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

  • Basal Metabolism

       Radiation

 

  • Muscular activity  (shivering)

       Conduction/Convection

 

·         Thryoxine and epinephrine (stimulating effects on metabolic rate)

 

       Evaporation (vaporization)

 

  • Fever

 

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.

 

 

Why is this important to know?

·         Failure to recognize an auscultatory gap, when taking a blood pressure reading may lead to false low systolic or false high diastolic pressures.

·          Identify manometer reading when first clear Korotkoff sound is heard. Rationale: Indicates systolic pressure reading.

·         Continue to deflate, and note reading when sound disappears (fifth Korotkoff sound). Rationale: Indicates diastolic pressure reading.

·         Deflate cuff completely, and remove from client’s arm. Record blood pressure.  Assist client to comfortable position.

Case Study

1.        You are taking care of a labor patient, Melissa, who was sent from the doctor’s office to labor and delivery with a blood pressure of 160/100. At the office, the Nursing Assistant used a regular size cuff on Melissa even though she is obese.  She took the blood pressure 15 minutes after Melissa had a cigarette and while she was having a contraction. Melissa is extremely anxious because this is her first baby. As the nurse, what things can you do differently to obtain a more accurate blood pressure for this woman?

 

2.       When releasing the blood pressure cuff below the systolic reading, you are uncertain exactly where the sound becomes muffled. What would be the best action for you to take?

 

3.       Melissa had a caesarean birth, and you are taking care of her post-operatively. Her vitals are as follows: BP is 134/92; P 100; R 32. Her pain is an 8 on a scale of 1 to 10. What would be an appropriate nursing intervention? What should you do 30 minutes later?

 

4.       Later on in your shift, Melissa had a postpartum hemorrhage. How would this affect her blood pressure?

 

5.       Melissa’s systolic blood pressure is 88 mm Hg. What will you do?

 

Pulse oximeter

      Measures the % of HgB saturated with oxygen. A normal result is 95% to 100%. Pulse oximeter sensors may be placed on the client’s finger, toe, nose, earlobe, or forehead.

Factors affecting oxygen saturation reading

      A client could be severely anemic and have inadequate oxygen to supply the tissues, but the pulse oximeter would return a normal value. 

Circulation

      The oximeter will not return an accurate reading if the area under the sensor has impaired circulation.

Activity

      Shivering or excessive movement of the senor site may interfere with accurate readings.

Critical Thinking

      Joseph is complaining of being “extremely cold” and is visibly shivering. You want to measure this client’s oxygen saturation level. What should you do?

 

Orthostatic Blood Pressure

·         Occurs when the blood pressure falls as the client assumes an upright position. Common in patient’s on prolonged bed rest. Subjective data:  Client complains of dizziness, weakness, and blurred vision. Objective data:  Drop in blood pressure and pulse rate. Client is diaphoretic.

·         Position client supine with head of bed (HOB) flat for 10 minutes.  Rationale: Allow blood pooled in lower extremities to reenter circulation.

·         Check and record supine blood pressure and pulse. Keep blood pressure cuff attached.

·         Position client in sitting position with legs dangling over the edge of bed. Wait 2 minutes and check blood pressure and pulse. Rationale: Allow time for volume shifts.

·         Assist client to standing position. Wait 2 minutes and check blood pressure and pulse rate.

·         Assist client back to comfortable position.  At any time patient is dizzy assist back to bed.

·          Drop in systolic pressure of 25 mmHg or diastolic drop of 10 mmHg needs to be reported to MD. Client is at risk for falls.

·         Client teaching: Change positions slowly and pause several minutes between positions.

Case Study

1.       Karen reports to you, “My heart is racing. I feel so tired but I have not even done anything. This morning, I felt faint.”  What would be appropriate nursing interventions for this client?

 

2.       While you are performing orthostatic blood pressures on Karen, she becomes weak and hypotensive. You assist her back into bed with her legs elevated at 20 degrees. What was the rationale for placing the patient in this position?

 

Delegating Vital Signs to Others

      As a Registered Nurse you will need to delegate some of your tasks to others. You can delegate the task, but you retain the responsibility and accountability for the patient’s care.

Remind them:

·         Promptly report abnormals! Frequency and who need careful monitoring.

Critical Thinking

      In which of the following situations would it be most appropriate to delegate the taking of vital signs to unlicensed assistant personnel (UAP)?

 

Intake

      Any client with an IV or Foley or any cardiac or renal patient is automatically on intake and output. Oral (include medications, for example, liquid antacids). Ice chips: Record half volume, for example, 1 cup ice = 120 cc. Any food that will become liquid at room temperature (Jell-O, sherbets, frozen treats, and ice cream). IV, Nasogastric feedings, and Blood products are intake.

Output

       If client does not have at least 30 cc urine output per hour, report to physician. The patient could be in renal failure! Measure in “hat” and record at least every 8 hours in ccs. Client teaching: Keep toilet paper separate from urine. Urine output should be within 200 to 300 ml of intake for any 24 hour period. Liquid stool, emesis, drainage devices, e.g., chest tube. May weigh dressings and bed linens as needed.                                                                                     

Typical in 24 hours

      1300 ml intake to maintain fluid homeostasis (equilibrium). 1500 ml output. 

Critical Thinking

     Would you report any of the following intake and output for an 8 hour shift to the physician?

a.       Intake 400 cc Output 230 cc

b.       Intake 1500 cc Output 1000 cc

c.       Intake 650 cc Output 350 cc

d.       Intake 500 cc Output 350 cc