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Vital Signs Temperature (T) Pulse (p) Respiration (R) Blood pressure (BP) Pain (often called the fifth vital sign)

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Presentation on theme: "Vital Signs Temperature (T) Pulse (p) Respiration (R) Blood pressure (BP) Pain (often called the fifth vital sign)"— Presentation transcript:

1 Vital Signs Temperature (T) Pulse (p) Respiration (R) Blood pressure (BP) Pain (often called the fifth vital sign)

2 VITAL SIGNS ll WHY ARE TPR BP PAIN REFERRED TO AS VITAL SIGNS?

3 TPR BP PAIN-”VITAL SIGNS” SYSTEMIC/ORGAN MANIFESTATION IMPORTANT INDICATORS OF HEALTH STATES NECESSARY IN DIFFERENTIAL DIAGNOSIS IMPORTANT IN ESTABLISHING BASELINE INDICATES IMPORTANT CHANGES CAN REFLECT IMMEDIACY OF CHANGE

4 FACTORS AFFECTING PULSE, RESPIRATION & BLOOD PRESSURE AGE BODY FLUID BLOOD PRESSURE DRUGS EXERCISE FOODS TEMPERATURE DISEASE PROCESSES PAIN

5 VITAL SIGNS ll PULSE & BLOOD PRESSURE

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; 4 th 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)

7 Sites for Assessing Pulse by Palpation

8 Question Which one of the following pulse sites is located on the inside of the elbow? A. Temporal B. Radial C. Femoral D. 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: BPM ATHLETES: may be slightly lower as in the 50’s MEN WOMEN When you have cardiovascular systems lecture, you will learn more complex interpretation of BP and Pulse

11 Characteristics of the Pulse Pulse rate –Measured in beats per minute –BRADYCARDIA –TACHYCARDIA –PULSE DEFICIT Pulse quality (amplitude) –The quality of the pulse in terms of its fullness –PULSUS ALTERANS-A WEAK PULSE ALTERNATING WITH A STRONG ONE –PULSUS PARADOXUS-DECREASE IN THE STRENGTH OF THE PULSE (& SYS BP) DURING INSPIRATION—IN ALT DIS STATES e.g. asthma Pulse rhythm –Pattern of the pulsations and the pauses between them Normally regular DYSRHTHMIA-REG-IRREG; IRREG-IRREG

12 Methods of Assessing the Pulse Palpating peripheral arteries Auscultating the apical pulse with a stethoscope Using a portable Doppler ultrasound LISTEN AND COUNT THE APICAL PULSE IN ONE FULL MINUTE COUNT PERIPHERAL PULSES IN ONE FULL MINUTE ESPECIALLY WHEN IT IS IRREGULAR

13 Palpating the Radial Pulse

14 Assessing an Apical Pulse Indications –Patient is receiving medications that alter heart rate and rhythm –A peripheral pulse is difficult to assess accurately because it is irregular, feeble, or extremely rapid Method –Count the apical rate for one full minute by listening with a stethoscope over the apex of the heart –Most reliable method for infants and small children; can be palpated with fingertips

15 BLOOD PRESSURE

16 Physiology of Blood Pressure Force of the blood against arterial walls Two 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 walls Two 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 pressure –The highest point of pressure on arterial walls when the ventricles contract Diastolic pressure –The 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 GROUPS NORMAL ADULT: <120 SYSTOLIC; <80 DIASTOLIC PREHYPERTENSION: SYSTOLIC OR DIASTOLIC HYPERTENSION STAGE 1: SYSTOLIC OR DIASTOLIC HYPERTENSION STAGE 2: =OR >160 SYSTOLIC OR =OR >100 DIASTOLIC HYPOTENSION: LOWER THAN NORMAL BP (80/40)

22 Blood Pressure Assessment (Methods) Using a stethoscope and sphygmomanometer Using a Doppler ultrasound Estimating by palpation Assessing with electronic or automated devices

23 Equipment for Assessing Blood Pressure Stethoscope and sphygmomanometer Doppler ultrasound Electronic or automated devices

24 TECHNIQUE IN MEASURING BLOOD PRESSURE, continued ASSESSMENT SELECT APPROPRIATE LOCATION TO MEASURE BP ASSESS FOR BREAST OR AXILLARY SURGERY HX, LIMB WEAKNESS (HX STROKE) PRESENCE OF CAST, IV INFUSION SITE PRESENCE OF DIALYSIS SHUNT OR ANY DEVICE ON LIMBS PRESENCE OF WOUNDS, RASHES, LESIONS ASSESS SIZE OF LIMB

25 TECHNIQUE IN MEASURING BLOOD PRESSURE GATHER EQUIPMENT: STETHOSCOPE SPHYGMOMANOMETER WITH CUFF THAT IS CORRECT SIZE FOR PATIENT PEN AND PAPER TO RECORD READING ALCOHOL SWAB TO CLEAN STETHOSCOPE PPE AS INDICATED

26 CUFF SIZE SPHYGMOMANOMETER 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 ORDERS PERFORM HAND HYGIENE IDENTIFY THE PATIENT PROVIDE PRIVACY PPE AS INDICATED SELECT APPROPRIATE ARM FOR CUFF APPLICATION SUPINE OR SITTING POSITION

28 TECHNIQUE IN MEASURING BLOOD PRESSURE, continued IF THE PATIENT IS IN A SITTING POSITION HAVE PATIENT/CLIENT LEAN BACK IN THE CHAIR, SUPPORT HER BACK UNCROSS LEGS ARM SHOULD BE AT LEVEL OF THE HEART PALM UPWARD

29 TECHNIQUE IN MEASURING BLOOD PRESSURE, continued IF THE PATIENT IS IN A SUPINE POSITION SUPPORT 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 ARTERY The 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 PATIENT PLACE THE STETHOSCOPE EARPIECES IN YOUR EARS PLACE THE DIAPHRAGM OF THE STETHOSCOPE OVER THE BRACHIAL ARTERY PUMP THE PRESSURE 30 mm Hg ABOVE THE POINT AT WHICH THE FIRST SYSTOLIC WAS ESTIMATED OPEN 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 Hg DO 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 PRESSURE ALLOW THE REMAINING AIR TO ESCAPE QUICKLY REPEAT 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 RECORD REPORT ABNORMAL FINDINGS TO THE APPROPRIATE PERSON IDENTIFY THE BP SITE, PATIENT POSITION EXAMPLE: 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 fraction –The numerator is the systolic pressure –The denominator is the diastolic pressure Pulse pressure –The difference between the systolic and diastolic pressure –MAP: MEAN ARTERIAL PRESSURE (SYSTOLIC + TWICE THE DIASTOLIC DIVIDED BY THREE)

37 Ensuring an Accurate BP Reading CONTRIBUTING CAUSES FOR FALSE LOW READING HEARING DEFICIT, NOISE PUTTING EARPIECE OF STETHOSCOPE INCORRECTLY RELEASING VALVE TOO QUICKLY INCORRECT PLACEMENT OF STET DIAPHRAGM TOO WIDE CUFF FAILING TO PUMP CUFF mmHg ABOVE DISAPPEARANCE OF PULSE

38 Ensuring an Accurate BP Reading CONTRIBUTING CAUSES TO FALSELY HIGH ASSESSMENT USING A MANOMETER NOT CALIBRATED AT ZERO MARK CUFF TOO NARROW RELEASING THE VALVE TOO SLOWLY ASSESSING BP IMMEDIATELY AFTER EXERCISE, SMOKING WITHIN 30 MINUTES, RECENT CAFFEINE INTAKE REINFLATING THE BLADDER DURING AUSCULATION

39 Factors Affecting Blood Pressure Age Exercise Position Weight Fluid balance Smoking Medications

40 Occasions for Measuring Vital Signs Screenings at health fairs and clinics In the home Upon admission to a healthcare setting When certain medications are given Before and after diagnostic and surgical procedures Before and after certain nursing interventions In emergency situations


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