Key Point
I. Definition of Blood Pressure
A. The measurement of the force of blood against artery walls.
1. Force comes from the pumping of the heart
2. If arteries are hardened or narrowed, this force might be increased to pump the blood throughout the
body
B. Measurement is done by listening for two sounds with a stethoscope - the first sound and the change in sound/or
in some instances the last sound
1. The first sound is called the systolic blood pressure – it measures the pressure in an artery when the
heart is contracting
2. The change in sound/or last sound heard is the diastolic blood pressure - it measure the pressure in an
artery when the heart relaxes between contractions
C. The units of measurement are millimeters of mercury
1. the top number/systolic is charted first, then the diastolic as in systolic/diastolic
2. 120/80 is an example of a blood pressure and this would be in millimeters of mercury or mm Hg
II. Blood pressure values
A. Normal range of B/P = 90-100/60 - 140/90
B. Someone whose B/P is < 90-100/60 is said to be hypotensive
1. Someone with hypotension may have symptoms of dizziness, light-headedness, might faint
2. No presence of signs and symptoms
3. Contributing factors include
a. medications
b. level of physical fitness - ex. Someone who is extremely fit might be hypotensive, but this is
normal for them
c. illness
d. injury
D. Someone with a B/P greater than 140/90 is said to be hypertensive
1. Hypertension is called the silent killer because there are often no symptoms. Some people might
experience headache, pressure in the head, ringing in ears, general feeling of malaise
2. Continued elevation over time may result in a Cerebral Vascular Accident (stroke)
3. Contributing factors may include
a. overweight
b. emotional upset
c. family history
d. high salt diet
e. pain
f. illness
g. medications
AHA Recommendation
High blood pressure, or hypertension, is defined in an adult as a systolic pressure of 140 mm Hg or higher and/or a
diastolic pressure of 90 mm Hg or higher. Blood pressure is measured in millimeters of mercury (mm Hg).
Blood pressure (mm Hg)
Systolic (top number)
Diastolic (bottom number)
**Mm Hg = millimeters of mercury
Normal
less than 120
less than 80
Prehypertension
120–139
80–89
Hypertension
140 or higher
90 or higher
High blood pressure directly increases the risk of coronary heart disease (which leads to heart attack) and
stroke, especially along with other risk factors.
High blood pressure can occur in children or adults. It's particularly prevalent in African Americans, middle-aged and
elderly people, obese people and heavy drinkers. People with diabetes mellitus, gout or kidney disease have
hypertension more often.
High blood pressure usually has no symptoms. It's truly a "silent killer." But a simple, quick, painless test can detect
it. http://www.americanheart.org/presenter.jhtml?identifier=4623
III. Instruments necessary to complete the procedure
A. Blood pressure cuff/sphygmomanometer
1. This must fit the arm properly. The width of the cuff should approximately equal the width of the upper
arm.
2. The gauge should be calibrated and the needle should be on 0
B. Stethoscope
IV. Procedure
A. Person should be comfortably seated or lying down
B. Should have rested for 10-15 minutes prior to the reading
C. Arms that are paralyzed, injured, have an IV or shunt should not be used
D. Infant blood pressures can be taken on the leg, but adults must use the arm
E. Electronic blood pressure equipment can be used - the type used most often in the hospital setting is the Dyna
map
F. Excess air should be squeezed out of the cuff
G. Cuff should be placed snugly on upper arm.
H. Gauge should be easily visualized
I. Valve should be closed, but easily able to be opened
J. Two techniques for obtaining the pressure
1. Find radial pulse. Pump cuff till pulse no longer palpated. Then pump another 30 mm Hg higher. Place
diaphragm of stethoscope on brachial artery about ½ - 1
inch above the elbow. Release the valve and listen for the two measurements - slowly deflating the cuff.
2. Find brachial artery and put diaphragm over the site. Pump cuff to 120 mm Hg and listen for the heart
beat. If it is heard, pump another 30 mm Hg and listen again. When the pulse is no longer heard, then pump
another 30 mm Hg and slowly deflate, listening for the two measurements.
K. If reading is uncertain, wait 30 seconds to 1 minute before remeasuring
L. Record the reading and report any abnormalities. If the B/P reading is outside of the normal limits, retake it before
reporting the value to a supervisor to be certain of accuracy
Key Points
I. Vital signs include
A. Temperature
B. Pulse
C. Respiration
D. Blood Pressure
II. Temperature
A. Refers to temperature inside the body or core body heat.
B. Can be measured by four basic routes
1. Oral
2. Rectal
3. Axillary
4. Tympanic
C. Several types of thermometers
1. Electronic/Digital
2. Glass
3. Thermoscan for Tympanic measurement
D. Normal temperature ranges
1. Oral 97.6 degrees F. – 99.6 degrees F.
2. Axillary 96.6 degrees F. – 98.6 degrees F.
3. Rectal 98.6 degrees F. – 100.6 degrees F.
4. Tympanic: Manufacturer’s guidelines suggest that the measurement is
the same as rectal temperatures.
5. Axillary is one degree Fahrenheit lower than Oral
6. Rectal is one degree Fahrenheit higher than Oral
E. Reading temperatures
1. By degree and tenth of a degree
2. Place thermometer at eye level and look for silver line of mercury
3. Never place fingers on bulb of thermometer as this might change the
value
F. Thermometers and routes
1. Probes for electronic and mercury-free ends are color coded for route.
2. Red = rectal; Blue = oral/axillary
3. If no color present, the route will be written on the thermometer
G. Measurement of temperature
1. Use protective cover on each thermometer
2. Tympanic probe placed in ear
3. Rectal thermometer or probe placed in rectum one inch with lubrication
applied before insertion.
4. Oral thermometer placed in mouth under the tongue
5. Do not take oral temperatures on
a. preschool children
b. patients with oxygen
c. delirious, confused, disoriented patients
d. comatose patients
e. patients with nasogastric tubes in place
f. patients who have had oral surgery
g. patients who are vomiting or are quite nauseated
6. Do not take rectal temperatures on
a. infants or children unless a core temperature is needed
b. patients who have had rectal surgery
c. combative patients
H. Duration of taking temperature
1. Tympanic – a couple of seconds – long enough to gently press a
button.
2. Oral and rectal (glass thermometer) – three minutes.
3. Axillary glass thermometer) – 10 minutes
4. Electronic temperatures – when beep sounds, temperature is obtained
I. Abnormal temperatures
1. Fever, febrile, hyperthermia all indicate someone who has an elevated
temperature (greater than 100 degrees Fahrenheit).
2. High fever would include anything over 103 degrees Fahrenheit.
3. Moderate fever would include anything 100 – 103 degrees Fahrenheit.
4. Hypothermia is subnormal temperature. This can be equally
problematic for a person. Anything under 96 degrees Fahrenheit would
indicate hypothermia.
III. Pulse
A. Wave of blood produced by beating of heart and traveling along the
Artery.
B. Can feel at points where the artery is between finger tips and a bony
area
C. These areas are called pulse points and include
1. Temporal
2. Carotid
3. Apical
4. Brachial
5. Radial
6. Femoral
7. Popliteal
8. Dorsal Pedalis
D. Measured by index, middle, and ring fingers over pulse point.
E. Do not take with the thumb, since it has a pulse of its own.
F. Count for 30 seconds and multiply by 2, or count for 60 seconds
G. Normal range is 60 – 100 beats per minute. The area of 90-100 is a
gray area in that a pulse should never constantly remain in this area.
H. > than 100 = tachycardia
I. < than 90 = bradycardia
J. Quality of pulse is determined as well as rate
1. Rhythm – regular or irregular
2. Strength – Bounding or thready
K. Circumstances affecting pulse rate
1. Body temperature
2. Emotions
3. Activity level
4. Health of heart
L. Perfusion is the flow of blood throughout the body. Someone with
sufficient perfusion has a strong enough heart beat to adequately
oxygenate the body.
IV. Respiration
A. Each breath includes inspiration and expiration.
B. Measure by observing chest rise and fall.
C. Measured in breaths per minute.
D. Normal range = 12-24 breaths per minute.
E. > than 24 = tachypnea – if breathing in great depth then called hyperpnea
F. < than 12 = bradypnea
G. Difficulty in breathing is called dyspnea
H. Quality of breathing is determined as well as the rate of breathing
1. Depth
2. Clarity of breath sounds
3. Pain with breathing
4. Difficulty breathing – use of accessory muscles – sternocleidomastoid
and intercostal muscles
V. Procedure for taking TPRs
A. If using glass thermometer, insert the thermometer. If axillary or rectal
hold the thermometer throughout the time. If oral, insert the thermometer
and proceed to take the pulse and respiration.
B. If using electronic – take the temperature first, then proceed to the pulse
and respiration.
C. When taking the pulse and respiration, do not drop the wrist until both the
pulse and respiration are taken. This way the person does not know when
his/her respirations are being measured – insuring a more accurate
measurement.
D. When measuring axillary temperature, remove any clothing that could
impede the accuracy of the temperature. Also clean the axilla if there is
excessive deodorant or perspiration present.
E. When measuring the rectal temperatures, always lubricate the
thermometer with water-soluble gel before inserting into the rectum.
F. Never touch the bulb end of the thermometer with the fingers.
V. Charting
A. Chart in order of TPR
B. Do not write T =, P =, etc., simply 98.6 – 84 – 22