Vital Signs Flashcards
1
Q
Description of Vital signs and name the 5
A
▪ Vital signs are a person’s
1. temperature (T)
2. pulse (P)
3. respiration (R)
4. blood pressure (BP)
5. Pain
Pulse oximetry, the noninvasive measurement of
arterial oxyhemoglobin saturation of arterial blood, is also often included with the measurement of vital signs.
2
Q
Objective and Definition of Vital Sign
A
Objective: Measurement of one’s overall health status.
A change in vital signs may indicate a change in health.
3
Q
What are the general guidelines when assessing vital signs?
A
- Measuring vital signs is your responsibility.
- Healthcare provider 5 patients, you are responsible for 5 patients unless in your institution you have other modalities of care aside from general ruling
- Assess equipment to ensure that it is working correctly and provides accurate findings.
- aneroid: gauge
- if the manometer does not point to 0, you have to
calibrate to achieve normal results
- You need to calibrate it
- They should have not have a defect - Select equipment on the basis of the patient’s condition and characteristics
- The BP cuff fit properly - Know the patient’s usual range of vital signs
- partial systolic pressure
- range or baseline data of patient - Know your patient’s medical history, therapies, and prescribed medications
- Adverse effects: palpitation; : side effect of drug
- PATHOLOGIC
- What the patient has
- Eg have hypertension they won’t have a normal BP - Control or minimize environmental factors that affect vital signs
- Temperature
- Too hot too cold - Use an organized, systematic approach when taking vital signs
- assemble all materials that you need before doing the procedure
- Follow procedural in making or doing vital signs
- Organized - assemble all the materials
- Systematic - Orderly manner - On the basis of a patient’s condition, collaborate with health care providers to decide the frequency of vital sign assessment.
- One parameter/order may have something to do
with other interventions of other healthcare
professional
- Collaboration - You are a team working for one end goal
- Physician, nurse, pharmacist
- It may have other factors
- Eg surgeon - Use vital sign measurements to determine indications for medication administration
- standard maintenance dose; backup medication
- Eg anti hypersensitive tract
- When BP shoots up you need to take this type of medication
- You need to have your vital signs
- You need to know first before you drink - Verify and communicate significant changes in
vital signs
- not enough to know
- denotes patient deterioration
- You need to communicate with the physician
- You don’t know if decrease or increase can
cause a coma
4
Q
State the 6 ways on when to assess vital signs
A
- Upon admission and before discharge of the
client. - At the start of every shift.
- Before, during and after an invasive procedure
- Before and after an intervention, therapy or
treatment. - Before and after medication administration
- Whenever a client’s condition changes
5
Q
Description of Upon admission and before discharge of the client
A
- ER
- Ward
- Admission (ER & Ward)
6
Q
Description of At the start of every shift.
A
- If you have 8 hour shift
- At the start of every shift you take the vital signs
7
Q
Description of Before, during and after an invasive procedure
A
What is an invasive procedure?
Anything that they insert, makes a cut and insert or an opening in the body and inserts
Ex: Catheterization, NGT insertion
Bedside procedures
- insertion
Diagnostic procedure
- endoscopy
- biopsy
8
Q
Description of Before and after an intervention, therapy or treatment.
A
Therapy
- Physical
- Occupational
9
Q
Description of Before and After medication administration
A
Just Before and After medication administration
10
Q
Description of Whenever a client’s condition changes
A
Level of Consciousness
- conscious
- lethargic - Sleepy or fatigued and sluggish
- stupor - Near unconsciousness
- coma
For as long as the change or discrepancy is not significant, the standard vital signs table is credible
11
Q
ACCEPTABLE RANGES OF VITAL SIGNS FOR ADULTS: Temperature
A
Tympanic 36.5 - 38.1°C
Oral 36.4 - 37.6°C
Rectal 37 - 38.1°C
Axillary 35.9 - 37.0°C
Temporal 37 - 38°C
(NOTE: References may vary)
12
Q
ACCEPTABLE RANGES OF VITAL SIGNS FOR ADULTS: Pulse
A
60 - 100 bpm
13
Q
ACCEPTABLE RANGES OF VITAL SIGNS FOR ADULTS: Respiration
A
12 - 20 bpm
14
Q
ACCEPTABLE RANGES OF VITAL SIGNS FOR ADULTS: Blood pressure
A
SBP <120 (less than)
DBP <80 mmHg (less than)
Pulse pressure
30 - 50 mmHg
SBP - Systolic (start)
DBP - Diastolic (end)
15
Q
HOW TO CALCULATE FOR PULSE PRESSURE
A
Pulse pressure = Systolic - diastolic
(120 - 80 = 40)
30-50 is the normal pulse pressure
90 pulse = wide
16
Q
ASSESSING BODY TEMP
A
- Oral temp
- Ear temp
- Rectal temp
- Axillary temp
- Temporal artery temp
17
Q
Definition of Body Temperature
A
The result of the amount of heat produced and the amount of heat lost by the body.
18
Q
Purposes of Body Temperature
A
- To obtain baseline information
- To assess the progression of an illness
- Eg Dengue
- Infection UTI - To monitor a response to therapy
- Progression
19
Q
2 TYPES OF BODY TEMP
A
- Core temperature
- Inside the body
- Rectal
- Oral cavity
- Tympanic membrane
- Surface temperature
- Skin & axillae
20
Q
WHAT IS THE DIFFERENCE BETWEEN THE 2 CONTROL CENTERS?
(Anterior & Posterior hypothalamus)
A
Compensatory Mechanism to achieve HOMEOSTASIS
They need to work hand in hand for us to be able to have homeostasis
21
Q
Description of anterior hypothalamus
A
- Control heat loss; nerve sensors send out signals that initiate sweating, peripheral vasodilation and inhibition of heat production
- Too hot we want to stay cool
- Sweating
22
Q
Description of Posterior hypothalamus
A
- Controls heat productions; nervous sensors send out signals that initiate shivering, vasoconstriction (increases BP), release of epinephrine
- compensatory mechanism
- Super cool want to stay warm
- Shivering
23
Q
FACTORS THAT PROMOTE HEAT PRODUCTION
A
- Basal metabolic rate
- Muscle activity
- Thyroxine production
- Epinephrine, norepinephrine, and sympathetic
stimulation stress response - Fever.
24
Q
Description of BASAL METABOLIC RATE (BMR)
A
Number of calories burned performing basic life sustaining functions
- Different metabolic rates that affects heat
production - Eg laying in bed we have resting metabolic rate
- It has a link to heat production
- Higher metabolic rate = More heat production
25
Description of MUSCLE ACTIVITY
Ranges from internal substance movement to exterior muscle locomotion
- Internal substance movements
- Controls body heat
- Contraction of skeletal muscle
- Metabolism increases and released as heat
26
Description of THYROXINE PRODUCTION
Thyroxine is a thyroid hormone
- Hyperthyroidism
- Hypothyroidism
Stimulated neurological system affects heat production
Hyperthyroidism (hotter) - Thyroid glands produces too much hormone thyroxine causing unintentional weight loss and rapid or irregular heartbeat
Hypothyroidism (cooler) - Thyroid gland doesn’t produce enough hormones
- Blood vessels
- Secrete different hormones to aid different production
- Thyroid hormones
- If you have too much thyroxine they always feel hot
- Hypothyroid - to make the ppl cooler
27
Description of EPINEPHRINE, NOREPINEPHRINE, AND SYMPATHETIC STIMULATION STRESS RESPONSE
neurotransmitter and hormone also known as adrenaline “fight or flight response”
Stress - Epinephrine body responses
- Flight or flight response
- Adrenal glands give epinephrine which causes an increase in body temperature
28
Description of FEVER
our body's attempt to fight an infection, produces more White Blood Cells that affects hypothalamus that increases body temperature (heat production)
29
FACTORS THAT PROMOTE HEAT LOSS
1. Conduction
2. Radiation
3. Convection
4. Vaporization
(evaporation
30
Description of conduction
The process of losing heat through physical contact with another object or body. For example, if you were to sit on a metal chair, the heat from your body would transfer to the cold your body would transfer to the cold metal chair
31
Description of radiation
Form of heat loss through infrared rays.
This involves the transfer of heat from one object to another, with no physical contact involved. For example, the sun transfers heat to the earth through radiation
32
Description of convection
The transfer of heat from a body to moving molecules such as air or liquid
Convection is the process of losing heat through the movement of air or water molecules across the skin.
33
Description of Vaporization (evaporation)
Loss of heat that occurs when a liquid is converted to a vapor
34
FACTORS AFFECTING TEMPERATURE
1. Age
2. Diurnal variations
3. Environment
4. Exercise
5. Hormones
6. Stress
35
Description of age
Influenced by the environment
extreme ages due to thermoregulation functions
- young - not fully developed
- old - easily deteriorated
36
Description of Diurnal variations
Changes throughout the day
Diurnal Cycle: vital signs can change due to metabolic rate
Changes through out the day
- Urinal cycles
- Vital signs can change
37
Description of Environment
- Too hot and too cold
38
Description of exercise
the more you engage in strenuous activity, the more you increase body temperature
39
Description of hormones
Progesterone rises body temperature
Synthetic production system
40
Description of stress
stimulation of the sympathetic nervous system can increase the production of epinephrine and norepinephrine thereby increasing metabolic rate and heat production
41
TYPES OF THERMOMETER
- Digital and paper strip thermometer
- Temperature Sensitive Skin Tape
Tympanic thermometer
Temporal Artery thermometer
42
ROUTES OF TEMPERATURE ASSESSMENT
1. Oral
2. Rectal
3. Axillary
4. Tympanic
43
Where is the oral route?
In the mouth
44
Advantages of the Oral Route
▪ most accessible and convenient
▪ reflects rapid change in core temperature
45
Disadvantages of the Oral Route
▪ contraindicated in children below 3 y/o
- chew/play/remove
▪ Seizure-prone client
- jaw tightening causing injury as paced under the tongue, hypervascularized which is very fragile
▪ Confused irrational and unconscious clients
▪ clients who experience nausea and vomiting
▪ contraindicated after oral and nasal surgery.
46
Client Care Considerations for Oral Route
1.Ensure that the client has not smoke or
ingested hot or cold foods or liquids for 9
minutes before measurement and capable
of sealing the lips around the
thermometer.
2.Insert the thermometer under the tongue
in the posterior sublingual pocket.
3. Hold the thermometer in place until
temperature is obtained.; 3-5 minutes for a
glass or plastic thermometer.
4. Wash the thermometer
a. Bulb to stem (before use) - tip to body
b. Stem to bulb (after use) - body to tip
47
Where is the rectal route?
In the rectal
48
Advantages of Rectal Route
▪most accurate and reliable measurement of temperature
49
Disadvantages of Rectal Route
▪inconvenient and difficult to clients who are unable to turn to sides
- Bedridden
- Stroke patients
- Impacted stool
▪ presence of stool may interfere with thermometer placement
▪ may cause ulcerations and rectal perforations in children and infants
▪ contraindicated to client with diarrhea, after rectal and/or prostatic surgery or injury, recent myocardial infarction and post head injury
- May stimulate subnoval maneuver (pagire)
- Increased workload on the heart
- Increased ICP (Increased Intracranial Pressure)
▪ may embarrass the client; requires
privacy
▪ contraindicated for newborns; clients with hemorrhoids, or a fragile rectal mucosa and those underwent colon and rectal surgery, clients with heart conditions
- Imperforate anus
- Newborn - There is a procedure where we get
the temperature per anus
- Check if there is an anal opening
- Some may have imperforiated anus (no hole)
50
Client Care Considerations for Rectal
1. Draw the curtain and position the client
properly.
2. Wash hands and don gloves.
3. Lubricate the tip of the thermometer.
4. Raise the upper buttock with one hand,
instruct the client to take a deep breath
while inserting the thermometer into the
anus.
▪ 1 – 1.5 inches = adult
▪ 0.5 - 0.9 inches = child
▪ 0.5 inches = infant
5. Hold the thermometer in place until it is time of
removal; 2 minutes (adult) & 5 minutes (infants).
6. Remove, clean and read the thermometer.
7. Remove any gel from perianal area after
the removal.
8. Remove and discard your gloves in an
appropriate receptacle; wash your hands.
51
Where is the axillary route?
Armpit
52
Advantages of Axillary route
▪ Safest and non-invasive; accessible
▪ Can be used for newborns and uncooperative clients
53
Disadvantages of Axillary route
▪ Thermometer must remain in place for long periods; approx. 8 minutes.
▪ Not as accurate as rectal route
54
Client Care Considerations for axillary route
1. Pat dry the axilla if moist.
2. Place the thermometer in the middle of the axilla and instruct to position the arms across the chest.
3. Leave the thermometer for 8-10 minutes.
4. Remove the thermometer and wipe with
rotating motion from stem to bulb.
5. Hold the thermometer at eye level.
6. Read the temperature.
7. Clean the thermometer with soap and water (if
mercurial glass).
8. Use same thermometer for repeat temperature
taking to ensure accuracy.
55
Where is the tympanic route?
Ear
56
Advantages of tympanic route
▪ Easily accessible
▪ Reflects results within seconds
▪ Unaltered by eating, smoking, drinking, and
oxygen administration
▪ Can be used for infants, unconscious and
dyspneic clients.
57
Disadvantages for tympanic route
▪ Equipment is expensive
▪ Can be uncomfortable
▪ Contraindicated for clients with ear infection and
those who underwent ear surgery
▪ Earwax may result to inaccurately low result
58
Client Care Considerations for Tympanic route
1. Clean the lens under the probe before use.
2. Straighten the ear canal.
▪ Pull the pinna UP and BACK (adult).
▪ Pull the pinna DOWN and BACK (children 3
years and younger).
3. Insert the probe into the ear canal firmly but
gently towards tympanic membrane.
4. Push the button to take the temperature.
5. Remove the device when it beeps.
6. Eject the probe cover into an appropriate trash receptacle.
7. Repeat procedure for the other ear using a new
probe cover.
59
Where is the temporal artery?
Head
60
Advantages of Temporal Artery
▪ Easily accessible
▪ Reflects results within seconds
▪ Unaltered by eating, smoking, drinking, and
oxygen administration
▪ Can be used for infants, unconscious and
dyspneic clients.
61
Disadvantages of Temporal Artery
▪ Head covering, hair or temporal area against a
pillow or mattress can cause inaccurately high
results.
▪ Influenced by perspiration
62
Client Care Considerations for Temporal Artery
1. Determine that the site is not influenced by hair, a hat or lying on a pillow or mattress.
2. Dry the site if there is perspiration.
3. Ensure the device is charged.
4. Remove the protective cap & clean the probe
following the manufacturer’s instructions.
5. Place probe with gentle pressure on the center
of the forehead, halfway between the hairline and eyebrows.
6. Depress and hold the start button while dragging the probe laterally across the forehead to the opposite hairline.
7. Continue to depress the start button and touch the probe behind the ear lobe on the soft area below the mastoid process.
8. Release the button and read the result.
9. Clean the probe.
63
Alterations in Body Temperature
A. Decreased body temperature
1. Hypothermia - Body temperature < 36°C (less than)
2. Severe hypothermia - Body temperature < 28°C (less than)
B. Increased body temperature
1. Hyperthermia - Temperature >40.5°C
a. Heat exhaustion - Caused by excessive environmental heat and dehydration
Clinical indicators: Weakness, muscle aches,
headache, syncope, N/V, pallor, dizziness,
diaphoresis.
b. Heat stroke - caused by exercise in hot
weather
Clinical indicators: Flushed, hot & dry skin;
throbbing headache; rapid, strong pulse;
Watch Out For: Impaired judgment, delirium,
unconsciousness & seizure
64
10 Clinical indicators
- Shivering initially
- Decreased, irregular pulse
- Decreased respirations
- Hypotension
- Pale, cool skin
- Oliguria
- Reduced muscle coordination
- Disorientation
- Decreased level of consciousness
- WOF (watch out for): Coma
65
Fever (pyrexia, febrile)
Temperature 37.8°C (orally) or 38.3°C (rectally).
NOTE: Fever up to 38.9°C enhances immune response, promote phagocytosis, hinder reproduction of pathogens.
66
Hyperpyrexia
temperature of 41°C or more.
Clinical indicators: agitation, confusion, stupor (unconsciousness) and may progress to coma.
67
Definition of Pulse
⮚ wave of blood created by contraction of the left
ventricles of the heart.
⮚ regulated by autonomic nervous system (involuntary)
68
What are the related terms of pulse?
- Stroke volume
- Cardiac output
69
Definition of Stroke Volume
Amount of blood that enters the aorta with each ventricular contraction.
70
Definition of Cardiac Output
Amount of blood pumped by the heart in one full minute.
71
FACTORS AFFECTING PULSE RATE
1. Age
2. Sex
3. Exercise
4. Fever
5. Medications
6. Stress and hormones
7. Blood volume
8. Position
72
Description of age - Pulse rate
As age increases the pulse rate gradually decreases
73
Description of sex - Pulse rate
After puberty the average male’s pulse rate is slightly lower than the female
74
Description of Exercise - Pulse rate
The pulse rate increases with activity especially if it's vigorous. When engaged in very strenuous exercise
75
Description of Fever - Pulse rate
- The pulse rate increases due to response due to the lowered blood pressure that results from peripheral vasodilation because when there is fever there is vasodilation & increased metabolic rate
- Increased BMR. It is one factor which in charge of heat production
76
Description of Medications - Pulse rate
- Decreases the pulse rate and other increases the pulse rate
- Eg cardiac tracts, cardiotonics, bronchodilators (people who have asthma. One effect is increase in pulse rate)
77
Description of Stress and Hormones - Pulse rate
- Increase your pulse rate
78
Description of Blood volume - Pulse rate
- Decrease in blood volume it can affect the pulse rate
79
Description of Position - Pulse rate
Check your pulse in a supine position (lying position) and during standing assume different positions and check your pulse, there is a little difference.
80
Name the Pulse Sites
1. Head - Temporal
2. Carotid pulse - Side of the neck
3. Apical - Apex of the heart
4. Brachial - Arm
5. Radial - Along the radial bone
6. Femoral
7. Popliteal - Behind the knee
8. Posterior tibial
9. Dorsalis pedis
81
Description of Head - Temporal = Pulse site
- Temporary artery passes over the temporal bone of the head
- Superior & lateral to the eye
- We use this when the radial pulse is not accessible
82
Description of Carotid pulse - Side of the neck = Pulse site
- Where the carotid artery runs between the trachea & the sternocleidomastoid muscle
- We use this during cardiac arrest, shock in adults, used to determine the circulation to the brain
- Used for emergency situations.
83
Description of Apical - Apex of the heart = Pulse site
- Adult - Located on the left side of the chest
- 8cm to the left of the sternum (breastbone)
- Fifth intercostal space between the ribs
- Use for infants to children up to 3 years of age to observe during assessment when you take the heart rate
- Used to determine discrepancy in radial pulse
- During consultations with a doctor
84
Description of Brachial - Arm = Pulse Site
- Used for palpating in BP taking
- Inner aspect of your bicep muscles of the arm or medially in the antecubital space
- Used for cardiac arrest for infants
85
Description of Radial Along the radial bone = Pulse site
- Common site wherein you get the pulse of an adult patient
- Radial artery along the radial bone on the thumb side of the inner aspect of the wrist
86
Description of Femoral = Pulse site
- Where the femoral artery is along the inguinal ligament
- We use incase of cardiac arrest or shock
- Used to determine the circulation of the leg
87
Description of Popliteal - Behind the knee = Pulse site
- Used to determine the circulation of the lower leg
88
Description of Posterior tibial = Pulse site
- Used to determine the circulation of the foot
89
Description of Dorsalis pedis = Pulse site
- Used to determine the circulation of the foot
- Artery passes of the bones of the foot
- From the middle of the angle to the middle of the big toe and second toe.
90
State the 2 Techniques in Pulse Assessment
1. Palpation
2. Auscultation
91
Description of Palpation
⮚ Select the pulse site.
⮚ Place the client in a comfortable resting position.
⮚ Place two or three fingertips and apply moderate pressure. Do not use thumb to palpate arterial pulsation.
⮚ Count for 1 full minute to obtain accurate picture of rate and irregularities.
92
Description of Auscultation
⮚ Use the diaphragm of the stethoscope to count the
apical pulse at Left 5th ICS MCL for adult and Left 4th ICS MCL for children.
⮚ Make sure the tubing extends straight as kinks can
distort sound transmission.
ICS = Intercoastal space
MCL - Midclavical
93
APICAL-RADIAL PULSE ASSESSMENT
- An apical-radial pulse may need to be assessed for clients with certain cardiovascular disorders.
- Normally, the apical and radial rates are identical.
If there is a significant deviation (difference) then it
needs to be evaluated or the patient needs to undergo
more diagnostic procedure (cardiovascular procedures)
Eg ECG, Treadmill
PULSE DEFICIT- significant deviation/ discrepancy between the two pulse rates
94
STATE THE PULSE SCALE
0 = Pulse is Absent
1+ = Pulse is weak
2+ = Pulse is normal
3+ = Pulse is bounding
95
Definition of Respiration - Act of breathing
⮚ movement of gases into and out of the lungs, promoting an exchange of gases between the atmosphere and the capillary beds in the alveoli.
- Take note of the rate, depth, rhythm, quality &
effectiveness of respiration
- Described “in breathes per minute”
⮚ involves inhalation and exhalation.
96
2 TYPES OF BREATHING:
1. Coastal breathing
2. Diaphragmatic breathing
97
Description of Coastal Breathing
External intercostal muscles (shoulder blade) and other accessory muscles, such as the sternocleidomastoid muscles
- You can observe the rise and fall during breathing
- For patients who have difficulty of breathing
- Eg patients suffering abnormalities of the respiratory
system (pateints with emphysema, copd)
- The shoulder blades, torso it is widened because of the
lots of use
98
Description of Diaphragmatic breathing
The contraction and relaxation of the diaphragm, and it is observed by the movement of the abdomen
- Normal breathing for adults
99
FACTORS AFFECTING RESPIRATION:
Increases respiratory rate
1. Exercise (increases metabolism)
- The more strenuous exercise the more it increases our
respiration
2. Stress (readies the body for “fight or flight”)
3. Increased environmental temperature
4. Lowered oxygen concentration at increased altitudes.
- If you go to high lands (baguio, tagaytay) you have a
difficult time breathing due to low oxygen levels
100
FACTORS AFFECTING RESPIRATION
Decreases respiratory rate
1. Decreased environmental temperature
- When it is hot it affects
2. Certain medications (e.g., narcotics)
- Given to patients who have pain
- In the hospital recovery room if the patient is given
narcotics there is always an order to monitor since it
can cause respiratory depression. (regulated drugs)
3. Increased intracranial pressure
- If the patient sustained head injury and all of the
sudden heart rate decreases there is a problem there
might be an increase in your ICP
- 1 parameter
101
ASSESSING RESPIRATIONS
A. Count respiration with client in comfortable position. Place client’s arm in relaxed position across abdomen or lower chest
B. Discreetly observe the rise and fall of the chest
- Assume you are not done taking the pulse rate of the
patient but in reality you are already done
- So the patient will not be conscious since the patient
can increase or decrease their heart rate
- Do not tell them you are getting respiratory rate
assume you are still getting their pulse rate
C. Observe the character of respirations
102
STATE RATE OF RESPIRATIONS
A. Eupnea
B. Tachypnea
C. Bradypnea
D. Apnea
E. Hyperpnea
103
Definition of Eupnea
Normal
104
Definition of Tachypnea
Fast
105
Definition of Bradypnea
Slow
106
Definition of Apnea
Absence of breathing
107
Definition of Hyperpnea
labored respiration normally occurring during exercise
You are trying to catch up with your breathing
108
STATE EFFORT OF RESPIRATIONS
1. Dyspnea
2. Orthopnea
109
Definition of Dyspnea
Difficulty in breathing
110
Definition of Orthopnea
Ability to breathe only in upright, sitting or standing position.
111
Definition of Blood Pressure
Pressure exerted by blood against the walls of the
arteries.
Blood moves in waves
112
3 TYPES OF BLOOD PRESSURE
1. Systolic pressure
Ventricular contraction
1st beat
2. Diastolic pressure
Ventricular relaxation
last beat
3. Pulse pressure
Difference between systolic and diastolic pressure
113
4 PHYSIOLOGICAL DETERMINANTS OF BLOOD PRESSURE
1. PUMPING ACTION OF THE HEART
2. BLOOD VOLUME
3. PERIPHERAL VASCULAR RESISTANCE
4. BLOOD VISCOSITY
114
Description of Pumping action of the heart
When the pumping action of the heart is weak, less blood is pumped into arteries (lower cardiac output), and the blood pressure decreases.
When the heart’s pumping action is strong and the volume of blood pumped into the circulation increases (higher cardiac output), the blood pressure increases.
For example:
If you have an old patient and their pumping action of the heart is weak they will have lower cardiac output and sometimes the blood pressure is decreased
For an adult the pumping action is strong so there is a higher cardiac output.
115
Description of Blood volume
When the blood volume decreases (for example, as a result of a hemorrhage or dehydration), the blood pressure decreases because of decreased fluid in the arteries.
- Hemorrhage - severe breathing
Conversely, when the volume increases (for example, as a result of a rapid intravenous infusion), the blood pressure increases because of the greater fluid volume within the circulatory system.
- Reason why we need to regulat our IV fluid diligently
and check every now and then since the patient can
manipulate
116
Description of Peripheral vascular resistance
Something to do with blood vessels
The internal diameter or capacity of the arterioles and the capillaries determines in great part the peripheral resistance to the blood in the body.
- The elederly are usally more affected, chronic
illnesses especially with cardiac abnormalities
The smaller the space within a vessel, the greater the resistance. Normally, the arterioles are in a state of partial constriction.
- Eg you have a patient with an unhealthy lifestyle that
inhinders the person so their arterioles get narrow
especially with smoking as it can cause
vasoconstriction.
Increased vasoconstriction, such as occurs with smoking, raises the blood pressure, whereas decreased vasoconstriction lowers the blood pressure
- The more blood vessel constricted the higher the
pressure
117
Description of Blood viscosity
Blood pressure is higher when the blood is highly viscous (thick),that is, when the proportion of red blood cells to the blood plasma is high.
- When the proportion of blood cells to the blood plasma
is high
- The more viscous = pressure increases
- Eg patients suffering from diabetes the patients due to
the glucose the blood become viscous. Most of them
are hypertensive
- Proportion is referred to as the hematocrit. The
viscosity increases markedly when the hematocrit is
more than 60% to 65%.
118
STATE THE PERSONAL DETERMINANTS OF BLOOD PRESSURE
1. Age
2. Exercise
3. Stress
4. Race
5. Sex
6. Medications
7. Obesity
8. Dinural variations
9. Medical conditions
119
Description of Age - Personal Determinants
of Blood Pressure
Older people have higher blood pressure due to decreased elasticity of blood vessels
120
Description of Exercise - Personal Determinants
of Blood Pressure
Physical activity increases the cardiac output and hence the blood pressure.
121
Description of Stress - Personal Determinants
of Blood Pressure
Stimulation of the sympathetic nervous system increases the blood pressure reading;
122
Description of race - Personal Determinants
of Blood Pressure
African Americans over 35 years tend to have higher blood pressures than European Americans of the same age
123
Description of Sex - Personal Determinants
of Blood Pressure
After puberty, females usually have lower blood pressures
than males of the same age; this difference is thought to be due to hormonal variations. After menopause, women generally have higher blood pressures than before.
124
Description of Medications - Personal Determinants
of Blood Pressure
Many medications, including caffeine, may increase or decrease the blood pressure.
125
Description of Obesity - Personal Determinants
of Blood Pressure
Both childhood and adult obesity predispose to
hypertension.
126
Description of Diurnal variations - Personal Determinants
of Blood Pressure
Pressure is usually lowest early in the morning, when the metabolic rate is lowest, then rises throughout the day and peaks in the late afternoon or early evening.
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Description of Medical conditions - Personal Determinants of Blood Pressure
Any condition affecting the cardiac output, blood volume, blood viscosity, and/or compliance of the arteries has a direct effect on the blood pressure.
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Client Care Considerations - Personal Determinants of Blood Pressure
1. Ensure that the client is rested
2. Allow 30 minutes to pass if the client had engaged
in exercise or had smoked or ingested caffeine
before taking the BP.
3. Use appropriate size of the BP cuff. Too narrow
cuff causes false high reading. Too wide cuff
causes false low reading.
4. Position the client in sitting or supine position
5. Position the arm at the level of the heart, with the
palm of the hand facing up. The left arm is
preferably used because it is nearer the heart
6. Apply BP cuff snugly, 1 inches above the
antecubital space
7. Use the bell of the stethoscope since the BP is a
low-frequency sound
8. Inflate and deflate BP cuff slowly, 2-3 mmHg at a
time
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ASSESSING BLOOD PRESSURE
* The blood pressure is usually assessed in the client’s
upper arm using the brachial artery and a standard
stethoscope.
Assessing the blood pressure on a client’s thigh is
indicated in these situations:
* The blood pressure cannot be measured on either arm
(e.g., because of burns or other trauma).
* The blood pressure in one thigh is to be compared with
the blood pressure in the other thigh.
Blood pressure is not measured on a particular
client’s limb in the following situations:
* The shoulder, arm, or hand (or the hip, knee, or
ankle) is injured or diseased.
* A cast or bulky bandage is on any part of the
limb.
* The client has had surgical removal of breast or axillary (or inguinal) lymph nodes on that side.
*The client has an intravenous infusion or blood transfusion in that limb.
*The client has an arteriovenous fistula (e.g., for renal dialysis) in that limb.
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WHAT ARE THE OTHER VITAL SIGNS
* Pain assessment
* Oxygen Saturation
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DESCRIPTION OF PAIN
⮚ an unpleasant and highly personal experience
that maybe imperceptible to others, while
consuming all parts of the person’s life.
⮚ subjective data; “what & where the client says
it is.”
⮚ Pain Assessment Scale: 0-10
* Zero-No pain
* 10-Worst Possible scale
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ASSESSING PAIN
1. Check the temperature, pulse rate, respiration,
and blood pressure. If the client is in pain, proceed to
the succeeding steps.
2. Ask the patient to point to the pain (location).
3. Determine the severity. Three scales are
commonly used:
a. Visual Analog scale
b. Numeric rating scale (1-10)
c. Faces pain scale
4. Ask the patient to describe the pain and how it started
(associated features). Pursue the seven (7) features/attributes of pain, as you would with any symptom:
a. Location. Where is it? Does it radiate?
b. Quality. What is it like?
c. Quantity or severity. How bad is it? (For pain, ask for a
rating on a scale of 1 to 10.)
d. Timing. When did (does) it start? How long did (does) it
last? How often did (does) it occur?
e. Setting in which it occurs. Include environmental
factors, personal activities, emotional reactions, or other
circumstances that may have contributed to the illness.
f. Remitting or exacerbating factors. Does anything
make it better or worse?
g. Associated manifestations. Have you noticed anything
else that accompanies it
5.Refer to the primary care provider as necessary.
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DESCRIPTION OF OXYGEN SATURATION
* A pulse oximeter is a noninvasive device that estimates a client’s arterial blood oxygen saturation (SaO2) by means of a sensor attached to the client’s finger
* The oxygen saturation value is the percent of all hemoglobin binding sites that are occupied by oxygen.
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WHAT IS THE NORMAL OXYGEN SATURATION
Normal oxygen saturation is 95% to 100%, and below 70% is life threatening
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MEASURING OXYGEN SATURATION
ASSESS
a. The best location for a pulse oximeter sensor based on
the client’s age and physical condition. Unless
contraindicated, the finger is usually selected for adults.
b. The client’s overall condition including risk factors for
development of hypoxemia (e.g., respiratory or cardiac
disease) and hemoglobin level
c. Vital signs, skin color and temperature, nail bed color,
and tissue perfusion of extremities as baseline data
d. Adhesive allergy
2. Assemble the necessary equipment:
a. Nail polish remover as needed
b. Alcohol wipe
c. Sheet or towel
d. Pulse oximeter
3. Check if the pulse oximeter is functioning
normally
IMPLEMENTATION
1. Prior to performing the procedure, introduce self and verify the client’s identity using agency protocol. Explain to the client what you are going to do, why it is necessary, and how he or she can participate. Discuss how the results will be used in planning further care or treatments.
2. Perform hand hygiene and observe appropriate infection control procedures.
3. Provide for client privacy.
4. Prepare the site. Remove nail polish with acetone or polish remover if there is, as it may interfere with accurate
measurement.
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MEASURING OXYGEN SATURATION
Clinical Decision Point:
a. Do not attach sensor to finger, ear, forehead, or bridge
of nose if area is edematous or skin integrity is
compromised.
b. Do not attach sensor to fingers that are hypothermic.
Select forehead, ear, or bridge of nose if adult patient has
history of peripheral vascular disease
c. Do not use earlobe and bridge of nose sensors for
infants and toddlers because of skin fragility.
d. Do not use disposable adhesive sensors if patient has
latex allergy.
e. Do not place sensor on same extremity as electronic
blood pressure cuff because blood flow to finger is
temporarily interrupted when cuff inflates and causes
inaccurate readings that trigger alarm
5. Once sensor is in place, turn on oximeter by
activating power. Observe pulse
waveform/intensity display and audible beep.
Correlate oximeter pulse rate with patient’s radial
pulse.
Differences require reevaluation of oximeter sensor
placement and may require reassessment of pulse
rates
6. Leave sensor in place until oximeter
readout reaches constant value and pulse
display reaches full strength during each
cardiac cycle. Inform patient that oximeter
alarm will sound if sensor falls off or patient
moves sensor. Read SpO2 on digital
display.
7. Assess skin integrity every 2 hours under sensor.
Routinely relocate sensor at least every 24 hours or more
frequently. This is especially important if skin integrity is
altered or tissue perfusion is compromised. Use care
during removal to avoid damage to skin.
8. Clean the surface of a reusable sensor between patients with 70% Isopropyl alcohol solution or solution
recommended by manufacturer.
9. Discuss findings with patient as needed.
10. Perform hand hygiene.
11. Record SpO2 on vital signs flow sheet
