Vital Signs
• Temperature (T)
• Pulse (p)
• Respiration (R)
• Blood pressure (BP)
• Pain (often called the fifth vital sign)
VITAL SIGNS ll
WHY ARE TPR BP PAIN
REFERRED TO
AS VITAL SIGNS?
TPR BP PAIN-”VITAL SIGNS”
• SYSTEMIC/ORGAN MANIFESTATION
• IMPORTANT INDICATORS OF HEALTH STATES
• NECESSARY IN DIFFERENTIAL DIAGNOSIS
• IMPORTANT IN ESTABLISHING BASELINE
• INDICATES IMPORTANT CHANGES
• CAN REFLECT IMMEDIACY OF CHANGE
FACTORS AFFECTING PULSE,
RESPIRATION & BLOOD PRESSURE
• AGE
• BODY FLUID
• BLOOD PRESSURE
• DRUGS
• EXERCISE
• FOODS
• TEMPERATURE
• DISEASE PROCESSES
• PAIN
VITAL SIGNS ll
PULSE
&
BLOOD PRESSURE
What is pulse
• “The pulse is the bounding of blood flow in an artery that
is palpable at various points of the body. It is caused by
the stoke volume ejected during systole and distension of
the walls of the aorta, which creates a pulse wave as it
travels rapidly towards the distal end of the arteries.”
(DeLaune & Ladner, Fundamentals of Nursing; 4th ed.
P.505)
• Superficial peripheral pulses can be palpated over a
muscle or bone.
• Pulse pressure is a measurement of the ratio of stroke
volume to compliance of the arterial system (systolic BP
minus diastolic BP)
Sites for Assessing Pulse by Palpation
Question
Which one of the following pulse sites is located on the
inside of the elbow?
A. Temporal
B. Radial
C. Femoral
D. Brachial
Answer
Answer: D. Brachial
Rationale:
The brachial pulse site is located on the inner elbow.
The temporal site is located on the side of the head, the
radial site is on the wrist, and the femoral site is located
on the groin.
Normal pulse rate
• NORMAL Adult: 60-100 BPM
• ATHLETES: may be slightly lower as in the 50’s
• MEN
• WOMEN
When you have cardiovascular systems lecture, you will
learn more complex interpretation of BP and Pulse
Characteristics of the Pulse
• Pulse rate
–
Measured in beats per minute
–
BRADYCARDIA
–
TACHYCARDIA
–
PULSE DEFICIT
• Pulse quality (amplitude)
–
The quality of the pulse in terms of its fullness
–
PULSUS ALTERANS-A WEAK PULSE ALTERNATING WITH A STRONG ONE
–
PULSUS PARADOXUS-DECREASE IN THE STRENGTH OF THE PULSE (& SYS
BP) DURING INSPIRATION—IN ALT DIS STATES e.g. asthma
• Pulse rhythm
–
Pattern of the pulsations and the pauses between them
• Normally regular
• DYSRHTHMIA-REG-IRREG; IRREG-IRREG
Methods of Assessing the Pulse
• Palpating peripheral arteries
• Auscultating the apical pulse with a stethoscope
• Using a portable Doppler ultrasound
• LISTEN AND COUNT THE APICAL PULSE IN ONE FULL
MINUTE
• COUNT PERIPHERAL PULSES IN ONE FULL MINUTE
ESPECIALLY WHEN IT IS IRREGULAR
Palpating the Radial Pulse
Assessing an Apical Pulse
• Indications
– Patient is receiving medications that alter heart rate
and rhythm
– A peripheral pulse is difficult to assess accurately
because it is irregular, feeble, or extremely rapid
• Method
– Count the apical rate for one full minute by listening
with a stethoscope over the apex of the heart
– Most reliable method for infants and small children;
can be palpated with fingertips
BLOOD PRESSURE
Physiology of Blood Pressure
• Force of the blood against arterial walls
• Two factors determine blood pressure:
cardiac output and peripheral vascular
resistance.
Physiology of Blood Pressure
• Cardiac output is the volume of blood pumped by
the heart in one minute. (stroke volume x heart
rate)
• Peripheral vascular resistance is the force in the
blood vessel that the ventricle must overcome to
eject the blood from the heart.
REVIEW-Physiology of Blood Pressure
• Force of the blood against arterial walls
• Two factors determine blood pressure: cardiac output and
peripheral vascular resistance.
• Cardiac output is the volume of blood pumped by the heart in
one minute. (stroke volume x heart rate)
• Peripheral vascular resistance is the force in the blood vessel
that the ventricle must overcome to eject the blood from the
heart.
• Resistance to blood flow is determined by the diameter of the
blood vessel and blood viscosity.
• Controlled by a variety of mechanisms to maintain adequate
tissue perfusion (brain, kidneys, cardiovascular system)
Blood Pressure
– The force of the blood against arterial walls
• Systolic pressure
– The highest point of pressure on arterial walls when
the ventricles contract
• Diastolic pressure
– The lowest pressure present on arterial walls during
diastole is the diastolic pressure (Taylor, 2007).
Physiology of Blood Pressure
• Resistance to blood flow is determined by the
diameter of the blood vessel and blood viscosity.
• Controlled by a variety of mechanisms to maintain
adequate tissue perfusion (brain, kidneys,
cardiovascular system)
NORMAL & ABNORMAL BLOOD PRESSURE
• NORMAL BLOOD PRESSURE READINGS VARY WITH
DIFFERENT AGE GROUPS
• NORMAL ADULT: <120 SYSTOLIC; <80 DIASTOLIC
• PREHYPERTENSION: 120-139 SYSTOLIC OR 80-89
DIASTOLIC
• HYPERTENSION STAGE 1: 140-159 SYSTOLIC OR 90-99
DIASTOLIC
• HYPERTENSION STAGE 2: =OR >160 SYSTOLIC OR =OR
>100 DIASTOLIC
• HYPOTENSION: LOWER THAN NORMAL BP (80/40)
Blood Pressure Assessment (Methods)
• Using a stethoscope and sphygmomanometer
• Using a Doppler ultrasound
• Estimating by palpation
• Assessing with electronic or automated devices
Equipment for Assessing Blood Pressure
• Stethoscope and sphygmomanometer
• Doppler ultrasound
• Electronic or automated devices
TECHNIQUE IN MEASURING BLOOD
PRESSURE, continued
• ASSESSMENT
• SELECT APPROPRIATE LOCATION TO MEASURE BP
• ASSESS FOR BREAST OR AXILLARY SURGERY HX, LIMB
WEAKNESS (HX STROKE)
• PRESENCE OF CAST, IV INFUSION SITE
• PRESENCE OF DIALYSIS SHUNT OR ANY DEVICE ON
LIMBS
• PRESENCE OF WOUNDS, RASHES, LESIONS
• ASSESS SIZE OF LIMB
TECHNIQUE IN MEASURING BLOOD
PRESSURE
• GATHER EQUIPMENT:
• STETHOSCOPE
CUFF THAT IS
CORRECT SIZE FOR PATIENT
• SPHYGMOMANOMETER WITH
• PEN AND PAPER TO RECORD READING
• ALCOHOL SWAB TO CLEAN STETHOSCOPE
• PPE AS INDICATED
CUFF SIZE
• SPHYGMOMANOMETER CUFF SHOULD HAVE BLADDER
WIDTH THAT IS AT LEAST 40% OF THE ARM
CIRCUMFERENCE BETWEEN THE ACROMIAL PROCESS
AND THE OLECRANON.
• THE LENGTH OF THE CUFF SHOULD BE AT LEAST 80%
OF THE ARM CIRCUMFERENCE MIDWAY BETWEEN THE
ACROMION AND THE OLECRANON
TECHNIQUE IN MEASURING BLOOD
PRESSURE, continued
• CHECK PHYSICIAN’S ORDERS
• PERFORM HAND HYGIENE
• IDENTIFY THE PATIENT
• PROVIDE PRIVACY
• PPE AS INDICATED
• SELECT APPROPRIATE ARM FOR CUFF APPLICATION
• SUPINE OR SITTING POSITION
TECHNIQUE IN MEASURING BLOOD
PRESSURE, continued
• IF THE PATIENT IS IN A SITTING POSITION
• HAVE PATIENT/CLIENT LEAN BACK IN THE CHAIR,
SUPPORT HER BACK
• UNCROSS LEGS
• ARM SHOULD BE AT LEVEL OF THE HEART PALM
UPWARD
TECHNIQUE IN MEASURING BLOOD
PRESSURE, continued
• IF THE PATIENT IS IN A SUPINE POSITION
• SUPPORT THE ARM WITH A PILLOW, AT THE LEVEL OF
THE HEART, PALM UPWARD
Proper Positioning for Blood Pressure
Assessment
TECHNIQUE IN MEASURING BLOOD
PRESSURE, continued
• INFLATE THE CUFF WHILE CONTINUING TO PALPATE THE
ARTERY
The point where the pulse disappears provides an
estimate of the systolic pressure. To identify the
first KOROTKOFF sound accurately, the cuff must
be inflated 20-30mm above the point at which the
pulse is no longer felt.
DEFLATE THE CUFF AND WAIT ONE MINUTE
TECHNIQUE IN MEASURING BLOOD
PRESSURE, continued
• ASSUME A POSITION THAT IS NOT 3 FEET AWAY FROM
THE PATIENT
• PLACE THE STETHOSCOPE EARPIECES IN YOUR EARS
• PLACE THE DIAPHRAGM OF THE STETHOSCOPE OVER
THE BRACHIAL ARTERY
• PUMP THE PRESSURE 30 mm Hg ABOVE THE POINT AT
WHICH THE FIRST SYSTOLIC WAS ESTIMATED
• OPEN THE VALVE ON THE MANOMETER AND ALLOW THE
AIR TO ESCAPE SLWLY (GAUGE DROP 2 T0 3 mm/sec)
TECHNIQUE IN MEASURING BLOOD
PRESSURE, continued
• NOTE THE POINT ON THE GAUGE AT WHICH THE FIRST
FAINT, BUT CLEAR, SOUND APPEARS THAT SLOWLY
INCREASES IN INTENSITY.
• NOTE THIS NUMBER AS THE SYSTOLIC PRESSURE.
• READ THE PRESSURE TO THE CLOSEST 2 mm Hg
• DO NOT REINFLATE THE CUFF ONCE THE
AIR IS BEING RELEASED TO CHECK THE
SYSTOLIC READING
TECHNIQUE IN MEASURING BLOOD
PRESSURE, continued
• NOTE THE POINT AT WHICH THE SOUND COMPLETELY
DISAPPEARS. THIS GENERALL CONSIDERED AS THE
DIASTOLIC PRESSURE
• ALLOW THE REMAINING AIR TO ESCAPE QUICKLY
• REPEAT ANY SUSPICIOUS READING, BUT WAIT AT LEAST
ONE MINUTE.
• REMOVE CUFF REMOVE PPE.
• CLEAN STETHOSCOPE WITH ALCOHOL
TECHNIQUE IN MEASURING BLOOD
PRESSURE, continued
RECORD THE FINDINGS ON THE PAPER, OR
FLOWCHART OR ON COMPUTERIZED RECORD
REPORT ABNORMAL FINDINGS TO THE APPROPRIATE
PERSON
IDENTIFY THE BP SITE, PATIENT POSITION
EXAMPLE:
8/17/2011 0800 BP TAKEN RIGHT ARM 120/80, SITING.
Measuring Blood Pressure
• Blood pressure is measured in millimeters of mercury
(mm Hg)
• Blood pressure is recorded as a fraction
– The numerator is the systolic pressure
– The denominator is the diastolic pressure
• Pulse pressure
– The difference between the systolic and diastolic
pressure
– MAP: MEAN ARTERIAL PRESSURE (SYSTOLIC +
TWICE THE DIASTOLIC DIVIDED BY THREE)
Ensuring an Accurate BP Reading
• CONTRIBUTING CAUSES FOR FALSE LOW READING
• HEARING DEFICIT, NOISE
• PUTTING EARPIECE OF STETHOSCOPE INCORRECTLY
• RELEASING VALVE TOO QUICKLY
• INCORRECT PLACEMENT OF STET DIAPHRAGM
• TOO WIDE CUFF
• FAILING TO PUMP CUFF 20-30 mmHg ABOVE
DISAPPEARANCE OF PULSE
Ensuring an Accurate BP Reading
• CONTRIBUTING CAUSES TO FALSELY HIGH ASSESSMENT
• USING A MANOMETER NOT CALIBRATED AT ZERO MARK
• CUFF TOO NARROW
• RELEASING THE VALVE TOO SLOWLY
• ASSESSING BP IMMEDIATELY AFTER EXERCISE,
SMOKING WITHIN 30 MINUTES, RECENT CAFFEINE
INTAKE
• REINFLATING THE BLADDER DURING AUSCULATION
Factors Affecting Blood Pressure
• Age
• Exercise
• Position
• Weight
• Fluid balance
• Smoking
• Medications
Occasions for Measuring Vital Signs
• Screenings at health fairs and clinics
• In the home
• Upon admission to a healthcare setting
• When certain medications are given
• Before and after diagnostic and surgical procedures
• Before and after certain nursing interventions
• In emergency situations