses. If
pulse count differs by more than 2, a pulse deficit exists.
For example,An apical rate of 92 with a radial rate of 78 leaves a pulse
deficit of 14 beats. Pulse deficits are freguantly associated with
abnormal rhythms.
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Classify the Strength of the Pulse
Regular -- Pulse is easy to feel and has even beats of good force.
Bounding -- Pulse is easily detected due to the exceptionally large
amount of blood being pumped with each heartbeat.
Weak -- Pulse is difficult to detect due to a decreased amount of blood
flowing through the arteries, usually due to bleeding or shock.
Absent -- Pulse cannot be detected, usually due to a blocked or injured
artery or due to a lack of heart action.
Question:At which pulse site will you probably feel the most distinct
pulse?
Response:The carotid pulse site.
If you remain with the casualty for a significant amount of time, take the
casualty's pulse periodically and note any significant changes in rate,
rhythm, or strength of the casualty's pulse. Remember that an irregular
or fluctuating pulse may indicate an early stage of hypovolemic shock
and a weak and rapid pulse may indicate a more advanced stage of
hypovolemic shock.
Taking a casualty's pulse is important in identifying shock and in
evaluating a nerve agent casualty, which we will discuss shortly. In a
chemical environment,Copyright
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casualty's carotid pulse
rate while
wearing
your protective gloves.
Nursing Considerations
1. An irregular pulse rate, if not previously
documented, should be reported
immediately.
2. Clients on certain cardiac medications may
need to monitor their pulse rate.
3. Routine exercise lowers resting and activity
pulses.
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Assessing Pulse
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Hemodynamic Regulation
• Blood Pressure
Measurement of pressure pulsations exerted against
the blood vessel walls during systole and diastole
Systolic Pressure
Maximum pressure exerted
against arterial walls during
systole
Diastolic Pressure
Pressure remaining in
the arterial system
during diastole
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Assessing Blood Pressure
•
purpose:To assess cardiovascular
function by measurement of peripheral
blood flow
•
The most common site for indirect
measurement is the client’s arm over the
brachial artery.
•
Accurate measurement requires the
correct width of the blood pressure cuff as
determined by the circumference of the
client’s extremity.
•
•
In order to measure the BP, proceed as follows:
Wrap the cuff around the patient's upper arm so
that the line marked "artery" is roughly over the
brachial artery, located towards the medial
aspect of the antecubital fossa (i.e. the crook on
the inside of their elbow). The placement does
not have to be exact nor do you actually need to
identify this artery by palpation.
•
Blood vessels become less elastic with
age. The "average" blood pressure
increases from 120/70 to 150/90 and
may persist slightly high even if
treated. The blood vessels respond
more slowly to a change in body
position.
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Blood Pressure: Blood pressure (BP) is measured using
mercury based manometers, with readings reported in
millimeters of mercury (mm Hg). The size of the BP cuff will
affect the accuracy of these readings. The inflatable
bladder, which can be felt through the vinyl covering of the
cuff, should reach roughly 80% around the circumference
of the arm while its width should cover roughly 40%. If it is
too small, the readings will be artificially elevated. The
opposite occurs if the cuff is too large. Clinics should have
at least 2 cuff sizes available, normal and large. Try to use
the one that is most appropriate, recognizing that there will
rarely be a perfect fit.
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Assessing Blood Pressure
• Korotkoff sounds are five distinct phases
of sound heard with a stethoscope during
auscultation.
• The forearm or leg sites can be palpated
to obtain a systolic reading when the
brachial artery is inaccessible.
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If you have difficulty hearing the BP, double-check the
following:
a.
c.
e.
direction of stethoscope ear pieces in your ears.
b.
is all air out of the BP cuff before beginning?
are you keeping the stethoscope check piece against the pt's
brachial artery?
d.
are the tubes free from twists, bends, occlusions?
is the environment too noisy and needs temporary adjusting, i.e.
people, radio, TV, etc.?
• If you have difficulty getting the BP, deflate the
cuff, allow the arm to rest a minute, reassure the
pt. that you need to take it again for accuracy,
and try again.
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Blood pressures would not be taken on arms in
which IV's are infusing (or heparin locks), or on the
side of women who have had mastectomies (may
cause severe edema/swelling). They are also
contraindicated if the arm has a phlebitis, an
arterio-venous shunt (for dialysis clients), or is
paralyzed and atrophied from past injury.
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Assessing Blood Pressure
• Hypotension refers to a systolic blood
pressure less than 90 mm Hg or 20 to 30
mm Hg below the client’s normal systolic
pressure.
• Hypertension refers to a persistent systolic
pressure greater than 135 to 140 mm Hg
and a diastolic pressure greater than 90
mm Hg.
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