Presentation on theme: "Vital Signs Temperature (T) Pulse (p) Respiration (R)"— Presentation transcript:
1 Vital Signs Temperature (T) Pulse (p) Respiration (R) Blood pressure (BP)Pain (often called the fifth vital sign)
2 VITAL SIGNS llWHY ARE TPR BP PAINREFERRED TOAS VITAL SIGNS?
3 TPR BP PAIN-”VITAL SIGNS” SYSTEMIC/ORGAN MANIFESTATIONIMPORTANT INDICATORS OF HEALTH STATESNECESSARY IN DIFFERENTIAL DIAGNOSISIMPORTANT IN ESTABLISHING BASELINEINDICATES IMPORTANT CHANGESCAN REFLECT IMMEDIACY OF CHANGE
6 What is pulse“The pulse is the bounding of blood flow in an artery that is palpable at various points of the body. It is caused by the stoke volume ejected during systole and distension of the walls of the aorta, which creates a pulse wave as it travels rapidly towards the distal end of the arteries.” (DeLaune & Ladner, Fundamentals of Nursing; 4th ed. P.505)Superficial peripheral pulses can be palpated over a muscle or bone.Pulse pressure is a measurement of the ratio of stroke volume to compliance of the arterial system (systolic BP minus diastolic BP)
8 QuestionWhich one of the following pulse sites is located on the inside of the elbow?A. TemporalB. RadialC. FemoralD. Brachial
9 Answer Answer: D. Brachial Rationale: The brachial pulse site is located on the inner elbow.The temporal site is located on the side of the head, the radial site is on the wrist, and the femoral site is located on the groin.
10 Normal pulse rate NORMAL Adult: 60-100 BPM ATHLETES: may be slightly lower as in the 50’sMENWOMENWhen you have cardiovascular systems lecture, you will learn more complex interpretation of BP and Pulse
11 Characteristics of the Pulse Pulse rateMeasured in beats per minuteBRADYCARDIATACHYCARDIAPULSE DEFICITPulse quality (amplitude)The quality of the pulse in terms of its fullnessPULSUS ALTERANS-A WEAK PULSE ALTERNATING WITH A STRONG ONEPULSUS PARADOXUS-DECREASE IN THE STRENGTH OF THE PULSE (& SYS BP) DURING INSPIRATION—IN ALT DIS STATES e.g. asthmaPulse rhythmPattern of the pulsations and the pauses between themNormally regularDYSRHTHMIA-REG-IRREG; IRREG-IRREG
12 Methods of Assessing the Pulse Palpating peripheral arteriesAuscultating the apical pulse with a stethoscopeUsing a portable Doppler ultrasoundLISTEN AND COUNT THE APICAL PULSE IN ONE FULL MINUTECOUNT PERIPHERAL PULSES IN ONE FULL MINUTE ESPECIALLY WHEN IT IS IRREGULAR
14 Assessing an Apical Pulse IndicationsPatient is receiving medications that alter heart rate and rhythmA peripheral pulse is difficult to assess accurately because it is irregular, feeble, or extremely rapidMethodCount the apical rate for one full minute by listening with a stethoscope over the apex of the heartMost reliable method for infants and small children; can be palpated with fingertips
16 Physiology of Blood Pressure Force of the blood against arterial wallsTwo factors determine blood pressure: cardiac output and peripheral vascular resistance.
17 Physiology of Blood Pressure Cardiac output is the volume of blood pumped by the heart in one minute. (stroke volume x heart rate)Peripheral vascular resistance is the force in the blood vessel that the ventricle must overcome to eject the blood from the heart.
18 REVIEW-Physiology of Blood Pressure Force of the blood against arterial wallsTwo factors determine blood pressure: cardiac output and peripheral vascular resistance.Cardiac output is the volume of blood pumped by the heart in one minute. (stroke volume x heart rate)Peripheral vascular resistance is the force in the blood vessel that the ventricle must overcome to eject the blood from the heart.Resistance to blood flow is determined by the diameter of the blood vessel and blood viscosity.Controlled by a variety of mechanisms to maintain adequate tissue perfusion (brain, kidneys, cardiovascular system)
19 Blood Pressure The force of the blood against arterial walls Systolic pressureThe highest point of pressure on arterial walls when the ventricles contractDiastolic pressureThe lowest pressure present on arterial walls during diastole is the diastolic pressure (Taylor, 2007).
20 Physiology of Blood Pressure Resistance to blood flow is determined by the diameter of the blood vessel and blood viscosity.Controlled by a variety of mechanisms to maintain adequate tissue perfusion (brain, kidneys, cardiovascular system)
21 NORMAL & ABNORMAL BLOOD PRESSURE NORMAL BLOOD PRESSURE READINGS VARY WITH DIFFERENT AGE GROUPSNORMAL ADULT: <120 SYSTOLIC; <80 DIASTOLICPREHYPERTENSION: SYSTOLIC OR DIASTOLICHYPERTENSION STAGE 1: SYSTOLIC OR DIASTOLICHYPERTENSION STAGE 2: =OR >160 SYSTOLIC OR =OR >100 DIASTOLICHYPOTENSION: LOWER THAN NORMAL BP (80/40)
22 Blood Pressure Assessment (Methods) Using a stethoscope and sphygmomanometerUsing a Doppler ultrasoundEstimating by palpationAssessing with electronic or automated devices
23 Equipment for Assessing Blood Pressure Stethoscope and sphygmomanometerDoppler ultrasoundElectronic or automated devices
24 TECHNIQUE IN MEASURING BLOOD PRESSURE, continued ASSESSMENTSELECT APPROPRIATE LOCATION TO MEASURE BPASSESS FOR BREAST OR AXILLARY SURGERY HX, LIMB WEAKNESS (HX STROKE)PRESENCE OF CAST, IV INFUSION SITEPRESENCE OF DIALYSIS SHUNT OR ANY DEVICE ON LIMBSPRESENCE OF WOUNDS, RASHES, LESIONSASSESS SIZE OF LIMB
25 TECHNIQUE IN MEASURING BLOOD PRESSURE GATHER EQUIPMENT:STETHOSCOPESPHYGMOMANOMETER WITH CUFF THAT IS CORRECT SIZE FOR PATIENTPEN AND PAPER TO RECORD READINGALCOHOL SWAB TO CLEAN STETHOSCOPEPPE AS INDICATED
26 CUFF SIZESPHYGMOMANOMETER CUFF SHOULD HAVE BLADDER WIDTH THAT IS AT LEAST 40% OF THE ARM CIRCUMFERENCE BETWEEN THE ACROMIAL PROCESS AND THE OLECRANON.THE LENGTH OF THE CUFF SHOULD BE AT LEAST 80% OF THE ARM CIRCUMFERENCE MIDWAY BETWEEN THE ACROMION AND THE OLECRANON
27 TECHNIQUE IN MEASURING BLOOD PRESSURE, continued CHECK PHYSICIAN’S ORDERSPERFORM HAND HYGIENEIDENTIFY THE PATIENTPROVIDE PRIVACYPPE AS INDICATEDSELECT APPROPRIATE ARM FOR CUFF APPLICATIONSUPINE OR SITTING POSITION
28 TECHNIQUE IN MEASURING BLOOD PRESSURE, continued IF THE PATIENT IS IN A SITTING POSITIONHAVE PATIENT/CLIENT LEAN BACK IN THE CHAIR, SUPPORT HER BACKUNCROSS LEGSARM SHOULD BE AT LEVEL OF THE HEART PALM UPWARD
29 TECHNIQUE IN MEASURING BLOOD PRESSURE, continued IF THE PATIENT IS IN A SUPINE POSITIONSUPPORT THE ARM WITH A PILLOW, AT THE LEVEL OF THE HEART, PALM UPWARD
30 Proper Positioning for Blood Pressure Assessment
31 TECHNIQUE IN MEASURING BLOOD PRESSURE, continued INFLATE THE CUFF WHILE CONTINUING TO PALPATE THE ARTERYThe point where the pulse disappears provides an estimate of the systolic pressure. To identify the first KOROTKOFF sound accurately, the cuff must be inflated 20-30mm above the point at which the pulse is no longer felt.DEFLATE THE CUFF AND WAIT ONE MINUTE
32 TECHNIQUE IN MEASURING BLOOD PRESSURE, continued ASSUME A POSITION THAT IS NOT 3 FEET AWAY FROM THE PATIENTPLACE THE STETHOSCOPE EARPIECES IN YOUR EARSPLACE THE DIAPHRAGM OF THE STETHOSCOPE OVER THE BRACHIAL ARTERYPUMP THE PRESSURE 30 mm Hg ABOVE THE POINT AT WHICH THE FIRST SYSTOLIC WAS ESTIMATEDOPEN THE VALVE ON THE MANOMETER AND ALLOW THE AIR TO ESCAPE SLWLY (GAUGE DROP 2 T0 3 mm/sec)
33 TECHNIQUE IN MEASURING BLOOD PRESSURE, continued NOTE THE POINT ON THE GAUGE AT WHICH THE FIRST FAINT, BUT CLEAR, SOUND APPEARS THAT SLOWLY INCREASES IN INTENSITY.NOTE THIS NUMBER AS THE SYSTOLIC PRESSURE.READ THE PRESSURE TO THE CLOSEST 2 mm HgDO NOT REINFLATE THE CUFF ONCE THE AIR IS BEING RELEASED TO CHECK THE SYSTOLIC READING
34 TECHNIQUE IN MEASURING BLOOD PRESSURE, continued NOTE THE POINT AT WHICH THE SOUND COMPLETELY DISAPPEARS. THIS GENERALL CONSIDERED AS THE DIASTOLIC PRESSUREALLOW THE REMAINING AIR TO ESCAPE QUICKLYREPEAT ANY SUSPICIOUS READING, BUT WAIT AT LEAST ONE MINUTE.REMOVE CUFF REMOVE PPE.CLEAN STETHOSCOPE WITH ALCOHOL
35 TECHNIQUE IN MEASURING BLOOD PRESSURE, continued RECORD THE FINDINGS ON THE PAPER, OR FLOWCHART OR ON COMPUTERIZED RECORDREPORT ABNORMAL FINDINGS TO THE APPROPRIATE PERSONIDENTIFY THE BP SITE, PATIENT POSITIONEXAMPLE:8/17/ BP TAKEN RIGHT ARM 120/80, SITING.
36 Measuring Blood Pressure Blood pressure is measured in millimeters of mercury (mm Hg)Blood pressure is recorded as a fractionThe numerator is the systolic pressureThe denominator is the diastolic pressurePulse pressureThe difference between the systolic and diastolic pressureMAP: MEAN ARTERIAL PRESSURE (SYSTOLIC + TWICE THE DIASTOLIC DIVIDED BY THREE)
37 Ensuring an Accurate BP Reading CONTRIBUTING CAUSES FOR FALSE LOW READINGHEARING DEFICIT, NOISEPUTTING EARPIECE OF STETHOSCOPE INCORRECTLYRELEASING VALVE TOO QUICKLYINCORRECT PLACEMENT OF STET DIAPHRAGMTOO WIDE CUFFFAILING TO PUMP CUFF mmHg ABOVE DISAPPEARANCE OF PULSE
38 Ensuring an Accurate BP Reading CONTRIBUTING CAUSES TO FALSELY HIGH ASSESSMENTUSING A MANOMETER NOT CALIBRATED AT ZERO MARKCUFF TOO NARROWRELEASING THE VALVE TOO SLOWLYASSESSING BP IMMEDIATELY AFTER EXERCISE, SMOKING WITHIN 30 MINUTES, RECENT CAFFEINE INTAKEREINFLATING THE BLADDER DURING AUSCULATION
40 Occasions for Measuring Vital Signs Screenings at health fairs and clinicsIn the homeUpon admission to a healthcare settingWhen certain medications are givenBefore and after diagnostic and surgical proceduresBefore and after certain nursing interventionsIn emergency situations