Vital signs 1 Flashcards
Where is the radial pulse?
Superficial to the radius
How do you assess the radial pulse for rate and rhythm?
Method;
1). Undertake hand hygiene.
2). Introduce self and confirm patient’s identity. Write patient’s name and date of birth on
observation chart.
3). Seek informed consent.
4). The radial pulse is felt between the radial styloid and the tendon of flexor carpi radialis. Feel with two or three fingers (not the thumb).
5). Check both radial pulses simultaneously to make sure that they are equal, and then concentrate on the right radial pulse.
6). Count the rate per minute by counting for 15 seconds and multiply by four. To do this you will require access to a clock with a second hand. If the patient’s pulse is irregular or abnormal, it should be counted over 60 seconds. Document the pulse rate on the chart provided.
7). Assess the rhythm: Is it regular? If it is not, is it occasionally irregular, as when an ectopic heart beat occurs, or is it totally irregular? In a patient with a very irregular pulse you may notice not just a variation in rhythm, but also a variation in volume of pulse although this is usually better assessed using the carotid pulse.
Where is the brachial pulse?
Superficial to the brachium
How do you measure blood pressure using a sphygmomanometer?
1). Undertake hand hygiene and clean your stethoscope.
2). Introduce self and confirm patient’s identity. Write patient’s name and date of birth on
observation chart.
3). Seek informed consent to measure blood pressure. Ask the patient if they are experiencing any
discomfort.
4). Position arm on a pillow so that the antecubital fossa is level with the heart and the arm is straight but supported e.g resting on a table surface.
5). Palpate brachial artery in antecubital fossa prior to positioning cuff. This pulse is located medial to
biceps tendon.
6). Wrap a suitably sized cuff around the arm with the lower border of the cuff approximately 2cm
above the antecubital fossa. Ensure the bladder of cuff is to the front.
7). Centre the cuff over the brachial artery (the arrow on the cuff should point towards the artery).
The brachial artery is located medial to the biceps tendon in the antecubital fossa.
8). Identify and palpate the radial pulse.
9). Inflate cuff whilst palpating the radial artery until the pulse disappears and mentally note the pressure on the sphygmomanometer dial.
10). Rapidly and completely deflate cuff. This is the
estimated systolic pressure.
11). Relocate the brachial artery and place the (opened) diaphragm of the stethoscope over the artery.
12).Re-inflate cuff quickly to 20mmHg above the estimated systolic value i.e. the pressure that occluded the radial pulse. (Please note: you will not hear any sound because the pressure in the
tourniquet is completely occluding the flow of blood in the artery)
13). Release the valve gently to slowly deflate the cuff. Listen carefully with the stethoscope and mentally note the pressure when exactly the first sharp thudding sounds are heard (Korotkoff K1). This is the systolic pressure. The biggest error is to underestimate this point. It must be exactly when the sound is first heard, K1.
14). Keep gradually deflating the cuff. The noise will get louder, then soft, then muffled and finally disappears. Mentally note the reading when the sound disappears, K5, the diastolic pressure.
15) Please take care to then quickly and completely deflate the cuff.
16). Document the readings to the nearest 2mmHg (on manual sphygmomanometer) as systolic
pressure over diastolic pressure: – e.g. 112/68 mmHg.
17). If you miss the readings do not re-inflate the cuff immediately. Deflate quickly, wait until the
patient is comfortable and try again.
18). Thank patient and undertake hand hygiene.
19). Explain and discuss significance of result with patient.
How should you document the pulse and BP results on an observation chart
Documenting the results should be carried out immediately.
Documentation details must include: Patient’s name, DOB, date, time and your initials.
What is the word for the apparatus used to take blood pressure?
sphygmomanometer
What is the normal range of heart rate for an adult?
60 to 100 beats per minute
What do the terms bradycardia and tachycardia mean?
Bradycardia - a slow or irregular heart rhythm
Tachycardia - abnormally rapid heart rate
What is an ectopic heart beat?
An ectopic heartbeat is when the heart either skips a beat or adds an extra beat. They are also called premature heartbeats.
Why does the correct cuff size matter?
A BP cuff that is too large will give falsely low readings, while an overly small cuff will provide readings that are falsely high.
Why does the arm need to be supported during blood pressure measurement?
If the upper arm is below the level of the right atrium (when the arm is hanging down while in the sitting position) the readings will be too high.
Why is accurate measurement of blood pressure important?
Accurate blood pressure measurement is vital in the prevention and treatment of blood-pressure–related diseases.
What are Korotkoff sounds?
Korotkoff sounds are produced underneath the distal half of the blood pressure cuff. The sounds appear when cuff pressures are between systolic and diastolic blood pressure, because the underlying artery is collapsing completely and then reopening with each heartbeat.
