Transcript Chapter_019_ studentx

Chapter 19
Vital Signs
Copyright © 2016 by Mosby, an imprint of Elsevier Inc.
Vital Sign Measurement
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Baseline values, or initial vital signs, are used to
identify changes in patient status.
A series of vital sign measurements establishes
patient trends.
The frequency of assessing vital signs is
determined individually for each patient and is
dependent on patient status.
Vital signs are interpreted on the basis of current
health status and previously established
(baseline) normal values for the patient.
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Vital Sign Measurement (Cont.)

Factors influencing vital signs:

Infection
 Renal disease
 Respiratory disease
 Cardiovascular disease
 The physical environment
 Emotional state of the patient
 Medications
 Food and fluid intake
 Activity level and tolerance

Accuracy depends on precise measurement
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Vital Sign Documentation
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
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Both normal and abnormal vital sign results are
appropriately documented and communicated to
all members of the health care team.
Values are recorded on the specified form or the
electronic medical record used by the facility.
With such documentation, multiple sets of vital
signs typically are easily visible at a time,
thereby showing trends for the patient.
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Situations that Require Vital Sign
Measurement
• On admission to a health care agency, to establish baselines
• As part of a physical assessment
• During an inpatient stay, as routine monitoring
• With any change in health status, especially complaints of chest pain
and shortness of breath or feeling hot, faint, or dizzy
• Before and after surgery or invasive procedures to establish
baselines and monitor effects
• Before and after administration of medications that impact cardiac,
respiratory, or thermal regulation systems
• Before and after interventions such as ambulation
• In ongoing care, to detect improvement in patient condition
• Before discharge or transfer from a unit, to validate patient readiness
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Health Assessment Questions
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Focus on temperature
Focus on pulse
Focus on respiratory rate
Focus on blood pressure
Focus on pain: S-O-C-R-A-T-E-S:
•
•
•
•
•
•
•
•
Site
Onset
Character
Radiation
Associations
Time course
Exacerbating/relieving factors
Severity
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Collaboration and Delegation
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The task of taking vital signs may be delegated to
unlicensed assistive personnel (UAPs), but before
delegating this task, the nurse assesses patients to
determine that they are medically stable.
UAPs may measure, record, and report vital signs for the
stable patient, but interpretation of vital signs remains
the responsibility of the licensed or registered nurse.
Interpreting vital signs is done in relation to other
assessment findings.
The nurse ensures that the UAP knows the proper
technique for taking vital signs and knows what values
need to be reported immediately for each patient.
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Informatics and Safety

QSEN focus
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Nurses use informatics when identifying essential information
such as vital signs that must be available in a common database
to support patient care.
Nurses must be able to navigate the electronic health record
(EHR) to view baseline patient data, and they must understand
the technology that supports clinical decision making.
Safety alert!


Sudden alterations in vital signs or values outside the normal
range are indicators of a priority situation for the nurse. Further
assessments and emergency measures should be initiated as
indicated by the patient’s status.
The health care provider is notified of alterations in vital signs.
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Temperature


Healthy people are able to maintain body
temperature within the normal range even when
exposed to temperature extremes for short
periods.
A person’s ability to manage body temperature
depends on certain behavioral abilities and
thought processes, such as adequate mobility to
leave an area of extreme heat or cold, the
capacity to sense temperature discomfort, and
the physical ability to add or remove clothing.
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Normal Parameters of Body
Temperature
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Temperature is measured in degrees,
represented by the symbol °.
The core body temperature remains relatively
constant within the range of 97.6° to 99.6° F
(36.5° to 37.5° C)
The average oral temperature is 98.6° F (37° C).
A person who maintains this normal body
temperature is considered to be afebrile.
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Physiology of Heat Production and Loss
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Body temperature is the difference between the
amount of heat produced by body processes
and the amount of heat lost to the external
environment.
Thermoregulation comprises the physiologic and
behavioral mechanisms that regulate the
balance between heat production and heat loss.
Heat is generated by metabolic processes in
core tissues of the body and is transferred by
circulating blood to the skin, where it is
dissipated into the environment.
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Heat Production
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Food is the primary fuel source for metabolism.
The amount of heat produced is related to the
rate of metabolism.
Factors that can increase heat production:



Exercise
Increased release of epinephrine and norepinephrine
Increased production of thyroid hormones
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Heat Loss


Core temperature: temperature of deep tissues
Heat loss is constant through:

Radiation, or the transfer of heat as waves or
particles of energy
 Conduction, or the transfer of and reaction to heat
through direct contact
 Convection, or the transfer of heat by movement or
circulation of warm matter such as air or water
 Evaporation, or the process by which a liquid is
changed to a vapor through heat
• Evaporation lowers body temperature
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Factors Affecting Body Temperature
Age
Newborns’ temp unstable; baseline temp drops with
age; infants and elderly more susceptible to
environmental temp extremes
Exercise
Hormonal
fluctuations
Circadian
rhythms
Stress
Increases body temperature
Women’s temp higher at ovulation; thyroxine,
epinephrine and norepinephrine increase temp
Lowest temp around 3 A.M.; highest around 6 P.M.
Levels of epinephrine and norepinephrine increase
during stress
Environment Extended extreme temps affects core body temp
Causes vasoconstriction can decrease temp of skin
Smoking
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Temperature Terminology
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Hypothermia = low body temperature
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Frostbite results from exposure to subnormal temperatures
Hypotension = decreased blood pressure
Hyperthermia = high body temperature
Fever = rise in body temperature above normal
Febrile describes a person with a fever
Heat stroke = when prolonged exposure to high
environmental temps overwhelms the body’s heat loss
mechanisms
Heat exhaustion = when extreme or prolonged
exposure to high environmental heat leads to profuse
sweating and consequent water and electrolyte loss
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Evidence-Based Practice and
Informatics
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To prevent hypothermia in older adults:
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Dress in layers, even while at home. Long underwear
may be worn under clothing, along with socks and
slippers.
Use a blanket or throw to keep legs and shoulders
warm.
When outside in cold weather, wear a scarf and
gloves. A hat is especially important to maintain body
heat.
Keep extremities covered to prevent heat loss.
Keep the thermostat at a minimum of 68° F.
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Assessment of Temperature
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Measured in degrees of Fahrenheit or Celcius
Reliability dependent upon:
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Selecting the most appropriate site
Using the correct equipment
Using the correct procedure
Five common sites = mouth, ear, rectum,
forehead, axilla
Site selection affected by patient age, state of
consciousness, pain level, treatment
Measuring device used depends on the site
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Types of Thermometers
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Temperature Variation by Site
Oral
Axillary
Rectal
Tympanic
Temporal
36.0°-37.6°
C
(96.8°99.68° F)
35.5°-37.0°
C
(95.9°98.6° F)
34.4°-37.8°
C
(93.92°100.04° F)
35.6°-37.4°
C
(96.08°99.32° F)
36.1°-37.3°
C
(96.98°99.14° F)
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Oral Temperature
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Advantages of this site are that it is readily
accessible and comfortable for the patient.
Eating, drinking, smoking, and the use of oxygen
by cannula or mask can affect measurements
obtained at the oral site.
The patient must be able to close the mouth
around the thermometer.
It is not a preferred site for infants and young
children, unconscious patients, post–oral
surgery patients, or people with seizure
disorders.
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Rectal Temperature
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Rectal temperature readings are considered to be very
accurate.
The rectum, however, is not a site preferred by patients.
The rectal route is contraindicated in newborns, in
patients who are neutropenic (low white blood cell
count), and in patients with spinal cord injury.
It should not be used for patients with diarrhea or rectal
disease, post–rectal surgery patients, or quadriplegic
patients.
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Rectal Temperature (Cont.)
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Safe Practice Alert!
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Taking rectal temperatures can cause rectal
perforation in young infants, and the site should be
used only when no other feasible option is available.
If a rectal temperature must be taken, a welllubricated thermometer, inserted no more than the
length of the thermometer’s bulb, should be used.
Taking the patient’s temperature using the rectal route
can cause bleeding in people with hemorrhoids.
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Ear (Tympanic) Temperature
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The tympanic membrane temperature is a core
temperature.
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Thermometer does not touch the tympanic
membrane.
 Easily accessed; not appropriate with drainage
 Readings not significantly affected by otitis media
 An accurate tympanic reading is obtained by grasping
the pinna and gently pulling up and back for the adult,
or down and back for a child younger than 3 years of
age; placing the covered probe snugly in the ear
canal; and angling it toward the jaw line before
activating the sensor.
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Forehead (Temporal Artery) and
Axillary Temperature
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Temporal artery site
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Well tolerated by infants and young children
Not affected by perspiration when performed correctly
Small, handheld unit
A covering on the head can affect accuracy
Axillary site
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
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Used when oral and rectal sites inaccessible
Often used for healthy newborns
Sensor must maintain skin contact
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Electronic Thermometers

Electronic and digital thermometers measure
oral, rectal, or axillary temperature in less than 1
minute.
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Battery-powered
Readings on digital screen within several seconds
Temperature-sensitive probe
• Disposable probe cover
• Same probe can be used for oral and axillary locations
• Separate probe (red) for rectal measurements
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Disposable Thermometers and
Temperature-Sensitive Strips
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Disposable paper thermometers
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Single-use or reusable
 Contain liquid crystal dots or bars + sensor
 Nurse reads highest reading among the dots that
have changed color.
 Excellent choice for maintaining asepsis
 Can be used for oral or axillary sites
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Temperature-sensitive strips
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
Give general indication of body surface temp
Perspiration affects reading.
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Implementation and Evaluation
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Treatment for increased temperatures
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Nonsteroidal antipyretic drugs
 Cool sponge baths, cooling blankets, and packs
 Avoid aspirin
 Antibiotics as prescribed if bacterial infection
 Oxygen may be needed
 Monitoring vital signs
 Monitoring intake and output
 Increasing fluid intake
 Maintaining oral hygiene
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Implementation and Evaluation (Cont.)
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Treatment for hypothermia
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Gradual warming through external wraps, a head
covering to prevent heat loss, and warm intravenous
fluids are means of warming the body.
Patients who are alert can drink hot liquids such as
soup.
Alcohol and caffeine beverages should be avoided.
Some facilities have blanket warmers.
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Implementation and Evaluation (Cont.)
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
When evaluating a temperature reading, the
nurse must compare the temperature
measurement obtained against any baseline
data, previous readings, and the normal range
for the patient.
The nurse interprets the findings by considering
the patient’s diagnosis, time of day, and other
factors such as medications administered.
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Skill 19-1: Measuring Body
Temperature
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PURPOSE is to determine the patient’s baseline
temperature. Body temperature may be
measured in degrees Fahrenheit or Celsius.
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

Identify whether the body temperature is within
normal range.
Monitor the patient for fever or an inability to maintain
normal body temperature.
Monitor the patient for change in physical condition.
Monitor temperature changes for response to
medications.
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Skill 19-1: Measuring Body
Temperature (Cont.)
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Collaboration and delegation
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
Measuring a temperature may be delegated to UAPs
after the initial assessment of the patient.
Assistive personnel should report the following to the
nurse:
• Deviations from baseline temperature
• Complaints related to temperature regulation
• Sores, wounds, irritations, and/or lesions in the area where
the temperature is being measured
• Any difficulties performing the procedure
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Skill 19-1: Measuring Body
Temperature (Cont.)

Collaboration and Delegation (Cont.)
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UAPs should be instructed in:
• Appropriate placement of the thermometer/probe
• Appropriate use of equipment (verifying accurate results)
• Appropriate documentation
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Skill 19-1: Measuring Body
Temperature (Cont.)
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Evidence-based practice
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Bradypnea may cause high temperature readings.
Hot and cold beverage intake influences oral
temperature assessment.
• Both situations require an average of 15 minutes for a return
to baseline measurements.

Baseline oral temperature does not deviate between
older and younger cohorts, but room temperature
affects elderly adults’ oral temperature readings more
than it does those of younger people.
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Skill 19-1: Measuring Body
Temperature (Cont.)

Evidence-based practice (Cont.)

All noninvasive temperature measurement methods
have been shown to be just as accurate as the rectal
temperature method (core temperature), provided the
nurse or caregiver is using the equipment properly
and has been well-trained on the procedure, including
the anatomy and physiology involved.
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Pulse
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The number of pulsing sensations occurring in 1 minute
is the pulse rate (beats per minute, or bpm)
The apical pulse is a central pulse that can be
auscultated over the apex of the heart at the point of
maximal impulse (PMI).
Peripheral pulses are
Normal Pulse Rates
those that can be
Newborn
80-160
palpated over arteries
1-year-old
80-140
located away from the
6-year-old
75-110
heart—at the wrist or
15-year-old
50-90
foot, for example.
Adult and Older adult
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60-100
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Factors Affecting Pulse Rate
The pulse rate is variable and is dependent
on physiologic and emotional factors.
Age
Medications
Gender
Hypovolemia
Fever
Pathology
Stress
Electrolyte balance
Hypoxia and hypoxemia
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Sites for Assessing Pulse
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Never palpate both carotid arteries at the same
time. Doing so could limit blood flow to the brain,
causing the patient to experience syncope
(fainting).
If the peripheral pulse is irregular, count an
apical pulse for 1 full minute to ensure accurate
measurement.
In infants and children younger than 2 years of
age, the pulse rate is obtained by auscultating
the apical pulse.
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Pulse Sites
Temporal
Carotid
Apical or PMI
Brachial
Radial
Femoral
Popliteal
Posterior tibial
Pedal (dorsalis pedis)
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Assessment of Pulse
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Pulse assessment = measuring
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Rate
Rhythm
Volume
And comparing findings on both sides of the body
Assessed by

Palpation
 Auscultation (listening with a stethoscope)
 Electronic monitoring

Too much or too little pressure gives inaccurate
readings
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Evidence-Based Practice

A stethoscope is a medical device that is critical
in listening to internal sounds of the body.


It commonly is used to listen to lung and heart
sounds.
It also is used to listen to intestinal activity and
blood flow in arteries and veins. In combination
with a sphygmomanometer, it is used for
measurements of blood pressure. It is important
that a stethoscope be used and cared for
correctly.
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Nursing Care Guideline

Using a Doppler ultrasound unit to obtain a pulse

Background
• A Doppler ultrasound unit may be used to assess peripheral
circulation when a pulse cannot be palpated.
• Each pulse wave makes a sound that the Doppler ultrasound unit
amplifies.
• Pulses may be difficult to palpate for many reasons, including poor
circulation, edema, obesity, and other obstructive issues.

Documentation concerns
• Note the rate and rhythm of the pulse.
• Note the location of the pulse and use of the ultrasound unit for the
assessment.
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Pulse Rate
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An excessively fast heart rate (>100 bpm in the
adult) is termed tachycardia.
A slow heart rate (<60 bpm in the adult) is called
bradycardia.
The radial pulse is palpated by placing the first
two or three fingers of one hand over the radial
artery at the groove along the radial, or thumb,
side of the patient’s inner wrist.
A pulse deficit results when the apical pulse
rate exceeds the radial pulse rate.
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Pulse Rhythm
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Rhythm is the regularity of the heartbeat.
An irregular rhythm in the pulse, caused by an
early, late, or missed heartbeat, is referred to as
a dysrhythmia or an arrhythmia.
When an irregular rhythm is detected, the apical
pulse is assessed.
An electrocardiogram (ECG) is necessary to
define the specific dysrhythmia.
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Pulse Volume
Scale Description of Pulse
0
Absent pulse
1+
Weak and thready pulse, difficult to palpate
2+
Normal pulse, able to palpate with normal
pressure
3+
Bounding pulse, may be able to see pulsation
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Skill 19-2: Assessing Pulses
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PURPOSE is to determine the baseline heart
rate and rhythm.

Monitor the heart rate and rhythm.
 Assess blood flow from the heart to the body.
 Monitor the patient for changes in physical condition.
 Monitor the patient’s response to medications.
 Monitor the patient’s response to therapy.
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Skill 19-2: Assessing Pulses
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Collaboration and delegation


Assessing a radial or peripheral pulse may be
delegated to UAPs after the initial assessment of the
patient.
Assessing an apical pulse usually is not delegated
unless the UAP has received special training. Check
with the facility’s guidelines and procedures.
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Skill 19-2: Assessing Pulses (Cont.)
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Collaboration and delegation (cont’d)
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UAPs should report the following to the nurse:
•
•
•
•
•
•
Deviations from normal pulse range
Complaints related to chest pain or discomfort
Irregular pulse, including a weak or thready pulse
Pulse less than 60 bpm or greater than 100 bpm
Difficulties in obtaining pulse (strength and/or quality)
Any changes in pulse rate, rhythm, or strength
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Skill 19-2: Assessing Pulses (Cont.)

Collaboration and delegation (Cont.)

UAPs should be instructed in:
• The appropriate technique and method required for obtaining
a pulse
• Appropriate use of equipment (verification of accurate
results, Doppler, stethoscope, electronic vital sign machines)
• Appropriate documentation
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Implementation and Evaluation



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Hand hygiene is performed before caring for a patient.
After selection of the appropriate site and method, the
pulse rate is measured.
An irregular pulse of new onset should be reported to the
primary care provider.
Interventions for an increased pulse rate include
identification and treatment of the cause.
Evaluation is accomplished by comparing the pulse rate
with baseline data or to the normal range for the age of
the patient.
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Respirations
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Respiration is the act of breathing.
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
Inspiration (inhalation) is the act of breathing in, and
expiration (exhalation) is the act of breathing out.
The process that is measured as a vital sign is
pulmonary ventilation, or respirations.
A normal respiratory rate is 12 to 20 bpm for an
adult.
The purpose of respiration is to allow the
exchange of oxygen and carbon dioxide among
the alveoli, circulating blood, and tissue cells.
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Physiology and Regulation of Breathing
and Ventilation
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
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Respiratory centers in the medulla and pons are
stimulated by impulses from chemoreceptors located
throughout the body.
Chemoreceptors located in the aortic arch and carotid
arteries are especially sensitive to low oxygen levels in
the blood (hypoxemia).
Respiratory rate and depth change on the basis of input
from these receptors, but the strongest respiratory
stimulant is an increase in carbon dioxide, which causes
an increase in respiratory rate and depth.
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Factors Affecting Respiration
Environmental or physiologic factors may
cause increases or decreases in respiratory
rate or depth.
Age
Illness processes
Exercise
Acid-base balance
Pain
Medications
Emotions
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Assessment of Respirations

Respiratory status

Assessment includes:
•
•
•
•

Breathing rate
Breathing depth
Breathing rhythm
Often includes oxygen saturation (amount of oxygen in arterial
blood) by pulse oximetry
Before assessing respirations, the nurse needs to be aware of:
•
•
•
•
The patient’s normal respiratory pattern
How the patient’s health status affects respirations
Any medications that may affect respirations
The impact of cardiovascular system factors on the respiratory
system
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Respiratory Rate
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

Normal respiration with a normal rate and depth
for the patient’s age is termed eupnea.
Tachypnea is an increase in respiratory rate to
more than 24 bpm in the adult.
Bradypnea is a decrease in respiratory rate to
less than 10 bpm in the adult.
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Depth and Quality of Respirations

Depth:



Hypoventilation is characterized by shallow
respirations.
Hyperventilation is exhibited by deep, rapid
respirations.
Quality:



Apnea is an absence of breathing; brain damage
occurs after 4 to 6 minutes of apnea.
Dyspnea is difficult, labored breathing, usually with a
rapid, shallow pattern, that may be painful.
Difficulty breathing experienced in positions other
than sitting or standing is termed orthopnea.
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Additional Respiratory Patterns
Pattern
Description
Associated Factors
CheyneStokes
respirations
Rhythmic respirations,
going from very deep to
very shallow or apneic
periods
Heart failure, renal
failure, drug overdose,
increased intracranial
pressure, impending
death
Kussmaul’s
breathing
Respirations abnormally
deep, regular, and
increased in rate
Diabetic ketoacidosis
Biot’s
breathing
Respirations abnormally
shallow for two or three
breaths, followed by
irregular period of apnea
Meningitis, severe
brain injury
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Skill 19-3 Assessing Respirations

PURPOSE is to determine the rate, rhythm,
quality, and depth of respiration.
Monitor the patient’s respirations and respiratory
changes.
 Monitor for change in the patient’s physical condition.
 Monitor the patient’s response to medications.
 Monitor the patient’s response to therapy.

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Skill 19-3 Assessing Respirations

Collaboration and delegation


Assessing a respiratory rate may be delegated to
UAP after the initial assessment of the patient.
UAPs should be instructed in:
• Appropriate technique
• Appropriate documentation
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Skill 19-3 Assessing Respirations
(Cont.)

Collaboration and delegation (Cont.)

UAPs should report any of the following findings to
the nurse:
• Difficulty breathing or any change in respiratory rate, rhythm,
or depth (report immediately)
• Patient’s complaints related to breathing difficulty or chest
discomfort
• Irregular respiratory rhythm
• Rates less than 12 or greater than 20 bpm
• Any difficulties in obtaining respiratory rates
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Oxygen Saturation



Measurement of respiratory rate is not a
measurement of how much oxygen actually
enters the bloodstream.
Saturation of peripheral oxygen, abbreviated
SpO2, reflects the percentage of hemoglobin that
combines with oxygen, usually 95% to 100%.
Cyanosis, bluish discoloration of the skin and
mucous membranes, results from decreased
oxygen levels in arterial blood.
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60
Oxygen Saturation (Cont.)

The level of consciousness is affected by
changes in oxygen levels.



Patients displaying signs of reduced oxygen require
additional assessment of mental status, activity
tolerance, and measurement of oxygen saturation.
Measurement of oxygen saturation is performed
noninvasively and painlessly by means of pulse
oximetry.
A pulse oximeter is a small device that is clipped
to a fingertip, a toe, the nose, or an earlobe, or
applied to the forehead.
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Skill 19-4: Assessing Pulse Oximetry

PURPOSE is to determine the patient’s baseline
SpO2 (saturation of peripheral oxygen).

Monitor any underlying respiratory disease.
 Monitor the patient’s recovery from anesthesia.
 Assess the patient for any change in physical
condition.
 Assess complaints of respiratory difficulty.
 Monitor patient response to medications.
 Monitor patient response to oxygen therapy.
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Skill 19-4: Assessing Pulse Oximetry
(Cont.)

Collaboration and delegation


Assessing SpO2 may be delegated to UAPs after
initial assessment of the patient.
UAP should report any of the following to the nurse:
• Readings less than 92% or other designated saturation, as
determined by the nurse or PCP
• Complaints related to breathing difficulty or chest discomfort
• Situations in which the patient is not using oxygen or it is not
at the appropriate level according to the PCP orders
• Any difficulties in procedure
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Skill 19-4: Assessing Pulse Oximetry
(Cont.)

Collaboration and delegation (Cont.)

UAPs should be instructed in:
• Appropriate placement of oximeter probe (finger, toe, bridge
of nose, earlobe, or forehead)
• Appropriate equipment use (verifying accurate results)
• Patient oxygen use and frequency of monitoring
• Appropriate documentation
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Arterial Blood Gases



Measurement of arterial blood gases (ABGs) is a
way of assessing the respiratory component of
acid-base balance and the adequacy of
oxygenation.
ABG values include the carbon dioxide level and
pH, and they are used to determine the need for
and response to treatment.
ABG studies are used to establish baseline
values, identify respiratory disorders, and
evaluate the effectiveness of interventions.
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65
Safe Practice Alert


Signs of respiratory distress include the use of
accessory muscles of the chest and neck and/or
an exaggerated effort to breathe.
Children and infants may exhibit nasal flaring or
sternal retractions if they are having trouble
breathing.
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Implementation and Evaluation



Interventions for the underlying disorder should improve
an altered respiratory pattern, and they include
positioning, supplemental oxygen, suctioning, and
medications such as bronchodilators.
Evaluation of respiration must be done in conjunction with
the other vital signs obtained and the medical status of
the patient.
A respiratory rate significantly above or below normal, any
notable changes in pattern, and inadequate oxygenation
must be reported to the PCP.
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Blood Pressure



Blood pressure can adapt to various stimuli and
still remain within a normal range.
Knowing the baseline, or usual, blood pressure
of an individual is important to be able to
interpret a single measurement in a potential
illness process.
An increase or decrease of 20 to 30 mm Hg in a
person’s blood pressure is considered a
significant change. Sustained change in blood
pressure is considered abnormal.
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Physiology of Blood Pressure

Blood pressure, the force of the blood against arterial
walls, rises as the ventricle contracts, and it falls as the
heart relaxes, creating a pressure wave through the
arterial system.




The peak of the pressure wave is systolic pressure.
The lowest pressure on arterial walls, which occurs when the
heart rests, is diastolic pressure.
The numerator, or top number, is the systolic pressure,
and the denominator, or bottom number, is the diastolic
pressure.
Pulse pressure is the difference between the diastolic
and systolic pressures.
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Physiology of Blood Pressure (Cont.)

Body regulates blood pressure

Arterioles regulate the distribution of blood to the
organs, tissues, and cells; they supply resistance.
• To respond to the body’s needs at any given moment, the
arterioles are normally partially contracted, creating
peripheral resistance.
• This resistance is a major factor affecting blood pressure.

Arteries stretch with systolic pressure and relax with
diastolic pressure; they provide compliance.
• A certain amount of pressure is always present in the
arteries.
• This constant pressure maintains a continuous flow into
capillaries rather than intermittent bursts of circulation.
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Physiology of Blood Pressure (Cont.)



The autonomic nervous system (ANS) manages
mechanisms to maintain short-term regulation of
blood pressure.
The renin-angiotensin-aldosterone system
controls vasoconstriction and water retention
that affects circulatory fluid volume.
The cardiac output is the amount of blood
pumped per minute.

An increase in cardiac output results in increased
blood pressure; a decrease in cardiac output leads to
a decrease in blood pressure.
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Hypotension

Hypotension is systolic blood pressure of




Less than 90 mm Hg
--or 20 to 30 mm Hg below the patient’s normal blood
pressure-Or diastolic blood pressure of 60 mm Hg or less
Cause = disruption in cardiovascular dynamics



Decreased blood volume (hemorrhage)
Decreased cardiac output (heart attack or heart
failure)
Decreased peripheral vascular resistance (shock).
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Hypotension (Cont.)




Orthostatic hypotension is a sudden drop of
20 mm Hg in systolic pressure and 10 mm Hg in
diastolic pressure when the patient moves from
a lying to sitting to standing position.
The low pressure occurs from peripheral
vasodilation with no rise in cardiac output for
compensation.
It occurs with aging and is a common side effect
of several medications
Other risk factors include prolonged immobility,
dehydration, and blood loss.
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Hypertension

Hypertension = elevated blood pressure




The leading cause of cardiovascular disorders
The most important risk factor for stroke
The leading cause of death in the U.S.
Origins

Dysfunction in neurohormonal system
• Overstimulation of angiotensin and aldosterone raises blood pressure
• May be permanent thickening of blood vessels, leading to peripheral
resistance

Classification


Prehypertension = 120-139 / 80-89
Higher values are stage 1 or stage 2 hypertension
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Hypertension (Cont.)



Primary (essential) hypertension occurs when
there is no known cause for the high blood
pressure.
Secondary hypertension is caused by a known
illness process, such as renal failure.
Risk factors for hypertension:
Smoking
Ongoing stress
Obesity
Sedentary
lifestyle
Family history of the disorder
Alcohol use
High-salt, high-fat-calorie diet
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Categories for Blood Pressure Levels
in Adults
Category
Systolic (mm Hg)
Diastolic (mm Hg)
Hypotension
Less than 90
Normal
Less than 120
Prehypertension
120-139
or
80-89
Stage I hypertension
140-159
or
90-99
Stage II hypertension
Greater than 160
or
Greater than 100
or
Less than 60
and Less than 80
High blood pressure
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Home Care Considerations

Lifestyle changes shown to lower blood
pressure:





Maintain normal body weight.
Adopt the Dietary Approaches to Stop Hypertension
(DASH) eating plan, which includes reduced fat intake
and increased intake of fruits and vegetables.
Reduce dietary sodium intake to 2.4 g daily.
Engage in regular aerobic physical activity at least 30
minutes a day, on most days of the week.
Limit alcohol consumption: for men, two drinks a day;
for women, one drink a day.
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77
Factors Affecting Blood Pressure
Age
Race
Emotions
Pain
Gender
Head injury
Weight
Circadian rhythm
Medications
Food intake
Increased blood volume
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78
Assessment of Blood Pressure

Measurement






During physical examination
At initial admission
With routine vital signs
When patient status changes
Requires excellent technique, correctly calibrated equipment,
and proper interpretation of the sounds obtained
Should be taken after the patient rests for at least 5
minutes and has not smoked or ingested caffeine for at
least 30 minutes before the measurement.
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79
Sites for Assessing Blood Pressure





Blood pressure can be measured in the upper or
lower extremity.
It is usually assessed manually, or indirectly.
The most common site for indirect blood
pressure measurement is the upper arm at the
brachial artery.
Use clinical judgment to choose a side.
If the brachial artery is not accessible, the
popliteal artery behind the knee can be used for
blood pressure measurement.
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Skill 19-5: Measuring Blood Pressure:
Manual and Electronic

PURPOSE is to determine the baseline blood
pressure.

Monitor blood pressure.
 Assess the heart’s pumping ability and the patency of
blood vessels.
 Monitor for changes in physical condition.
 Monitor the patient’s response to medications.
 Monitor the patient’s response to therapy.
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Skill 19-5: Measuring Blood Pressure:
Manual and Electronic (Cont.)

Collaboration and delegation


Electronic measurement of blood pressure may be
delegated to UAP after initial assessment of the
patient.
Manual measurement of blood pressure may be
delegated if the UAP has received special training.
Check the facility’s guidelines and procedures.
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Skill 19-5: Measuring Blood Pressure:
Manual and Electronic (Cont.)

Collaboration and delegation (Cont.)

UAPs should report any of the following findings to
the nurse:
• Deviations from normal range of blood pressure
• Complaints related to chest pain or discomfort
• Systolic blood pressure greater than 140 or less than 90 or
diastolic blood pressure greater than 100 or less than 70
• Difficulties in obtaining blood pressure
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Skill 19-5: Measuring Blood Pressure:
Manual and Electronic (Cont.)

Collaboration and delegation (Cont.)

UAPs should be instructed in:
• The appropriate technique and method required for the
patient
• Appropriate equipment use (verifying accurate results with
stethoscope, sphygmomanometer, electronic vital sign
devices, appropriate cuff size, and site choice)
• Sites and conditions that are contraindicated: intravenous
lines, arteriovenous (AV) fistulas or shunts, amputations,
breast surgery, and casts or bandages
• Appropriate documentation
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Skill 19-5: Measuring Blood Pressure:
Manual and Electronic (Cont.)

Evidence-Based Practice



Blood pressure does not always rise in response to emotion. The
patient’s culture may affect whether blood pressure is elevated
or lowered from normal range in response to emotion.
Automated blood pressure measurements are not always
accurate, especially in hypertensive patients and the elderly
population.
The two-step method, palpating a systolic pressure, is the most
accurate technique, especially in hypertensive and geriatric
populations in whom the auscultatory gap may be widened
considerably. When the two-step method is not used, manual
blood pressures are frequently inaccurate.
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Blood Pressure Devices

Electronic blood
pressure devices use
an electronic sensor
to detect vibrations
caused by blood
moving through the
artery.
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Nursing Care Guideline

Assessing orthostatic hypotension



Orthostatic hypotension, also known as postural
hypotension, is a condition in which there is an
abrupt decline in blood pressure when a person
moves from a supine to a sitting or standing position.
An accompanying increase in heart rate is typical.
An accurate assessment of orthostatic hypotension
requires identifying a blood pressure decline of 20
mm Hg in the systolic pressure or 10 mm Hg in the
diastolic pressure, or an increase in heart rate of 20
bpm, within 1 to 3 minutes of postural change.
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87
Nursing Care Guideline (Cont.)

Assessing orthostatic hypotension (Cont.)

Background (Cont.)
• Orthostatic hypotension can be indicative of dehydration
(leading to low blood volume) or anemia, or it may occur in
conjunction with prolonged immobilization.
• Orthostatic hypotension is most commonly due to a problem
with the autonomic nervous system and/or a delay of the
circulatory response to adjust to rapid movement.
• Symptoms may include dizziness, fainting, changes in mental
status, and anxiety. Nausea, rapid onset of pallor, and fast,
shallow breathing also are common during an episode of
orthostatic hypotension.
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Nursing Care Guideline (Cont.)

Assessing orthostatic hypotension (Cont.)

Delegation
• Assessment cannot be delegated to a UAP, but UAPs may
assist in obtaining the measurements and in positioning the
patient for safety.

Documentation concerns
• Vital signs are documented in conjunction with the position
and time.
• Any signs, symptoms, or other complaints during the
procedure should be documented.
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Nursing Care Guideline (Cont.)

Assessing orthostatic (Cont.)

Evidence-based practice
• An official diagnosis of orthostatic hypotension requires a 20
mm Hg drop in systolic blood pressure or a 10 mm Hg drop
in diastolic blood pressure, with or without symptoms, within
3 minutes of the positional change.
• There usually is a corresponding increase in heart rate,
although certain medications may prevent the heart rate from
increasing.
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Korotkoff Sounds


The sounds for which the nurse listens when
assessing blood pressure are called Korotkoff
sounds.
An auscultatory gap may occur in the latter part
of phase I and during phase II.


The auscultatory gap is the absence of Korotkoff
sounds noted in some patients after the initial systolic
pressure; the gap may cover a range as wide as 40
mm Hg.
Failure to recognize an auscultatory gap may lead to
major errors in measuring blood pressure.
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91
Korotkoff Sounds (Cont.)
Phase
Description
Phase I
The initial presentation of faint but clearly
audible tapping sounds, which gradually
increase in intensity to a thud or loud tap; the
first sound is recorded as the systolic
pressure
Phase II Muffled, swishing sounds
Phase III Crisp, loud sounds as the blood flows
through an opening artery
Phase IV A distinct, abrupt muffling sound
Phase V
The last sound heard before silence—this is
the diastolic measurement
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Implementation and Evaluation



The most common equipment used by the nurse
is a stethoscope and sphygmomanometer
(blood pressure cuff).
Blood pressure can be measured with a Doppler
stethoscope, estimated by palpation
(assessment by feeling with the hand or fingers),
or measured by an electronic, or automated,
cuff.
A stethoscope is used to hear the sounds
created by blood flowing through the artery.
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93
Blood Pressure Cuff Sizes

Cuff sizes range from
neonate to adult thigh
sizes. The width of the
cuff should be
approximately 40% of the
circumference of the
extremity being used, and
the bladder of the cuff
should be approximately
60% to 80% of the
circumference of the
extremity being used.
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Blood Pressure Assessment Errors
Inaccurate
Reading
Falsely Low Reading
Falsely High
Reading
•Defective
equipment
•Equipment
not
calibrated
•Improper
use of
equipment
•Patient not
positioned
correctly
•Hearing deficit in assessing person
•Arm positioned above heart level
•Extraneous noise in surrounding
environment
•Use of a cuff that is too wide
•Ear tips of stethoscope placed
incorrectly
•Breaks or kinks in cuff tubing
•Cuff deflated too rapidly
•Stethoscope bell not placed
directly over artery
•Failure to follow all steps in
recommended procedure
•Assessing blood
pressure too soon
after patient
smoking or exercise
•Use of a cuff that is
too narrow
•Releasing the
pressure valve too
slowly
•Reinflating the
bladder before it
has completely
deflated
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Pain




Pain is a subjective experience, and the intensity
and quality of pain are whatever the patient says
they are.
Pain may be acute (it resolves when the
underlying injury heals) or chronic (it lasts longer
than the healing period).
The perception of pain can be intensified by the
emotional state of the patient.
Poor assessment of pain is the primary barrier to
effective pain management.
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Assessment of Pain



Although pain is subjective, varying from one
patient to another and from one day to the next,
health care providers attempt to measure pain
as objectively as possible.
Pain usually is determined by asking the patient
to describe the pain and rate the pain level on a
scale.
In adult patients, this pain rating often is a
numeric measurement between 0 and 10, with 0
meaning “no pain” and a score of 10 indicating
“the worst pain imaginable.”
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Implementation and Evaluation



Choice of assessment scale important for
patient’s subjective report of pain
Physiologic and objective signs assessed
Nursing interventions to address pain:




Positioning with support
Complementary interventions
Ongoing assessment
Evaluation of pain focuses on the patient’s report
of pain relief and effectiveness of treatment.
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