Vital Signs or Cardinal Signs Body Temp, BP, Respiration, Pulse, and Pain Physiologic status of a person is reflected

ected by these indicators of body functions Checked to monitor body functions and functions that might not be observed Evaluated based on clients present and prior health status. When and how often: main nursing judgment depending on the clients health status and Physicians order.

5 Factors of Heat Production 1. Basal Metabolic Rate (Food Metabolism & Activity) Rate of energy utilization in the body. w/ age (Younger BMR) Muscle Activity BMR (including Shivering) Thyroxine Output rate of cellular metabolism; effect is Chemical Thermogenesis Hormones: Epinephrine & Norepinephrine(SNS Stimulation or Stress Response) Directly affect muscle and liver cells thus rate of cellular metabolism Fever - rate of cellular metabolism thus, temperature

2.

3.

Vital Signs are commonly assessed or Time to Assess 1. 2. 3. 4. 5. 6. Home Screenings at Health Fair Clinics Upon Admission to obtain baseline data. Before and after medications are given that could affect Respiratory & Cardiovascular System. Before & after diagnostic & surgical procedures Before & after nursing interventions that could affect v/s (ex. ambulating a client who has been on bed rest b/c he may have activity intolerance) During Emergency Situations (change in health status or s/s of chest pain or feeling hot or faint) 4.

5.

5 Process of Heat Loss 1. Radiation Transfer of heat on the surface of one object to the surface of another object w/o contact Mostly inform of infrared rays Conduction Transfer of heat to lower surface temperature; w/ contact between 2 surfaces Ex. Body immersed in cold water. Convection Loss of heat by the movement of air currents (ex. TSB) Evaporation or Vaporization Water to Steam Continuous evaporation of moisture from Respiratory Tract, Mucosa of mouth and skin. Elimination defecation and urination

7.

Delegation to UAP - RN must have assessed and determined that client is stable and v/s measurements are routinely for the client. Purposes of assessing V/S to Clients 1. 2. 3. To obtain baseline data Assess the response to a treatment or medication Monitor condition after surgery or invasive procedures 2.

3.

Body Temperature Measured in Degree Celsius / Fahrenheit Balance between heat produced & heat lost from the body. Body continually produces heat as a product of metabolism. When amount of heat produced = amount of heat lost, the person is in Heat Balance. 4.

5.

2 Kinds of Body Temperature 1. Surface Temperature Temperature of Skin, Subcutaneous Tissue, Fats May or in response to environment Site of Measurement: Oral and Axillary Core Temperature Temperature of Deep Tissues (Abdominal & Pelvic Cavity) which is relatively constant. Site of Measurement: Tympanic Membrane & Rectal

Regulation of Body Temperature Controlled by Hypothalamus Most sensory receptors are in the skin and skin detects cold more than warmth. 3 Physiologic processes occurs that Body Temp when a person is chilled a. Shivering b. Sweating c. Vasoconstriction

2.

Factors affecting Body Temperature 1. AGE With age. Infants & children must be protected from temperature extremes. Elders is at high risk of Hypothermia due to the ff: a. lack of activity b. loss of subcutaneous tissue c. inadequate diet d. decrease thermo regulatory efficiency SEX Women Hormone Progesterone during ovulation Body Temp to 0.3 C 0.6 C (0.5 F 1.0 F) EXCERICSE BT to 38.3 C 40 C (101 104 F) rectally EMOTIONS OR STRESS BT d/t SNS Stimulation increases production of epinephrine & norepinephrine Common to Stressed & Anxious clients TEMPERATURE EXTREMES BT in Warm Environment BT in Cold Environment (pay attention to mentally incapacitated clients who cant dress themselves)

6.

DIURNAL VARIATIONS /TIME OF DAY/ CIRCARDIAN RHYTHMS BT usually changes throughout the day at 1C or 1.8 F BT 8pm to midnight BT 4am to 6am at sleep

2.

3.

4.

5.

Sites for Body Temperature SITE PRIOR INSERTION ADVANTAGES DISADVANTAGES THERMOMETER PLACEMENT AND DURATION Place bulb on either side of Frenulum for 3 minutes. When checking temp using mercurial glass thermometer, check the triangular shape silver in color at eye level

Oral (Surface)

If client ingested hot or cold food or liquids and smoked a cigarette, wait for 30 minutes prior insertion.

Most frequently used Most Convenient Accessible

Inaccurate if client has just ingested hot or cold fluids or food or smoked Contraindicated to the ff Patient 1. Children below 3 y/o 2. PT with oral surgery & oral problems 3. Seizure Prone 4. Unconscious 5. Irrational 6. PT with Oxygen and Mouth Breathers Least accurate when assessing a fever For Patients with 1. Oral Problems 2. Oral Inflammation 3. Wired Jaw 4. Oral Surgery Contraindicated: Breast Surgery Invasive and Uncomfortable Difficult for PT who cant turn sideways Contraindicated to the ff PT: 1. Heart Problems (CHF or MI results to Vagal Stimulation = Bradycardia) 2. Hemorrhoids (more on elders) 3. Diarrhea 4. Clotting disorder 5. Immunosupressed ( infection) 6. Can injure rectum after rectal surgery.

Axillary (Surface)

For Newborns, Infants, Toddlers, and Children: Check agency protocol first

Safer than oral method and non invasive. Also a preferred site for Newborns

Pat axilla dry with towel if very moist then place bulb at the center of axilla for 7 - 10 minutes

Rectal (Core)

Check In Newborns 1. Patency of anus 2. Stool may interfere placement of thermometer

Most accurate and reliable route Preferred Site for Newborns

Position: Prone / Lateral or Sims Lubricate tip with KY Jelly Instruct client to take a slow deep breath during insertion for 2 3 mins a. 1 inches (3-5cm) in Adults b. 1 inch in Children *Never force thermometer when resistance is felt* Adult: Pull Pinna Up and Back 3 y/o & below: Down and Back Insert probe slowly using circular motion until snug for 2 secs

Tympanic (Core)

Check presence of cerumen (mostly in elders)

Accessible, Very Fast, Less Invasive Abundant Arterial Blood Supply Accurate route for Febrile Infants

Risk of injuring the membrane if probe is inserted too far Presence of cerumen affects reading (more on elders) Repeated measurements vary (Right and Left ear can differ) Contraindicated to the ff PT: 1. Earache 2. Ear Drainage 3. Scarred Tympanic expensive or unavailable; Technique needed in client has perspiration on the forehead

TEMPORAL ARTERY

Safe & non invasive; Very fast Useful for infants

Site: Forehead

Assessment Findings or Alterations in Body Temperature Febrile with fever; Afebrile w/o fever Normal Temp 36.5 37.5 (36.9 no more than 37.3; 37.5 warning sign) Primary Alterations in Body Temp 1. 2. 3. Pyrexia (Fever) above usual range (38 40.5C) Hyperpyrexia (High fever) 41C (42C Death) Hypothermia below usual range (<36C; if <34C = death)

3.

Absence of Chills Warm Skin Photosensitivity Glassy eyed appearance Increased Thirst Mild to Severe Dehydration Drowsiness, Restlessness, Delirium, Seizure Loss of Appetite Malaise, Weakness, Aching muscles

Types of fever 1. Intermittent - temp alternates at regular intervals between fever & normal/subnormal temperatures (ex. Malaria) Remittent wide range of temp fluctuations >2Celsius that occurs over 24 hours (ex. cold or influenza) Relapsing - short febrile periods (1/2 days of normal temp) Constant temp fluctuates minimally but always remains above normal (ex. occurs in typhoid fever) Resolution of Pyrexia by Crisis - fever then returns to normal Fever Spike temp that rises to fever level rapidly following normal temperature then returns to normal after a few hours; d/t bacterial infections

Defervescence or Fever Abatement or Flush Phase Skin appears flushed and feels warm Sweating Decreased Shivering Possible Dehydration

2.

Nursing Interventions for Clients with Fever 1. 2. 3. Monitor V/S Assess Skin Color and Temp Monitor WBC, Hematocrit, and other pertinent reports for indications of infection or dehydration. 4. Remove excess blankets when client feels warm, but provide extra warmth when client feels chilled 5. Provide 2, 500 3,000 ml of fluids per day to prevent dehydration 6. Measure intake and output 7. Physical activity to limit heat production 8. Administer Antipyretics (reduces fever) as ordered 9. Provide oral hygiene to moisten mucous membranes 10. Provide TSB to heat loss thru conduction 11. Provide dry clothing and linens HYPOTHERMIA 3 Physiologic mechanisms of Hypothermia

3. 4.

5.

6.

Heat Exhaustion D/t excessive heat and dehydration S/S: Paleness, dizziness, nausea, vomiting, fainting, and moderately increased temp (101F 102F)

Heat Stroke D/t hot weather S/s: Warm, flushed skin, often dont sweat, temp of 106F or higher and may be delirious, unconscious, or having seizures.

a. b. c.

Excessive Heat Loss Inadequate Heat production to counteract heat loss Impaired hypothalamic regulation

Induced Hypothermia deliberate lowering of body temp to increase need of oxygen by body tissues such as during surgeries. Accidental Hypothermia d/t exposure to cold environment, immersion in cold water, and lack of adequate clothing, shelter, or heat. Clinical Manifestations of Hypothermia

Clinical Signs or Manifestations of Fever 1. Onset / Cold or Chill Phase Heart Rate, RR, RR depth Shivering Pallid, Cold Skin Feeling cold Cyanotic Nail Beds Gooseflesh Skin Absence of Sweating Course / Plateau Phase RR and PR

2.

BT, PR, RR Severe Shivering (INITIAL) Feeling cold and chills Pale Frostbite (nose, fingers, toes) Hypotension Urinary Output

Muscle Coordination Disorientation, Drowsiness progressing to coma

2. 3.

Position Client (prone, lateral or sims, or side lying with knees flexed if rectal) Place Thermometer in the appropriate site

Nursing Interventions for Hypothermia 1. 2. 3. 4. 5. 6. 7. Provide warm environment Provide dry clothing Apply warm blankets Keep limbs close to body Cover scalp with cap or turban Supply warm oral or intravenous fluids Apply warming pads

4.

Wipe from bulb to end If rectal, lubricate with KY Jelly

Apply protective sheath or cover if appropriate Wait for appropriate amount of time a. Oral 3 mins b. Rectal 2 to 3 mins c. Axilla 10 mins d. Tympanic 2 secs

5. 6. 7. 8. 9.

Types of Thermometer 1. 2. 3. 4. 5. Electronic Thermometer (reading at 2 6 secs) Chemical Disposable Temperature Sensitive Skin Tape (for surface temp; useful @ home where temp to be monitored) Infrared Thermometer (for core temp; @ tympanic) Temporal Artery Thermometer (forehead)

Electronic and Tympanic thermometer will indicate complete reading via light or tone

Conversion of Temp Celsius Fahrenheit Celsius = (F 32) x 5/9 Fahrenheit Celsius F = (C x 9/5) + 32 Assessing Body Temp Purpose 1. 2. 3. Obtain Baseline Data for ff evaluation Check if core temp is within normal range (36.5 37.5) Determine if core temp changes in response to medications and therapies (antipyretics, immunosuppressive therapy, invasive procedures)

Check package instructions prior reading chemical dot or tape thermometer Remove Thermometer, Discard Cover or Wipe with tissue from End to Bulb Read Temperature (if temp is too high or low or inconsistent with PTs condition, recheck with a new thermometer) Wash Thermometer with soap and warm water Return to storage location Document in PT record.

Assess 1. 2. 3. Signs of Pyrexia/ Fever and Hypothermia Appropriate Site for Measurement (oral, axillary, rectal, or tympanic) Factors that can alter core body temp (see above)

Assemble Equipment and Check if functioning properly

Thermometer and Thermometer Sheath or Cover Towel for Axilla Tissues or Wipes (to wipe thermometer) Lubricant (KY Jelly if rectal)

Procedure 1. Introduce, Verify, Explain, Client Privacy

Respiration act of breathing Inhalation / Inspiration breathing in; intake of air into the lungs

Exhalation / Expiration breathing out; movement of gases from the lungs to the atmosphere. Two Types of Breathing 1.) Costal (Thoracic) Breathing Involves external intercostals muscles & accessory muscles such as sternocleidomastoid Observed by the up and down chest movements. Diaphragmatic (Abdominal) Breathing Involves contraction& relaxation of diaphragm. Observed by the movement of abdomen

Medications (narcotics such as morphine; large doses of barbituarates such as secobarbital sodium depress respiratory centers) Intracranial Pressure Supine suppress respiration by a.) Volume of blood inside thoracic cavity b.) Compression of chest. Poor lung ventilation, which predispose them to stasis of fluids and subsequent infections.

IMPORTANT: Adult sleeping respirations can fall to fewer than 10 shallow breaths. Use other vital signs to validate condition. Assessment of Respiratory Rate

2.)

1.

Respiratory Rate breaths per minute Age Group Newborn Adults Respiratory Range 30 60 breaths per min Ave: 35 12 20 breaths per min Ave: 18

Mechanics and Regulation of Breathing During Inhalation diaphragm contracts (flattens), ribs move up & down, sternum moves outward thus, enlarging thorax & permits lungs to expand. During Exhalation diaphragm relaxes, ribs move downward & inward, sternum moves inward, thus, decreases the size of thorax as lungs are compressed. Respiration is controlled by a. Respiratory Centers in Medulla Oblongata & Pons b. Chemoreceptors located centrally in Medulla and peripherally in Carotid and Aortic Bodies.

Age Group (Sir Roy) Respiratory Range Newborn 40 59 bpm 2 months 1 yr 30 49 bpm 1 yr to 5 mos 20 39 bpm Adults 12 20 (Main is 16 20 bpm) >50 bpm in Newborns Pretachypnea; fast breathing Assessment Findings

Assessing Respirations Assess when PT is relaxed b/c exercise RR. Anxiety RR and Depth Assess after exercise to identify clients tolerance to activity 1. 2. 3. 4. 5. 2. 1. 2. 3. 4. Clients normal breathing pattern Clients respiration problems Medications / Therapies that may affect respirations Relationship of clients respiration to Cardio Function. Eupnea normal, effortless breathing Hyperpnea deeper respiration with normal rate. Tachypnea - RR > 24bpm; fast respirations Bradypnea - RR <10bpm; slow respirations Apnea cessation of breathing or respirations. Respiratory Rhythms Regulation of inspiration and expiration Normal Rhythm is EVENLY SPACED. a. Regular effortlessly quiet b. Irregular abnormal rhythm

Prior assessment nurse should be aware of the ff:

Factors affecting Respirations 1. 2. Increases RR Exercise (increases metabolism) SNS Stimulation (Stress / Emotion) Environmental Temperature Low Oxygen Concentration at Altitudes High Carbon Dioxide Decreases RR with age environmental temperature

Abnormal Rhythms or Irregular Rhythms a. b. c. d. 3. Cheyne Stokes respirations become faster and deeper with alternate periods of Apnea Biots respirations become faster and deeper with abrupt pauses between each breath. Kausmals respirations become faster and deeper in between panting. Apneustic prolonged grasping of air. Respiratory Character or Quality a. Amount of effort a client must exert to breathe b. Breath sounds

Ease and Effort 1. 2. Dyspnea difficulty of breathing (DOB) Orthopnea difficult of breathing unless standing or in upright standing or sitting position.

*Chest Indrawings clients skin between ribs bumabaon; fast breathing; @ base of neck; observe at 1 full minute. 3. 4. 5. 6. 7. 8. Chest Pain Cerebral Anoxia (irritability, restlessness, LOC) Position for breathing (orthopneic position) Dyspnea / DOB Activity Intolerance Medications affecting RR

Breath Sounds (Normal is SILENT) 1. 2. 3. Stridor high pitch, shrill, or harsh sound during inspiration with laryngeal obstruction. Stretor snoring; partial obstruction of upper airway. Wheezing whistling, sighing, high pitched musical squeak during expiration & sometimes inspiration when air moves through a narrowed or partial obstructed airway. Bubbling gurgling sounds heard as air passes through moist secretions in respiratory tract. Rales air passing to mucus or fluids during inhalation. Rhonchi air passing to fluids, edema, muscle spasm during exhalation. Respiratory Depths assess by watching chest movements a. Normal - normal inspiration & expiration; 500 ml b. Deep large volume of air is inhaled & exhaled expansion of lungs c. Shallow small volume of air is inhaled & exhaled, minimal use of lung. Respiratory Volume a. Hyperventilation overexpansion of the lungs; rapid & deep breaths. b. Hypoventilation underexpansion of the lungs; slow, shallow breaths.

Delegation counting and observing respirations may be delegated to UAP. The follow up assessment, interpretation of abnormal respirations, and determination of appropriate responses are done by the nurse. Assemble Equipment watch with 2nd hand indicator Procedure 1. 2. Identify, Verify, Explain, Hand Hygiene, client privacy Palpate and Count RR Clients awareness that nurse is counting the RR could cause client to purposefully alter RR pattern. IF ANTICIPATED, place hand on clients chest to feel the movements with breathing OR Place clients arm across chest and observe chest movements while supposedly taking radial pulse. Count RR for 60 seconds (1 full minute). Inhalation and Exhalation counts as 1 respiration Observe depth, rhythm, char of respirations (ease & effort; breath sounds) a. Depth assess movements of chest (deep, shallow, normal) b. Rhythm regular or irregular (normally respirations are evenly spaced) c. Character of Respirations normally respirations are silent and effortless Document on the clients record (depth, rhythm, char of respi)

4. 5. 6.

4.

5.

3.

Secretions and Coughing 1. 2. 3. Hemoptysis blood in the sputum Productive Cough with expectorated secretions Nonproductive Cough dry, harsh, no secretions 4. SKILL: Assessing Respirations Purposes 1. 2. 3. 4. 5. Obtain Baseline Data Monitor abnormal respirations and respiratory patterns Monitor respirations before & after medications Monitor respirations after general anesthesia Monitor clients at risk for Respiratory alterations (ex. Asthma, COPD)

Assessment 1. 2. Skin Color (Cyanosis, Pallor) Chest Movements a. Intercostal Retractions indrawing between ribs b. Substernal Retractions beneath breastbone c. Suprasternal Retractions above clavicles

PULSE Pulse Wave of blood created by the contraction of the Left Ventricle. Stroke Volume amount of blood that enters the arteries with each contraction; Liter (Volume) Compliance ability of the arteries to contract & expand. Cardiac Output Volume of blood pumped into the arteries by the heart and equals the result of stroke volume. (ex. Stroke Volume x Heart Rate per minute; 65ml x 70 bpm = 4.55 liters per minute) Adult pumps 5L blood per minute. In a healthy person, pulse reflects the heartbeat; that is pulse rate is same w/ heartbeat except in clients with Cardio Diseases (ex. clients heart may produce very weak pulse that is not detectable by peripheral pulse sites. In these instances, assess apical pulse and peripheral pulse. 2.

Children between 4 6 y/o Midclavicular Line Children below 4y/o left of midclavicular line

Function of Apical Pulse 1. 2. 3. Newborns to 3y/o (d/t irregular peripheral pulse sites) If theres discrepancies with radial pulse Used in conjunction with some medications.

3.

Temporal Superior and lateral to the eye; passes temporal artery Function: Used when radial nerve is not accessible; to check circulation to the brain. Carotid At the side of the neck, where carotid artery runs *Never press both carotids at the same time it leads to reflex drop of Blood Pressure & Pulse Rate* Functions: a. During Cardiac Arrest or Shock in Adults b. Determines circulation to the brain. Brachial Medially in Antecubital Space Functions: a. For blood pressure b. During Cardiac Arrest of Infants Radial Thumb side of the wrist where radial artery runs Functions: Readily Accessible; Most commonly used in adults Never use thumb during palpation. Thumb has a pulse. Femoral Where femoral artery passes alongside inguinal ligament Functions a. During Cardiac Arrest and Shock b. Determines circulation to leg (lower extremities) Popliteal Where popliteal artery passes behind the knee Function: determines circulation to lower leg Posterior Tibial Medial surface of ankle where posterior tibial artery passes. Function: Determines circulation to the foot. Dorsalis Pedis (Pedal) Where dorsalis pedis artery passes; at the middle of the ankle to the space between big and second toe. Function: Determines circulation to the foot.

4.

Factors Affecting Pulse beats per minute (BPM) 1. 2. Age - As age , PR gradually Sex / Gender - After puberty, average males PR is than females. Exercise PR Professional athletes PR is than average person b/c of greater cardiac size, strength, and efficiency. 6. 4. Fever in response to BP d/t peripheral vasodilation associated w/ temp and metabolic rate Medications Cardiotonics (for Digitalis Preparation) Heart Rate Epinephrine Heart Rate Hypovolemia or Loss of Blood PR Stress / Pain / Emotion - PR Position Changes If sitting or standing, blood pools in the dependent vessels in venous system. Pooling results in venous blood return and in BP and in Heart Rate. Heart conditions or those w/ impaired oxygenation

5.

3.

5.

7.

6. 7. 8.

8.

9.

9 Pulse Sites 1. Apical Pulse Point of Maximal Impulse (PMI) or Central Pulse Located at the Apex of the Heart. In Adult Left side of chest; 5th intercostals space midclavicular line below the nipple) Children between 7 9 y/o 4th /5th intercostals space

9.

Assessing the Pulse 1. Assessed by Palpation for Peripheral Sites Use middle 3 fingertips with moderate pressure. No excessive pressure for it can obliterate (damage) pulse. Too Little pressure may not detect pulse. Assessed by Auscultation for Apical a. Stethoscope b. Doppler Ultrasound Stethoscope if difficult to assess (excludes environmental sounds) Nurse should be aware of the ff prior assessment: a. If client can assume a sitting position b. Baseline data of client of his normal heart rate c. Medications that affects heart rate (Ex. Epinephrine, Cardiotonics) d. Physically active PT can PR. Wait for 10 15 minutes

c.

Full or Bounding Pulse Forceful or full blood volume; obliterated only with difficulty

2.

When assessing a peripheral pulse to determine the blood flow to a particular area, the nurse must assess the corresponding pulse on the other side of the body to compare the pulses (ex. when assessing blood flow to the foot, assess the right and left dorsalis pedis. If pulse is same, it is bilaterally equal) Skill: Assessing Peripheral Pulse Purposes

3.

1. 2. 3. 4. 5. 6.

Pulse Deficit difference between apical & radial counts taken simultaneously. Rate of Pulse beats per minute Age Newborns - 3 y/o (apical pulse) Adults Pulse Average & Ranges 120 - 130 (80 180) 80 (60 100)

Obtain baseline data for further evaluation Identify if Pulse Rate is within normal limits (60-100bpm) Identify if Pulse Rhythm is regular Identify if Pulse Volume is appropriate Determine equality of peripheral pulses Monitor PT at risk for Pulse Alterations (ex. heartdisease, fever)

Assessment 1. 2. 3. Clinical Signs of Cardiovascular Alterations (Dyspnea) Factors that affect Pulse Rate Appropriate Pulse Site based on purpose

Assemble Equipment and Check if functioning properly 1. 2. Watch with second hand indicator Doppler Ultrasound Stethoscope (transducer probe, stethoscope headset, transmission gel, tissue or wipes)

Assessment Findings: 1. 2. 3. 4. 5. Pretachycardia >90 100 bpm (warning sign) Prebradychardia <50 60 bpm Tachycardia > 100bpm; Excessively fast heart rate Bradycardia -- <60bpm; Excessively slow heart rate If client is either 2, assess Apical Pulse.

Procedure 1. 2. 3. Identify, Verify, Explain, Hand Hygiene, Privacy Select Pulse (Use radial pulse unless it cant be assessed or to determine circulation of other body parts) Place client in a comfortable SITTING position Arms resting on a table / arm of chair / thigh Palm facing down Palpate and Count the Pulse for 1 full minute (60 secs) Place 2 or 3 middle fingertips over pulse point (thumbside of wrist) Using thumb is not allowed. Nurse Thumb has a pulse that could be mistaken for PTs pulse. Assess Pulse Rhythm and Volume Document Rate, Rhythm, and Volume

Pulse Rhythm or Heart Rhythm Pattern of the beats and time of interval between beats Assessment Findings a. b. c. Pulsus Regularis Equal Rhythm Premature Beat beat that occurs between normal beats Dysrythmia and Arrythmia Irregular Rhythm; predictable pattern of irregular beats; documented as regularly irregular; when dysrythmia is detected, assess apical pulse or a ECG or EKG is necessary to define it further. 4.

5. 6.

Pulse Volume or Pulse Strength or Amplitude Force of blood with each beat. a. b. Normal Pulse: felt with moderate pressure of fingers and can obliterate with greater pressure. Weak / feeble / Thready Pulse: readily obliterated with pressure of fingers.

Skill: Assessing Apical Pulse Purposes 1. 2. 3. 4. To obtain baseline data for further measurements To obtain heart rate of newborns to 3y/o (left side midclavicular line) To determine if cardiac rate is within normal range To monitor clients with cardiac, pulmonary, and renal disease. a. Rhythm note pattern of intervals between beats b. Strength or Volume if strong, weak, or normal 9. Document

Assess 1. 2. Signs of Cardiovascular Alterations Factors that may alter Heart Rate

Assemble Equipment and Check if functioning properly 1. 2. 3. 4. Watch with second hand indicator Sthetoscope DUS Antiseptic Wipes

Procedure 1. 2. 3. 4. Identify, Verify, Explain, Hygiene, Privacy Place client in SUPINE or SITTING position Expose chest area where apex is located Locate Apical Pulse Palpate Angle of Louis below suprasternal notch Slide index finger in 3rd intercostals space and continue to 5th intercostals space. Move index finger laterally along in 5th intercostals space towards Midclavicular Line. Auscultate and Count Heartbeats Clean earpiece of stethoscope and diaphragm with antiseptic wipes Warm diaphragm by holding with the your palm (Metal is usually cold and can startle the patient) Insert earpieces in the direction of ear canal to facilitate hearing Tap diaphragm lightly (to ensure its the active side of head) Place diaphgram over Apical Pulse and Listen to S1 and S2 sounds (LUB DUB) (Heartbeat is loudest at the apex of the heart. Each lub dub is counted as 1) S1 or Lub AV Valve closes after ventricles are filled S2 or Dub SV Valve close`s after ventricles empty. If its difficult to hear the Apical Pulse a. PT in a supine position ask to position side lying b. PT in a sitting position ask to lean slightly forward *These moves the apex closer to chest wall

5.

6.

7. Count heartbeats for 60 seconds or 1 full minute 8. Assess heart rhythm and heart volume or strength

Arterial Blood Pressure

Measure of force of blood against arterial walls Measured in mmHG (milliliters of mercury) B/c blood moves in waves, there are 2 BP: a. Systolic Pressure - pressure; ventricles contract b. Diastolic Pressure - pressure; ventricles at rest 6.

Some meds can increase or decrease BP

Obesity Predispose to Hypertension > 10% of Normal Body Weight Time of Day or Diurnal Variations BP is lowest early in the morning when metabolic rate is lowest BP is highest throughout the day and peaks late afternoon and early evening Disease Any condition that affects blood volume, blood viscosity, and cardiac output has a direct effect to BP. Race African Americans have > BP than European American males of the same age.

7.

Pulse Pressure difference between systole and diastole a. b. Normal: 40 mmHg and can increase to 100 during exercise Abnormal: If <25 mmHg occurs in severe heart failure 8. Determinants of Blood Pressure 1. Pumping of the heart If weak - lower cardiac output and BP If strong higher cardiac output and BP Blood Volume a. If blood volume (hemorrhage or dehydration) blood pressure b/c of decreased fluids in arteries. b. if blood volume (rapid intravenous infusion), blood pressure b/c of greater fluid volume Blood Viscosity (Thickness) If blood is viscous, BP is that is, the proportion (hematocrit) of RBCS > Blood Plasma Peripheral Vascular Resistance Can BP

9.

2.

Classification of Blood Pressure Category Normal Prehypertension Hypertension Stage 1 Hypertension Stage 2 Systole <120 120 140 140 160 >160 Diastole <80 80 90 90 100 >100

3.

4.

Assessment Findings 1. Hypertension BP is > than normal Cannot be diagnosed unless an elevated BP is found when measured 2x in a different time. Usually asymptomatic and contributes to Myocardial Infarction. a. Primary Hypertension Unknown cause b. Secondary Hypertension known cause Factors associated with Hypertension 1. 2. 3. Thickening of arterial walls decreases the size of lumen Inelasticity of arteries Lifestyle Factors Smoking and Alcohol Consumption Decreased Physical Activity High Blood Cholesterol Stress

Factors that Affects Blood Pressure 1. Age Newborns have Systolic Pressure of 75mmHg BP with age In elders, arteries elasticity is decreased and becomes rigid that produces elevated systole and diastole. Exercise BP d/t increase cardiac output Wait for 20 30 minutes before assessment Stress / Emotions BP d/t stimulation of SS increasing cardiac output However, SEVERE PAIN BP b/c of vasodilation. Gender After puberty, females have than males of same age. After menopause, women have BP than before.

2.

3.

4.

2.

5.

Medications Caffeine BP d/t vasoconstriction

Hypotension BP is below normal. Systole is between 85 & 110 mmHg Important: Prevent from FALLS d/t Orthostatic Hypotension (BP falls when client sit OR stand OR change in position; a result of peripheral vasodilation

wherein blood leaves central body organs (brain) and moves to periphery causing to feel fainting Factors associated with Hypotension 1. 2. 3. 4. 5. Shock Loss of Blood Massive Burns Dehydration Analgesics (ex. Demerol)

Blood Pressure Sites 1. 2. Brachial Artery (usually) Thigh (if cant measure either arm ; burns or trauma)

Blood Pressure is NOT MEASURED on a particular PTs limb d/t: 1. 2. 3. 4. 5. 6. Shoulder, Arm, or Hand / Hip, Knee, or Ankle is injured or diseased Cast Surgical removal of axilla Lymph Nodes (cancer) IV Intrafusion Renal Dialysis

Blood Pressure Assessment Methods 1. 2. Direct involves insertion of catheter in brachial, radial, or femoral Indirect a. Palpatory use of 2 or 3 middle fingertips; used when korotkoffs sounds are not heard; prevents misdirection from the presence of auscultory gap. b. Auscultory commonly used; using sphygmomanometer & stethoscope; identifies korotkoffs phases.

Selected Sources of Error in BP Measurements Error Assessing immediately after meal PT smokes or has pain Insufficient Rest Bladder cuff too narrow Bladder cuff too wide Cuff wrapped loosely or uneven Arm unsupported Arm above heart level Arm below heart level Failure to use same arm consistently Repeating assessment too quickly Deflating cuff quickly Failure to identify Auscultory Gap Effect High

Auscultory Gap occurs in hypertensive clients; a temporary absence of sounds in brachial artery. Korotkoffs Sounds / 5 Phases (a series of sounds; schematic diagram) 1. 2. 3. 4. 5. Phase 1 faint / sharp tapping (120 mmHg) Phase 2 swooshing (120 mmHg) Phase 3 loud knocking softer than phase 1 (80 mmHg) Phase 4 muffled sound that fades Phase 5 silence (0 mmHg

High Low High High Low High Inconsistent High S and D Low S and High D Low S and D

Equipment 1. Sphygmomanometer and Stethoscope a. Aneroid b. Digital or Electronic c. Manual Parts of Sphygmomanometer 1. 2. 3. 4. 5. 2. Bladder (inflated with air) Cuff Valve Bulb (pump) Tube to Sphygmomanometer

Doppler Ultrasound Stethoscope Used when sounds are difficult to hear For Infants, Obese, Shock Patients

Skill: Assessing Blood Pressure Purpose 5. 1. 2. 3. Obtain Baseline data for further measurements Determine Hemodynamic Status of Client (cardiac output, stroke volume, blood vessel resistance) Identify changes in BP resulting from a disease or therapies (cardio and renal disease)

in veins to be released. Otherwise, false increased systole will occur) Position Stethoscope Clean earpiece with antiseptic wipes and Insert Into ears tilted slightly forward Ensure stethoscope hangs freely from ears to diaphragm (if steth tube rubs against an object, the noise can block the sound) Warm bell diaphragm with palm (prevent startling PT) Place bell (best heard) over brachial pulse on skin not on clothing (to avoid noise rubbing against clothing) Hold bell diaphragm with index finger and thumb Auscultate BP Pump cuff until Sphygmo is 30 mmHg above the point where brachial pulse disappeared Release valve carefully so pressure decreases 2- 3 sec per mmHg As pressure falls, identify Korotkoffs phases I, IV, and V (no clinical significance on II and III) Deflate Cuff and Wait for 1 2 mins before further measurements Repeat steps once or twice to confirm if accurate If initial examination, repeat procedure on other arm. There should be no more than 10 mmHg difference between two arms. Arm that has higher pressure should be used.

Prior Assessment: 1. 2. 3. Ensure client didnt smoke, ingested caffeine it may increase BP. Wait for 10 15 minutes Ensure client didnt exercise. Wait for 20 30 minutes. Ensure client is not stressed or anxious.

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Assess 1. 2. 3. S/S of Hypertension (headache, fatigue, flushing of face, ringing of ears) S/S of Hypotension (Tachycardia, dizziness, mental confusion, cool skin, cyanosis) Factors affecting BP

Assemble Equipment and Check if functioning properly 7. 1. 2. 3. 4. Sphygmomanometer (appropriate size of cuff) Stethoscope DUS (for infants, obese, shock clients) Antiseptic Wipes

Procedure 1. 2. Introduce, Verify, Explain, Hand hygiene, privacy Position client Sitting Position with both feet flat on the floor (Cross legs Systole and Diastole) Left Elbow slightly flexed with palm facing up and forearm at Heart Level (If below heart level BP ; if above heart level BP ) Expose upper arm Normally there are similar findings when client is sitting, standing, or lying down. Wrap cuff evenly, Locate Brachial Artery and apply the center of bladder to Brachial a. Adult place cuffs lower border 1 inch above antecubital space If initial examination, palpate brachial artery w/ 2 or 3 middle fingertips to determine Systole (Prevents underestimation of Systole and Overestimation of Diastole should an auscultory gap occur) Close valve until you no longer feel brachial pulse Release pressure and wait for 1 2 mins before further measurements (Waiting time gives the blood trapped

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