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; 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)

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: 60-100 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