Vital Signs
Susan Darby, RNC, MSN. NURA 3240. Georgia College State
University
Vital Signs or Cardinal Signs
•
Reflect changes in
body function that otherwise might not be observed. Temperature – T. Pulse – P.
Respirations – R. Blood Pressure - BP
Veterans Administration
•
Has designated pain
as a fifth vital sign, to be assessed at the same time as each of the other
four.
Pulse oximetry
•
Also commonly
measured as the same time as the traditional vital signs.
Times to assess vital signs
•
On admission to a
health care agency to obtain baseline data.
•
When a client has a
change in health status or reports symptoms such as chest pain or feeling hot or
faint.
•
Before and after
surgery or an invasive procedure.
•
Before and/or after
the administration of a medication that could affect the respiratory or
cardiovascular systems, e.g., before giving digitalis.
•
Before and after
any nursing intervention that could affect the vital signs (e.g. ambulating a
client who has been on bed rest).
•
Measure vital signs
more often if the client’s health status requires it.
Variations in normal vital signs: Age
Adult and Older Adult (> 70 years)
•
P: 60-100.
R: 12-20. BP:
90-140/60-90. T: (Adult) 97.6 – 99.6. T: (Older Adult) 95-99
Pulse and Respirations
•
Decrease
from birth to old age. Newborn:
P 80-180; R 30-80. Adult/Older Adult: P 60-100; R
12-20.
Respirations
•
As you grow from
infant to an adult, you have a larger lung capacity. As lung capacity increases,
there is a lower respiration rate.
BP
•
Increases from
birth to old age. Newborn: BP 73/55. Adult/Older Adult: BP
90-140/60-90.
Temperature
•
Decreases as a
person ages. Newborn: 98.2.
Adult: 97.6-99.6. Older Adult: 95-99.
Body Temperature
•
The balance between
the heat produced and the heat lost from the body.
Core Temperature
•
The temperature of
the deep tissues of the body (e.g., abdominal and pelvic cavity, thorax).
Surface temperature
•
The temperature of
the skin, subcutaneous tissue, and fat.
Radiation
•
Loss of heat to a cold surface.
Example (name one)
1.
Conduction
•
Loss of heat
through contact with cold objects or surfaces.
Examples (name two)
1.
2.
Convection
•
Loss of heat
through air currents.
Examples (name three)
1.
2.
3.
Evaporation
•
Loss of heat as
water is transferred to gas.
Examples (name three)
1.
2.
3.
Vaporization
•
Continuous
evaporation of moisture from the respiratory tract and from the mucosa of the
mouth and the skin. Insensible water loss: continuous and unnoticed water
loss. Insensible heat loss: accompanying heat loss.
Heat Balance
•
The state a person
is in when the amount of heat produced by the body exactly equals the amount of
heat loss.
|
Heat Production
|
Heat Loss |
|
•
Radiation
|
|
•
Conduction/Convection
|
·
Thryoxine and
epinephrine (stimulating effects on metabolic rate)
|
•
Evaporation
(vaporization)
|
|
|
What part of the body regulates body temperature?
Factors affecting body temperature: Age
Diurnal variations
•
Circadian
rhythms: Event that occurs
approximately every 24 hours. Body temperature fluctuates throughout the day.
Critical Thinking
•
Circle the hours on
the clock that body temperature is the highest.
•
Circle the hours on
the clock that body temperature is the lowest.
•
Can vary as much as 1.8 F degrees.
Exercise
•
Increases heat
production as the body breaks down carbohydrates and fats to provide
energy.
Hormones
•
A woman’s body temperature increases by
0.5 to 1 degree above baseline at ovulation because progesterone is
secreted.
Pain, Anxiety, Fear, and Stress
•
Stimulates the
sympathetic nervous system (SNS) and increases body temperature.
Environment
•
Exposure to
extremely hot or cold temperature can alter body temperature and relates to
humidity, temperature, and length of exposure. If core temperature decreases to
77 degrees, death may occur.
External Factors affecting Body Temperature
Measurement
•
Small,
insignificant alterations in oral temperature readings can occur after smoking.
And when oxygen is administered by way of mask or cannula. Drinking hot or
cold liquids: May cause slight variations in oral temperature readings.
Critical Thinking
•
As you begin to
take Mr. King’s oral temperature, he tells you that he has just had some ice
chips. What would be an appropriate nursing action?
Alterations in Body Temperature
•
A body temperature
above the usual range is called pyrexia, hyperthermia or (in lay
terms) fever. Hyperpyrexia A very high fever, such as 105.8.
Febrile: client who has a fever. Afebrile: client who does not
have a fever.
Four types of fevers
•
Intermittent:
The body temperature alternates at regular intervals between periods of fever
and periods of normal or subnormal temperature.
•
Remittent: A
wide range of temperature fluctuations (more than 3.6 F) occurs over the 24 hour
period, all of which are above normal.
•
Relapsing:
Short fever periods of a few days are interspersed with periods of 1 or 2 days
or normal temperature.
•
Constant: The
body temperature fluctuates minimally but always remains above normal.
Fever spike
•
A temperature that
rises to fever level rapidly following a normal temperature and then returns to
normal within a few hours.
Clinical Signs of Fever
•
Onset (Cold or
chill stage): chills, feeling of
coldness, cold skin (due to vasoconstriction), and shivering. Course. Defervescence (fever
abatement): excessive sweating and a hot, flushed skin due to sudden
vasodilation.
During a fever,
•
The set point of
the hypothalamic thermostat changes suddenly from the normal level to a higher
than normal level, but several hours elapse before the core temperature reaches
the new set point.
Nursing interventions for clients with fever (name
eleven)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Hypothermia: 3 mechanisms
•
Excessive heat
loss. Inadequate heat production by body cells. Increasing impairment of
hypothalamic thermoregulation.
Signs and Symptoms
•
Decrease body
temperature. Initially tachycardia than bradycardia. Respirations increase than
decrease. Hypotension.
Critical Thinking
•
A postoperative
patient, Mrs. Mayo, tells you she is so cold that she thinks she will never be
warm again. While taking Mrs. Mayo’s temperature, you check her nail beds. What
is the rationale for checking the nail beds in relation to body temperature?
Nursing interventions (name 7)
1.
2.
3.
4.
5.
6.
7.
Body temperature
•
Can be measured
orally, tympanically, rectally, or by axilla.
Sites
•
Rectal route (most
reliable). The sites most commonly used for adults are:
1.
2.
Contraindications: Oral
•
Cannot follow
instructions to keep mouth closed. Mouth breathing or may bite down and break
thermometer. Unconscious. Seizure. Smoker. Bilateral nasal packing.
Contraindications: Rectal
•
Diarrhea. Rectal
surgery. Neutropenic: (abnormally small amount of neutrophils) Client is
susceptible to infection.
Types of thermometers
•
Oral (glass and
electronic): Easy access and
comfortable for patient. Tympanic: If patient smokes, obtain temperature
by this method. Disposable: Paper thermometer.
Glass thermometer
•
The rectal glass
thermometer tip is blunt to decrease trauma to the rectal mucosa and is color
coded red. The tip of the oral thermometer is slender and may be color coded
blue.
Student Responsibility
•
Read Table 27-2; p.
491; Advantages and disadvantages of four sites of body temperature.
Temperature Scales
•
Celsius © =
(Fahrenheit (F) temperature –32) X 5/9. Convert 100 F to C:
•
Fahrenheit=
(Celsius temperature X 9/5) + 32. Convert 40 C to F:
Procedure
•
Assess the most
appropriate site according to the client’s age and condition. Assemble the
necessary equipment. Wash hands. Position and prepare the
patient.
Clinical Alert
•
Whenever mercury-in-glass
thermometers are encountered, the nurse should recommend their immediate
replacement with less hazardous thermometers and their safe disposal.
Glass Thermometer (Oral)
•
Hold thermometer at
eye level. Shake mercury down to 35 degrees by holding away from bulb between
thumb and forefinger, and snap wrist sharply. Place in patient’s posterior
sublingual pocket. Maintain thermometer with lips closed. Leave in place 3
minutes.
Glass Thermometer (Axillary)
•
Close bedroom door
or bed curtains. Pat the axilla dry if very moist. Insert thermometer into
middle of axilla; fold client’s arm down and place across chest. Leave in place
9 minutes for adults. Remove thermometer. Wipe downward once from the tip to the
bulb end to remove foreign material. Rationale: To prevent transfer of
microorganisms to cleaner surface. Note reading. Wash thermometer with soapy,
tepid water. Rinse and return to storage container.
Electronic Thermometer
•
Remove thermometer
from battery pack. Oral (blue) Rectal (red). Attach disposable cover and obtain
temperature. Wait for a beep (10-20 seconds) and remove from mouth. Press probe
release button over waste container. Return thermometer to battery
pack.
Electronic thermometer
(Rectal)
•
Close bedroom door
or bed curtains. Position patient in Sim’s position with upper leg flexed.
Expose only anal area. Apply water-soluble lubricant to thermometer probe tip.
Separate patient’s buttocks with one glove hand. Ask patient to take a deep,
slow breath. Insert thermometer into anus in direction of umbilicus; 1.5 inches
for adult. Do not force.
Critical Thinking
•
What should you be
doing while a rectal thermometer is registering?
Tympanic Thermometer
•
Remove thermometer
for recharging base and attach tympanic probe cover to sensor unit. Insert probe
into ear canal so if fits snugly and rotate toward the jaw line. Activate the
thermometer. Temperature will read in 2 seconds. Eject sensor probe and replace
thermometer to base for recharging.
Case Study
1.
When you took Mrs.
Smeltzer temperature at 0800 using an oral electronic thermometer, the result
was 97.2. All other vital signs are within normal range. What would you do next?
2.
Your other client,
Mr. Snyder, body temperature fluctuates minimally but always remains above
normal. What type of fever would you record this as?
3.
Mr. Snyder’s has a
temperature of 101 F and is shivering and complain that he is cold. His skin is
pale and cold. What stage of fever is he in?
4.
What will happen to
his body temperature as Mr. Snyder begins to shiver?
5.
Mr. Snyder is
confused. What temperature route is contraindicated for this client?
6.
Which of the
following individuals would probably have the highest
temperature?
Factors affecting the pulse
•
Age
Gender
•
After puberty, what
gender has a slightly lower pulse rate?
Exercise
•
Pulse increases
with activity. Pulse decreases in a professional athlete because of greater
cardiac size, strength, and efficiency.
Fever
•
Pulse increases in
response to the lowered blood pressure that results from peripheral
vasodilatation associated with elevated body temperature and increased metabolic
rate.
Critical Thinking
•
When assessing the
pulse of a client on digitalis, what rate would you expect as compared with the
pulse prior to starting digitalis?
Medications
•
Epinephrine and
caffeine increases the pulse.
Hypovolemia
•
Loss of blood from
the vascular system normally increases pulse rate.
Stress and Pain
•
Stimulate the SNS
and increase the heart rate.
Position changes
•
When a person is
sitting or standing, blood usually pools in dependent vessels of the venous
system. Pooling results in a transient decrease in the venous blood return to
the heart and a subsequent reduction in blood pressure and increase in heart
rate.
Pathology
•
Certain diseases
such as some heart conditions or those that impair oxygenation can alter the
resting pulse rate.
Assessing Pulse sites: Temporal
•
Front of the upper
part of the ear.
Carotid
•
Medial border of
the sternocleidomastoid muscle in the lower half of the neck. Never press both
carotids at the same time because this can cause a reflex drop in blood pressure
or pulse rate. Always palpate the carotid in the lower half of the neck to avoid
stimulating the carotid sinus.
Critical Thinking
•
Place an X over the
intercostal space of where you would palpate or auscultate the apical pulse.
•
The apical pulse is
the most accurate and easy to assess for rate and rhythm.
Brachial
•
Inner aspect of the
upper arm.
Radial
•
Thumb side of the
inner aspect of the wrist.
Femoral
•
Anterior medial
aspect of the thigh just below the inguinal ligament. For a client in shock, use
the carotid or femoral.
Popliteal
•
Behind the knee on
the lateral aspect of the popliteal fossa (shallow depression).
Posterior tibial
•
Behind the
malleolus bone.
Dorsalis Pedal
•
Top surface of the
foot, lateral to the tendon that runs from the great toe toward the ankle.
Equipment (name three)
1.
2.
3.
Assessing the pulse
•
Wash hands, and
explain procedure to client. Position client comfortably with forearm across
chest or at side with wrist extended. Use first three fingertips. Why would you
not use your thumb?
•
Press against
radial artery to obliterate (occlude) pulse, then gradually release pressure
until you feel pulsations. If pulse is regular, count for 30 seconds and
multiply by two. Initial pulse is counted as zero. If pulse is irregular, count
for one full minute. Document pulse
on vital signs record.
If pulse is not easily palpable:
•
Use Doppler. Apply
conduction gel to end of probe or to radial site. Press “on” button and place
probe against skin on pulse site. Reposition slightly using firm pressure until
pulsating sound is heard.
If patient’s pulse is irregular and this is a new
finding:
•
Auscultate apical
pulse for one minute. Count the initial pulse as zero. Calculate the pulse
deficit.
Pulse Deficit
•
The heart’s ability
to perfuse the body adequately. Apical pulse – radial pulse = pulse deficit. Two
nurses simultaneously measure apical and radial pulse. Both nurses should use
the same clock to count the client’s pulse for a full
minute.
Note
•
When a pulse deficit is present, the
radial pulse is always lower than the apical pulse.
Assessing Pulse Characteristics: Rate
•
Normal Adult
rate:
•
Tachycardia:
•
Bradycardia:
Pulse Rhythm
•
The pattern of
beats and intervals between beats. Dysrhythmia or arrhythmia: A pulse
with an irregular rhythm.
Irregularities may be caused by:
•
Medications
(example: albuterol). Heart disease. Electrolyte imbalance (K, Mg, Ph, and CA in
blood). Origination of stimuli for contraction of the heart in a site other than
the SA node (example: atrial fibrillation).
Pulse Volume
•
The strength or
amplitude of the pulse, the force of blood exerted with each heart beat.
•
0 = No pulse.
•
+1 = Thready or
weak pulse.
•
+2 = Difficult to
palpate.
•
+3 = Full volume.
•
+4 = Bounding.
Arterial wall elasticity
•
Expansibility or
stretching of the vessels.
Presence or absence of bilateral
equality
Case Study
1.
Mr. Frost has
fractured both of his arms and has bilateral casts from his shoulders to his
hands. What is the best method of obtaining and monitoring his pulse?
2.
Mr. Frost has been
resting in the chair. Physical therapy ambulates him in the hall for
approximately eight yards. You take his pulse and it is 95 and regular. What
should you do next?
3.
You are concerned
because you cannot palpate Mr. Frost’s pedal pulse although the color of the
foot indicates profusion is occurring. How can you verify the pulse is present?
4.
You have taken Mr. Frost’s radial pulse
for 30 seconds, it is now irregular. What nursing interventions should you take
next?
5.
Mr. Frost pulse is
110 and irregular. How would you describe his pulse in the nurse’s notes?
6.
You plan to calculate Mr. Frost’s pulse
deficit with another nurse. You measure the apical pulse as 120 and your
colleague measures the radial pulse as 110. What is his pulse deficit?
7.
You are unable to
palpate Mr. Frost’s brachial pulse. Presence of what pulses indicates adequate
brachial artery flow?
8.
You are reviewing
Mr. Frost’s nurse’s notes and note that the pulse quality of his right pedal
pulse has been documented as 2+. What does this mean?
9.
The nurse charted
that Mr. Frost’s pulse was bounding. What does this mean?
External Respirations
•
The interchange of
oxygen and carbon dioxide (CO2) between the alveoli of the lungs and the
pulmonary blood.
Internal respiration
•
The interchange of
oxygen and CO2 between the circulating blood and the cells of the body
tissues.
Ventilation
•
The movement of air
in and out of the lungs.
Mechanics and Regulation of Breathing
•
Inspiratory
breathing (active) and expiratory breathing (passive) Involves movement of the
diaphragm, chest, and abdominal muscles.
Costal (thoracic) breathing
•
Use of the external
intercostal muscles and other accessory muscles, such as the sternocleidomastoid
muscles.
Diaphragmatic (abdominal) breathing
•
Observed by the
movement of the abdomen, which occurs as a result of the diaphragm’s contraction
and relaxation.
Hypercarbia or Hypercapnia
•
Hyper = Excessive.
A condition in which CO2 accumulates in the blood.
Take into account
•
The client’s normal
respiratory pattern and factors affecting respirations.
Factors affecting
Respirations
•
Age
Sleep
•
An adult sleeping
respirations can fall to fewer than 10 per minute. Use other vital signs to
validate the client’s condition.
Medications
•
Narcotics decrease
respiratory rate and depth. Albuterol dilates bronchioles and increase air into
and out of the lungs.
Stress, Pain, and Anxiety
•
Increase the rate and depth of
respirations.
Hyperventilation
•
Abnormally rapid
deep breathing usually due to anxiety. Produces symptoms of dizziness and
tingling in hands. Caused by respiratory alkalosis (not enough CO2 in blood).
Hypoventilation
•
Reduced respiratory
effort. Caused by respiratory acidosis (too much C02 in
blood).
Exercise
•
Increases the rate
and depth.
Hyperpnea
•
Pnea = Breathing.
An increased respiratory rate or breathing that is deeper than normal, e.g.,
after exercise.
Altitude
•
Increase
respiratory rate and depth because oxygen concentration decreases at high
elevation.
Gender
•
What gender has a
lower respiratory rate?
•
Why?
Body Position
•
When the body is
slumped or stooped, gas exchanged can become impaired. As a result, the rate and
depth may increase.
Critical Thinking
•
Mr. Brown is having
difficulty breathing. What position should the nurse place him in to help him
breathe easier?
Orthopnea
•
Difficulty
breathing except in upright breathing. Conditions: Congestive heart
failure (CHF), asthma, pulmonary edema, severe emphysema, pneumonia, chest pain,
and spasmodic cough.
Critical Thinking
•
Miss Ash’s
temperature is elevated. Since fever increases the rate of metabolism, how will
you anticipate her fever will affect her respiratory
rate?
Assess Respirations for:
•
Rate
•
Rhythm
•
Depth
•
Quality
Rate
•
Eupnea (normal
breathing rate)
Abnormal rate
•
Tachypnea or
polypnea
•
Bradypnea
•
Apnea
Apnea
•
The absence of
respirations. Describe by the length of time in which no respirations occurs (10
seconds). Continuous apnea leads to respiratory arrest.
Rhythm
•
Normal:
Expiration is normally twice as long as inspiration.
Depth
•
Observing the
movement of the chest wall. Deep respirations: A large volume of air is
inhaled and exhaled. Shallow: The exchange of small volume of air.
Tidal volume
•
The amount of air
moving in and out with each breath is 500 ml.
Abnormal rhythm and depth
•
Biot’s:
Cyclic breathing characterized by
shallow breathing alternating with periods of apnea. Conditions:
Neurological problems, head trauma, brain abscess, heatstroke.
Cheyne-Stokes
•
Cyclic breathing
patterns characterized by periods of respirations of increased respiratory rate
and depth, alternating with periods of apnea. Conditions: CHF, drug overdose, increased
intracranial pressure.
Kussmaul (Koos” mow)
•
Increased rate
(above 20 beats per minute) and depth of respirations. Conditions:
Metabolic acidosis, diabetic ketoacidosis, renal failure.
Quality
Normal:
Automatic, quiet, and effortless.
Abnormal: Quality
•
Dysp = difficult.
Dyspnea: Respirations that require excessive effort. Client is anxious,
restless, mouth is dry, using accessory muscles (forward leaning posture).
Stridor
•
A harsh inspiratory
sound that can sound like crowing. It may indicate an upper airway obstruction.
Commonly heard in children with croup or after aspiration of a foreign object.
Wheezing
•
High pitched
musical sound. Usually heard on expiration but may be heard on inspiration.
Associated with partial obstruction of the bronchi or bronchioles, as in asthma.
What is this called?
1.
Rate of
respirations are 10? 18? 25?
2.
Brian has just
jogged 5 miles and is breathing deeply.
3.
You are taking care
of Baby Jones who occasionally stops breathing for 10 seconds.
4.
Mrs. Smith, a
laboring patient, is extremely anxious, complaining of tingling in her hands,
dizziness, and is breathing very deeply.
5.
Mr. Harris has
reduced respiratory effort. The blood gases indicate that he is in respiratory
acidosis.
6.
Mr. Williams is in
renal failure. He has an increased rate and depth of respirations.
7.
Janice is in the
Emergency Room with head trauma.
Her breathing is shallow alternating with periods of apnea.
8.
Mr. James is
requiring excessive respiratory effort and using his accessory muscles. He is
anxious, restless, and complaining that his mouth is dry.
9.
Mr. White has CHF and can only breathe in
the upright position.
10.
Jack took a drug
overdose. His respirations rate and depth are increased with alternating periods
of apnea.
11.
Katie is diagnosed
with croup. She is making a harsh inspiratory sound that sounds like crowing.
12.
Rebecca is
diagnosed with asthma. You hear a high-pitched musical sound on expiration.
13.
Alice is inhaling
and exhaling a large amount of air. How would you document the depth of her
respirations?
Procedure
•
After assessment of
pulse, keep fingers on client’s wrist and observe or feel the rising and falling
of chest with respiration. If client is asleep, gently place hand on chest to
feel chest movement. Do not explain procedure to client. Begin counting after
one cycle of inspiration and expiration has been observed. Count 30 seconds and
multiply by two. If respirations are shallow and difficult to count, observe at
the suprasternal notch. Note rhythm, depth, and quality.
Blood Pressure
•
The force exerted
on arterial walls by blood flowing within a vessel.
Physiological factors determining blood
pressure
•
Systolic and
diastolic blood pressure
•
Pulse
pressure
Systolic
pressure
•
The pressure of the
blood against the arterial walls when the ventricles of the heart contract.
Diastolic pressure
•
The pressure of the
blood against the arterial walls when the ventricles of the heart are at rest.
Pulse Pressure
•
Indicates how well
the patient maintains cardiac output (the amount of blood pumped in one minute).
Pulse Pressure = Systolic – Diastolic. Normally 30-40 mm HG.
Critical Thinking
Which of the following shows the greatest pulse
pressure?
a)
136/86.
b)
148/100.
c)
150/96.
d)
152/100.
Blood
pressure reflects
•
Cardiac output.
Blood volume. Blood viscosity (thick). Peripheral vascular resistance:
impedance or opposition to blood flow to the tissues.
Factors affecting BP
•
Age
Exercise
•
Physical activity
increases the cardiac output and hence the blood pressure.
Stress and Smoking
•
Increases BP by
stimulating the SNS. Severe pain can decrease BP greatly by inhibiting the
vasomotor center and producing vasodilation. Must wait 30 minutes after smoking
and exercise to take blood pressure.
Race
•
What race has a
higher BP after 35 years old?
Gender
•
After puberty,
females usually have lower BP than males of the same age (due to hormonal
variations). After menopuase, women generally have higher BP than before.
Medications
•
Antihypertensive
medications and pain medications decrease blood pressure.
Obesity
•
Both childhood and
adult obesity predispose to hypertension.
Diurnal variations
•
Blood pressure is
usually lowest early in the morning (metabolic rate is lowest), then rises
throughout the day and peaks in the late afternoon or early evening.
Circulating Volume
•
Blood or fluid
loss, results in lower blood pressure. Conditions: Diarrhea, diaphoresis,
insufficient oral intake. Excess fluids (CHF) can elevate blood pressure
readings.
Hypertension
•
Equal to or greater than
140/90 on two different follow-up visits
for blood pressure reading.
Critical Thinking
•
At a health fair, Mr. James, a 50 year
old client, has a blood pressure of 168/100. What would be an appropriate
nursing intervention?
Hypotension
•
A systolic reading
consistently between 85 and 110 mm HG in an adult whose normal pressure is
higher than this.
BP Sites: Upper extremity
•
Forearm:
Used for obese patients that the large
cuff is not fitting their upper arm. Avoid arms with IV, Dialysis graft, or
mastectomy because it can impede circulation and contribute to lymphedema. Post
sign above client’s bed if you should not use a certain
arm.
Lower extremity
•
Thigh: Large
cuff. Flat, prone, or supine position.
20-30 mmHG greater than regular cuff. Cuff centered midthigh over
_________.
•
Calf: Regular
cuff. Position client in flat, supine position. Auscultate or palpate the
__________or _________ pulse as you deflate.
Equipment
•
Sphygmomanometer
•
Stethoscope
Electronic Devices
•
Automated BP
machines: check cuff limb frequently.
Methods
•
Basal
B/P: taken in the resting state. Will compare other readings to
this.
Obtaining Blood Pressure
Proper cuff size
•
Measure the width of the bladder cuff to
be 40% of the circumference of the midpoint of the limb. Cuff too
Large: false Low reading. Cuff too small: false high
readings.
Proper Positioning
·
Forearm
supported at heart level and palm up. Rationale: Blood pressure
increases when the arm is below heart level and decreases when above heart
level. Diastolic blood pressure may increase 10% if arm is unsupported.
·
Expose the upper
arm completely. Rationale: Accurate placement of cuff and stethoscope.
·
Wrap deflated cuff
snugly around upper arm with center of bladder over brachial artery. Lower
border of cuff should be about 2 cm above anetecubital space. Rationale:
Loose or uneven application can result in falsely high reading.
·
If using a mercury
manometer, the manometer should be vertical and at eye level. Rationale:
Prevents distortion and promotes accurate reading of mercury level.
Palpation
·
Palpate brachial or
radial artery with fingertips. Close valve on pressure bulb and inflate cuff
until pulse disappears. Inflate cuff 30 mmHG higher. Slowly release valve and
note reading when pulse reappears. Rationale Identify approximate
systolic blood pressure reading, to prevent underestimating systolic blood
pressure should client have an auscultatory gap.
·
Fully deflate cuff,
and wait 1 to 2 minutes. Rationale: Allows blood trapped in the vein to
be recirculated to prevent false high readings.
·
Place stethoscope
ear piece in ears. Repalpate the brachial artery and place diaphragm or bell.
Rationale: BP is a low-frequency sound and is best heard with the
stethoscope bell, but the diaphragm is widely used because it is easily placed
and more generally available.
Proper Inflation and
Deflation
·
Close bulb valve by
turning clockwise. Inflate cuff to 30 mmHg above reading where brachial pulse
disappeared. Rationale: Ensure accurate assessment of systolic blood
pressure.
·
Slowly release
valve so pressure drops about 2 to 3 mmHg per second. Rationale:
Inaccurate measurement may occur if deflation rate is too fast or too slow.
Auscultation: Korotkoff
Sounds
•
Systolic
|
•
Phase
I: Faint clear tapping sounds of
gradual intensity.
|
•
Auscultatory
Gap
|
•
Absence of
Korotkoff sounds between phase I and II.
|
•
Diastolic
|
•
Phase
5: Absence of sound.
|