BLURTING
CONVERTING Cº and Fº
1. To convert Fº to Cº subtract 32 from F result and multiple by 5/9
C = (F-32) x 5/9
Ex: (104º - 32) x 5/9 = 40º C
2. To convert Cº to Fº multiply Cº by 9/5 and + 32
F = (9/5 x Cº) + 32
Ex: (9/5 x 40º) + 32 = 104º F
PULSE
 The palpable bounding of blood flow in the peripheral artery. Blood flows through the
body in a continuous circuit, it is an indirect indicator of circulatory status.
Physiology and Regulation:
 Pulse rate- number of pulsing sensations in 1 min
 Electrical impulses originating from the sinoatrial (SA) node travel through the heart
muscle to stimulate cardiac contraction
 Mechanical, neural, and chemical factors regulate strength of ventricular contraction and
stroke volume
Nursing process:
 Assessment of pulse- use stethoscope
 Character of the pulse- rate, rhythm, strength, and equality
 Nursing Diag.- cluster defining characteristics to form nursing diag.
 E.g., of nursing diag. related to pulse assessment- activity intolerance, dehydration,
hypervolemia, impaired cardiac function, and impaired peripheral tissue perfusion
 Planning and implementation- independent nursing interventions based on the nursing
diag. identified and the risk factors or related factor. Dependent interventions that focus
on the timely administration of meds and careful management of fluid balance
 Evaluation- patient outcomes (evaluation of the character of the pulse in response to
interventions)
Assessing the pulse
- Typically use the radial because it is easiest to palpate
- When a patient’s condition suddenly worsens use the carotid is recommended because it
is easiest to find and assess heart continues to deliver blood through here to the brain for
as long as possible
- When cardiac output declines rapidly peripheral pulses weaken and are hard to palpate
- Radial and apical locations are most common sites for pulse rate assessment. Use radial
to teach patients how to monitor their own HRs. if radial is abnormal resulting from
dysrhythmias or inaccessible assess the apical.
- Brachial or apical is best for kids
Character of the Pulse
- Assessment of radial includes measuring rate, rhythm, strength, and equality. When
auscultating an apical pulse only assess rhythm and rate
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Rate: if abnormal rate’s detected while palpating the peripheral then assess the apical
rate. The apical requires auscultation of heart sounds, which provides more accurate
assessment of cardiac contraction
o Assess apical by listening to heart sounds
o 2 common abnormalities in pulse rate are TACHYCARDIA and BRADYCARDIA
o PULSE DEFICIT- to assess pulse deficit you and colleague assess radial and apical
pulses at the same time and compare rates. Difference between apical and radial
is pulse deficit. Also associated with abnormal rhythms
Rhythm: normally a regular interval occurs between pulse or heartbeat
o DYSRHYTHMIA- threatens the ability of the heart to provide good cardiac output
especially if it occurs repeatedly. Identified by palpating an interruption in
successive pulse waves
Strength: or amplitude of pulse reflects the volume of blood ejected against the arterial
wall with each heart contraction and the condition of the arterial vascular system leading
to the pulse
o Document pulse strength as bounding 4. Bounding 3. Full / strong 2. Normal 1.
Diminished 0. Absent
Equality: assess radial pulse on both side of the peripheral vascular system
RESPIRATION
 Involves: ventilation, diffusion, and perfusion
 Physiological control: regulated via CO2 levels
 Mechanisms of breathing: inspiration is an active process. Expiration is a passive process
Nursing process:
 Assessment of ventilation- respiratory rate, ventilatory depth, ventilatory rhythm
 Assessment of diffusion and perfusion- measurement of arterial oxygen saturation
 Capnography
 Nursing Diag.- cluster defining characteristics
 E.g., of nursing diag.- activity intolerance, impaired airway clearance, impaired breathing,
impaired gas exchange
 Planning and implementation- interventions are based on the nursing diag. identified and
the related factors
 Evaluation- evaluate patient outcomes by evaluating the respiratory rate, ventilatory
depth, rhythm, and SpO2. Consider the physiological changes expected from nursing
interventions as you evaluate patient outcomes
BLOOD PRESSURE
 Physiology of arterial blood pressure: cardiac output, peripheral resistance, blood
volume, viscosity, elasticity
 Factors influencing blood pressure: age, stress, ethnicity and genetics, gender, daily
variation, meds., activity and weight, smoking
 Hypertension
 Hypotension
Nursing Process:
 Assessment- bp equipment for auscultation
 Auscultation- orthostatic hypotension, ultrasonic stethoscope, palpation
 Equipment for oscillometric measurement
 Bp measurement using oscillometric device
 Bp assessment in children
 Lower extremity bp
 Self-measurement bp
 Nursing Diag.- cluster defining characteristics
 Examples of diag. related to bp- activity intolerance, anxiety, impaired cardiac output,
fluid imbalance, acute pain
 Planning and implementation- health promotion (incorporate patient teaching)
 Evaluation- recording VS (documenting on a graphic). Document any interventions
initiated because of VS measurement
Respiration
- The mechanism the body uses to exchange gases between atmosphere & blood and
blood & the cells
- VENTILATION
SAFETY GUIDELINES FOR NUSRING SKILLS
 Clean devices between patients to decrease risk of infection
 Rotate sites during repeated measurements of bp and pulse ox to decrease risk of skin
breakdown
 Analyze trends for VS and report abnormal findings
 Determine the appropriate frequency of measuring VS based on the patient’s condition
 Determine a patient’s status before delegating a VS skill