Transcript Blood Pressure

NRS 310
Vital Signs,
Measurements and Pain
assessment
Chapters 4 & 6.
Nancy Sanderson MSN, RN
Introductions
2
Introductions
Introduce yourself!
 Wash your hands (hand sanitizer)

Ask what brought patient to
 hospital, clinic, or doctor’s
office
 As the patient is talking,
summarize their appearance:

3
General Survey


Be careful about
“assumptions”
and stereotyping
Gives overall impression of patient’s
health
Provides information about:
Physical Appearance
Hygiene (body, breath)
Body Structure
Mobility
Behavior
4
Appearance
Dress
 Clothing appropriate to climate, looks clean & fits the body,
& is appropriate to the patient’s culture & age group
 Appropriate for setting, season, age, gender & social group
 Personal hygiene & Grooming
 Patient appears clean & groomed appropriately for his/her
age, occupation, & socioeconomic group. Hair & nails neat
and clean Hair groomed, brushed. Make-up appropriate.
 Body odor
 Unpleasant odor may result from exercise, poor hygiene or
certain disease states
 No body odor present

5
Ways to summarize patient’s
appearance
High functioning






Feeling well
Cleanly dressed
Showered
No body odor
No smell of alcohol or
other drugs
Follows the
conversation well
Low functioning

Feeling poor or low
self-esteem*
◦ (*really sick brought in
911)





Unkempt
Dirty (no shower)
Body odor
Alcohol, marijuana or
other drug smells
Can’t follow
conversation
6
Summary or in a nutshell:
Introduce yourself
 Observe the patient

◦ Appearance
◦ Behavior

Listen to concerns/complaints
7



Height
Weight
Head Circumference
◦ Children only

Body Mass Index
Measurements
Why Height & Weight?

Height & weight reflects a person’s general
level of health
◦ In older adults, height & weight coupled with a
nutritional assessment determine the cause of
and treatment for chronic disease or helps to
identify those who have difficulty feeding or
other dietary issues
◦ In children, data is used to assess both growth
and development
 Weight also necessary for dosing of medication
Increased or Decreased Height


Gigantism & Dwarfism
Increased
◦ Gigantism

Decreased
◦ Elderly (osteoporosis)
◦ Malnutrition
◦ Dwarfism
 Hypopituitary
 Achrondroplastic
10
How to Measure Height
Use a specially
designed board for
measuring

Height (>2 y/oadulthood)
◦ Remove shoes,
and outer wear
◦ Place back to scale
or wall
◦ Look straight
ahead
◦ Document in
centimeters or
inches to nearest
1/8 in.

Length (< 2y/o)
◦ Hold head midline,
push down knees
until legs are flat.
Increased or Decreased Weight

Increased
◦ Excess Nutrition
◦ Cushing’s syndrome
◦ Fluid retention

Decreased
◦ Malnutrition
◦ Acute or Chronic illness
 Cancer
 Cystic Fibrosis
 TB
◦ Eating Disorder
◦ Mental Illness
12
How to Measure Weight

Weight (2 y/o-adult)

Weight (< 2y/o)
◦ Remove shoes and
heavy outer clothing
◦ Record in pounds or
kilograms (often kg
for children)
◦ Record to nearest ¼
lb
◦ Check calibration,
remove all clothing,
stay very close to
infant so does not fall.
◦ Record to nearest ½
oz in infants and ¼ lb
or 0.1kg for toddlers
13
Why Head Circumference?

Assess for brain growth and abnormalities
◦ Microcephaly
◦ Macrocephaly
 Hydrocephalus
14
Head Circumference

Measured at birth and
each well child visit and
then yearly until age 2
years.
◦ (Well child visits: 1 wk, &
months 1, 2, 4, 6, 9, 12, 15,
18, 24) or if
◦ Anterior Fontanel (soft spot)
closes around 18 – 24
months

Circle tape at widest point
and record in centimeters
◦ Above pinna or ears and
around occipital prominence
◦ May need to repeat a few
times.
15
Measuring an Infant: Putting it all
Together
16
BMI
The Body Mass Index(BMI) formula
was developed by Belgium statistician
Adolphe Quetelet (1796-1874)
 Was known as the Quetelet Index.
 BMI is an internationally used measure
of obesity.
 http://www.whathealth.com/bmi/chartimperial.html

17
Body Mass Index (BMI)








More accurate estimate of body fat than
weight alone.
Weight (kg)/Height (m²) or
Weight (lbs)/height (in.²) x 703
Underweight
Normal
Overweight
Obesity I
Obesity II
Obesity III
<18.5
18.5-24.9
25.0-29.9
30.0-34.9
35.0-39.9
>40
18
BMI: Body Mass Index



More than than half of U.S. adults are
overweight (>25)
More than one quarter of U.S. adults are
obese (>30)
These are risk factors for diabetes, heart
disease, stroke, hypertension, osteoarthritis,
sleep apnea, and some forms of cancer
19
Summary (in a nutshell)
Height and Weight needed for BMI
 Following trends/health status
 Measure head circumference up to the
age of 2

20
Vital signs
21
Vital Signs—5, 6, 7, or 8 VS








Temperature (T)
Pulse (P)
Respiratory Rate (R)
Blood Pressure (BP)
Pulse Ox
Pain
Level of consciousness
Urine out put
Vital Signs (VS/VTS)
 There is a variety of vital signs to be
established in an acute care setting.
 Base line data include measurement of
temperature, pulse, respirations, blood
pressure and oxygen saturation.
 Assessing pain is also considered
standard baseline data to be collected
on all patients and is often included with
vital signs.
 Other measurements may need to be
included when calling a physician or
discussing care with another health care
provider.
Use of Vital Sign Measurements

Establish patient’s baseline
◦ On admission to health care facility
◦ Before surgical or invasive diagnostic procedure,
transfusion of blood products, administration of
medications that affect cardiovascular, respiratory or
temperature control functions

Monitor current condition & identify problems
◦ According to routine schedule ordered by provider
◦ During transfusion of blood products, administration of
medications that affect cardiovascular, respiratory or
temperature control functions
◦ -When pt’s general physical condition changes
◦ When pt reports nonspecific symptoms of physical
distress
Use of Vital Sign Measurements

Evaluating Response to Intervention
◦ After administration of medications for:
Pain; Breathing treatments; Blood
Transfusions: Chemotherapy; etc.
 Temperature
 Pulse
 Blood pressure
 Respiration
 Pulse Ox
 Pain
 Level of consciousness
Guidelines for Nursing Practice
Can delegate, but nurse caring for the
patient is responsible for analyzing vital
signs & making decisions about
interventions
 Make sure equipment is functioning
and appropriate for the size, age, and
condition of the patient
 Know each patient’s:

◦ Medical history
◦ Prescribed medications and therapies
◦ Baseline vital signs
Vital Signs: Temperature
28
Temperature Conversions

Convert Fahrenheit to Celsius
◦ C = (F -32°) x 5/9

Convert Celsius to Fahrenheit
◦ F = (9/5 x C) + 32°

There are graphs everywhere!
How to Measure


Surface Sites
◦ Oral
◦ Axillae
◦ Skin
Core Sites
◦ Rectum
◦ Tympanic Membrane
◦ Temporal Artery
Oral


Oral sublingual site with rich blood supply from
carotid arteries
How to use:
◦ Slide probe cover over BLUE tip probe & place in the
posterior sublingual pocket with mouth completely closed.
After beeps eject probe cover.
◦ Ideally wait 20-30 minutes after patient smoked or ingests
hot liquids/foods.


Advantages: Accurate & convenient
Disadvantages: Cannot be used if the patient is
unconscious, confused, seizure prone, shaking
chills, less than 5 years old, disease/surgery of the
mouth, mouth breather, or tachypnea
Axillary
Axillary temperature is 0.9°F lower than oral temp
 Typically used with newborns and unconscious
patients

◦ Not recommended for fever in infants or young children

How to use:
◦ Slide probe cover over BLUE tip probe and place tip into
center of unclothed axilla. Lower arm and place across
patient’s chest. If child- hold child’s arm next to body
Advantages: Safe & accessible for infants & children
when environment controlled
 Disadvantages: Long measurement time. Lags
behind core temp during rapid temperature change.
Easily affected by the environment.

Rectal Temperature

Higher than oral temps by 0.9 °F (average 99.399.6°F )
◦ Infants/Children-Rectal temp higher than adult (100 °F)
Measures temperature from blood vessels in rectal wall
 How to use:

◦ Apply gloves, place in Sims position, separate buttocks, & dip
probe cover into lubricant. Attach probe with RED tip. Insert
lubricated probe cover 1-1.5 inch into rectum. Eject probe
cover and wipe probe with alcohol.

No Longer recommended in infants or
children*!!
◦ *Unless a soft flexible temperature probe
Rectal Temperature
Advantages: Not influenced by eating,
drinking, smoking, or ability of patient to
hold probe, more accurate
 Disadvantages: Patient discomfort & time
consuming. Lags behind core temp during
rapid temperature changes.
Contraindicated in pre-term infants,
immunosuppressed, and patients with
diarrhea or rectal/GI surgery.

Tympanic
Higher (1°F ) than oral temperature.
Senses infrared emissions of the tympanic
membrane
 How to use:


◦ Apply speculum cover. Pull ear up and back for
>3y/o & down and back for <3y/o. Place covered
probe tip snugly into ear canal, point speculum
towards nose and press button and hold until beeps.
Remove and eject cover.
◦ Make sure patient has been indoors for at least 10
minutes
◦ Use other ear or route if: drainage from ear, ear
surgery, large amount of cerumen, pain from
perforation or infection
Tympanic

Advantages

Disadvantages
◦ Fast, convenient, safe, reduced risk of injury
and infection, and non-invasive. Provides
accurate core reading because eardrum close to
hypothalamus; sensitive to core changes. Not
affected by food/drink or smoking.
◦ Requires removal of hearing aids. Only one
size*. Inaccuracies reported due to incorrect
positioning. Affected by ambient temp devices
(incubators, radiant warmers, facial fans). Otitis
media and cerumen may distort reading.
Contraindicated in ear/TM surgery.
◦ *(This is changing, pediatric size has been
developed)
Temporal Artery (TAT)

Infrared sensor tip detects temperature of
cutaneous blood flow through superficial
temporal artery.
◦ Often used for infants, newborns, and children

How to Use:
◦ Ensure forehead is dry. Place probe flush on skin. Push
button and hold as move across
forehead from center
of hairline and ending
with a touch behind
earlobe. Release button
and clean probe with
alcohol.
Temporal Artery (TAT)

Advantages:
◦ Fast, convenient, and comfortable. No risk to
patient or nurse. Reflects rapid change in core
temp. Sensor cover not required.

Disadvantages:
◦ Inaccurate with head covering or hair on
forehead. Affected by diaphoresis and
sweating.
What do the Values Mean?

Normal Range
◦ 96.8 – 100.4 °F

Fever/Hyperthermia
◦ > 100.4 °F

(36 °- 38 °C)
Hypothermia
◦ < 96.8 °F
◦ Severe:
 < 86.0
What do the Values Mean?

Increased: Fever/Hyperthermia
◦
◦
◦
◦
◦
◦
Infection or inflammation
Trauma or disease to hypothalamus
Spinal cord injury
Prolonged exposure to sun/ high temperatures
Fluid volume deficit
On medications that decrease body’s ability to
lose heat or promote fluid loss
◦ Have congenital absence of sweat glands or
serious skin disease that impairs sweating

Decreased
Fever (Afebrile/febrile)

Mild temp elevation up to 102.2F (39C) enhances
immune system
◦ White blood cell production stimulated
◦ Body decreased iron concentration in blood plasma ,
suppressing growth of bacteria
◦ Stimulates interferon's, bodies natural virus-fighting
substance

Prolonged fever weakens patient by exhausting
energy stores, increasing oxygen demands and
decreasing fluid volume
◦ Risk of Febrile seizures & dehydration in children
Hyperthermia- Additional S & S









Sweating/Diaphoresis
Skin warm to touch
Inactivity
Confusion
Excessive thirst
Nausea
Muscle cramps
Visual disturbances
Incontinence
 Increased heart
rate
 Decreased BP
If progresses
 Unconscious
 Nonreactive pupils
 Permanent
neurological
damage
What do the Values Mean?

Decreased: Hypothermia
◦
◦
◦
◦
Trauma or disease to hypothalamus
Spinal cord injury
Prolonged exposure to cold temperatures
Unintentional exposure to cold (falling through
ice at lake)
◦ Intentional- surgical to reduce metabolic
demands and oxygen requirements
Hypothermia- Additional S & S







Skin cool to touch
Voluntary muscle
contraction
Shivering
Memory loss
Poor judgment
Decreased heart rate
Decreased
respiratory rate


Decreased blood
pressure
Skin cyanotic
If progresses
◦ Cardiac dysrhythmias
◦ Loss of consciousness
◦ Unresponsive to
painful stimuli





You have delegated vital signs to assistive
personnel. The assistant informs you that
the client has just finished a bowl of hot
soup. The nurse’s most appropriate advice
would be to:
A. Take a rectal temperature.
B. Take the oral temperature as planned.
C. Advise the client to drink a glass of cold
water.
D. Wait 30 minutes and take an oral
temperature.
32 - 45
Vital Signs: Pulse
Pulse Basics



Pulse is the palpable bounding of blood flow
created by ejection of blood into the aorta.
Peripheral pulses felt by palpating arteries
lightly against underlying bone or muscles
Provides clinical data regarding the heart’s
pumping action (cardiac output)
◦ Cardiac output = heart rate x stroke volume
◦ Abnormally slow, rapid, or irregular pulse alters
CO.
Pulse Basics

Changes in pulse rate caused by:
◦
◦
◦
◦
◦
◦
◦
◦
Heart disease/dysrhythmias (decreased CO)
Age
Exercise
Positions changes
Fluid balance (i.e. hemorrhage)
Medications
Temperature
Sympathetic stimulation
Radial & Carotid
Pulse Site

Radial
◦ Place patient’s forearm straight alongside body
or across lower chest or abdomen. If sitting
bend elbow at 90°and support
◦ Place pads of first 2-3 fingers in groove along
thumb side (radius)

Carotid
 Place pads of first 2-3 fingers along medial
edge of sternocleidomastoid muscle in neck
Radial & Carotid Pulse Sites

Rate (beats/minute)
◦ If pulse is regular then count for 30 seconds and
multiply by 2.
 If pulse irregular or weak count for 1 minute at apical
site
◦ Normal Range
 Adult 60-100 bpm
◦ Infants/Children (less than or 2 years of age: apical
pulse—brachial in BLS)
◦ Adults Abnormal
 > 100 bpm = Tachycardia
 < 60* bpm = Bradycardia (*exception: extreme athletic
person)
Radial & Carotid Pulse Sites
 Rhythm
◦ Normal
 Regular
 Sinus Arrhythmia in children
◦ Irregular/Dysrhythmia
 Regularly irregular
 Irregularly irregular
Radial & Carotid Pulse Sites

Strength (Amplitude)
◦ Normal
 Strong (2+)
◦ Abnormal
 Weak or thready (1+)
 Bounding (3+)

Equality
◦ Radial: Assess on both sides to determine if
equal
◦ Carotid: Never palpate simultaneously. Only
one at a time.
Apical Pulse Site
Listen to the Apical heart sound
 Although called “pulse” you want to listen
w/stethoscope
 Auscultate with stethoscope & assess rate
& rhythm—1 full minute

◦ If you feel an irregular pulse when feeling
radial pulse (bounding, weak, irregular, or
skipped beats
◦ Any child less than 2 years old
Apical Pulse Site
 Auscultation
of heart sounds
 Often used when:
◦ Heart rate is irregular
◦ Peripheral pulse is weak
◦ Patient taking medication that affects
pulse rate
◦ Patient is < 2 y/o




You notice that a teenager has an irregular pulse. The
best action you should take includes:
A.
Read the history and physical.
B.
Assess the apical pulse rate for one full minute.
C. Auscultate for strength and depth of pulse.
D. Ask if the client feels any palpations or faintness of
breath.
32 - 55
Vital Signs: Respiratory Rate
Respiratory Rate
Assess breathing pattern.
Observe chest wall expansion and
bilateral symmetrical movement of
thorax.
 Assess the rate, depth, and rhythm of
each breath.
 Count for 30 seconds & multiply by 2 if
regular pattern
 In infants watch abdomen and count full
minute


So Patient isn’t aware. . .

Ask patient to move arm over chest and
as you “count the radial pulse” you
actually count the respirations
Question





You are counting respirations in a male
patient you notice his chest is not
moving much, but his abdomen has
movement with each respiration this is:
A. A symptom of severe respiration
problems
B. Normal diaphragmatic breathing
C. You need to notify the doctor
D. A & C
Vital Signs: Blood Pressure
Blood Pressure
Systolic: force of pressure in the walls
of the arteries when the (L) ventricle
contracts
 Diastolic: force of pressure on walls of
arteries when the heart is filling
 Physiological factors controlling BP:

◦
◦
◦
◦
◦
Cardiac output
Peripheral vascular resistance
Volume of circulating blood
Viscosity
Elasticity of vessel walls
Blood Pressure
Blood Pressure


Allow patient to sit for 5 minutes with feet flat
on floor and legs uncrossed. Allow 30 minutes
if just smoked or consumed caffeine.
Select appropriate cuff size (see W & G pg.
34)
◦ Width of the bladder should cover 40%
of the upper arm
◦ Length of the bladder should be about
80% of upper arm (almost long enough
to encircle the arm)
 Cuff too small, the BP will be falsely
elevated
 Cuff too large, the BP will be falsely
lowered
40%
Blood Pressure
Place arm at heart level
 Palpate brachial artery and apply cuff to bare
arm 1 inch above antecubital space with arrow
over brachial artery
 Palpate the radial pulse & inflate cuff until unable
to palpate the radial pulse. Read this pressure
on the manometer & add 30 mmHg to it.
 Deflate the cuff & wait 15-30 seconds

Blood Pressure
Place the diaphragm lightly over the brachial artery
Inflate the cuff rapidly to the level just determined,
and then deflate it slowly at a rate of about 2-3 mm
Hg per second.
◦ If you deflate too slowly, you can cause
congestion that falsely increases the blood
pressure.
◦ Too fast falsely decreased reading
 Note the level at which you hear the sounds of at
least two consecutive beats. This is the systolic
pressure
 Continue to lower the pressure until the sounds
disappear. This is the diastolic.
 Read both the systolic and diastolic levels to
the nearest 2 mm Hg.


What makes the sounds?
160
120
110
78
Recording Blood Pressure
Systolic/Diastolic
 Record what arm the BP was taken on
 Blood pressures can normally vary 5-10
mm Hg in different arms. Subsequent
BP’s should be checked in the arm that
has the higher value.

◦ >10-15mmHg suggests arterial compression or
obstruction on side with lower pressure
Blood Pressure Classification




Normal
<120/<80
Pre-hypertension
120-139/80-89
Hypertension stage 1
140-159/90-99
Hypertension stage 2
>160/>100

Hypotensive
<90 systolic
depending on
baseline BP
The Seventh Report of the Joint National Committee on
Prevention, Detection, Evaluation, and Treatment of High
Blood Pressure
Blood Pressure

Thigh
◦ Use if dressings, casts, double mastectomy,
intravenous catheters, arterio-venous
fistulas/shunts surgery, trauma or burn
makes upper extremities inaccessible for
blood pressure measurement
◦ With patient in prone position put cuff 1 inch
above popliteal artery
◦ Systolic BP 10-40mmHg higher than UE
◦ Diastolic same as UE
MAP: Mean Arterial Pressure
Approximation of the average pressure in
the systemic circulation throughout the
cardiac cycle; reflects the components of
the cardiac cycle
 Will be read on automatic BP cuff and on
arterial lines.

When assessing the blood pressure of a schoolage child, using a normal-size adult cuff will
affect the reading and produce a value that is:
 A. Accurate
 B. Indistinct
 C. Falsely low
 D. Falsely high
32 - 72
Vital Signs: Pulse
Oximetry
Pulse Oximetry (SpO2)


Indication of oxygen saturation
Normal range typically 95-100% @ sea level.
◦ >92% in Colorado

May place clip on:
◦
◦
◦
◦

Finger
Toe
Nose
Earlobe
Include the use of any type of oxygen
equipment, including route and flow rate
Summary:
Vital signs are one of the most important
assessment you can do!
 Should be done after introduction and
getting history (Do first if EMERGENCY)
 Retake per orders or if patient shows signs
of going downhill.

Pain Assessment
The often forgotten VS
Pain






The assessment of pain is based primarily on
subjective data gathered from the patient
Use your OLDCARTS/OPQRST in gathering
information http://www.ems1.com/emsproducts/education/tips/475522-RefiningOPQRST-as-an-Assessment-Tool/
Pain intensity / rating scale is a good tool to
use in assessing pain
What is the patient’s acceptable level of pain
Find out if the pain is new
Find out what helps or relieves the pain
◦ Pharmacologic
◦ Non - pharmacologic
Physiology of Pain Perception
Things to remember!!!
Pain is subjective
 Different cultures will report differently
 Subjective – The patient’s own words
 Objective – What you see and can chart

◦ Crying
◦ Rigid
◦ Increase BP
Standards for Pain Assessment
Criteria for accreditation for hospitals Joint
Commission has set a standard that patients have the
right to appropriate assessment and management of
pain.
 The standard includes:
1) Initial assessment and regular assessment of pain,
taking into account personal, cultural, ethical and
spiritual beliefs.
2) Education of all relevant health care personnel in
pain assessment and management.
3) Education of patients and families regarding their
roles in managing pain, potential limitations, &
adverse effects of pain treatments.

Pg. 60 W & G
McGill Pain
Questionnaire
“OPQRST”






PAIN ASSESSMENT
Onset: “Did your pain start suddenly or gradually get worse and worse?”
This is also a chance to ask, “What were you doing when the pain started?”
Provokes or Palliates: Instead of asking, “What provokes your pain?” use
real, casual words. Try, “What makes your pain better or worse?”
Quality: Asking, “Is your pain sharp or dull?” limits your patient to two
choices, when their pain might not be either. Instead ask, “What words
would you use to describe your pain?” or “What does your pain feel like?”
Radiates: This is another chance to use real, conversational words during
assessment. Asking, “Does your pain radiate?” sounds silly and pompous to
the patient. Instead use this question, “Point to where it hurts the most.
Where does your pain go from there?”
Severity: Remember, pain is subjective and relative to each individual
patient you treat. Have an open mind for any response from 0 to 10.
Time: This is a reference to when the pain started or how long ago it
started.
FLACC
Acute Pain Behaviors
Guarding
 Grimacing
 Rubbing/splinting of body parts
 Stillness
 Restlessness/reduced attention span
 Avoidance of social contact or conversation
 Refusing to eat, nausea, vomiting
 Vocalization (i.e. moaning, crying)
 Agitation/striking out
 Diaphoresis
 Change in vital signs (
Pulse, Resp, BP)

Summary:
Pain assessment is the most under
assessed VS
 Pain is culturally dependent and
subjective
 Several tools to help you assess pain
 Children in the hospital for surgery or
accident this is probably their worse pain

Summary Cont.
A practical definition of pain is, “ Pain is
whatever the experiencing person says it
is, existing wherever he says it is.”
 Know the difference between the types of
pain pg. 55.
 Review box 6-1 and table 6-1 pg. 57.
 Review Health history, Problem-based
history and examination.
