Week 11: Vital Signs I - Blood Pressure and Pulse Flashcards
When should a nurse take a patient’s vital signs?
Newly admitted for baseline
– baseline important because vitals is good to measure over time (what textbook normal is, isn’t normal for everyone)
As per MD order or facility’s routine - you don’t need to wait for an order
Pre- and post-surgery or certain procedures
Before, during, & after administration of specific drugs
As indicated by client condition/response: “I feel dizzy, weird, funny, different”
It’s always the best place to start with any assessment: tells an amazing story!
what is a pulse?
Diastole feedback about what your heart is doing (diastole = away)
With each ventricular contraction of ~60 mL of blood (stroke volume) a pulse wave travels from the aorta through to the distal ends of the arteries
what should be assessed in a pulse?
rate [bpm], rhythm, strength, & equality (symmetry)
atrium
pumps blood into the ventricle
Recieves blood
Right from body
Left from lungs
contraction phase (letting blood go out), and relaxation phase (letting blood come in)
Ventricle
Accept blood from atrium
Left – all around body
Right – to the lungs
valve in left ventricle
mitral valve
valve in right ventricle
tricuspid valve
heart sounds
S1 - S2
lub” - “dub”
S1 - Signals beginning of systole
- Systole: contraction
- S1 is loudest at apex or left lower sternal border
S2 – Beginning of diastole
- Diastole: relaxation
- S2 is loudest at the base. The top of the heart is the base.
where should the chest be palpated for an apical pulse?
In between ribs, midclavicular line
Men – right under the nipple
Women – under wire of bra
PMI
point of maximal index
when are apical pulses checked?
Any time the radial pulse is irregular*
In children whose rates are difficult to
count at the radial pulse point
Infants < 2 yrs
Whenever uncertainty exists (ie whenever you, as a nurse, decide it’s needed)!
Whenever a pulse deficit exists
Before administering drugs that can
alter heart rate / rhythm ie.digoxin/lanoxin
How do we auscultate the Apical Pulse
Auscultated with stethoscope
Using the diaphragm part of your stethoscope place it at apex of heart
Apex located on the left side of the chest
between the 4th and 5th ribs MCL
Just below left nipple in men, under left
breast in women
Listen for two sounds – LUB / DUB
The louder sound LUB is counted
Count for one full minute (60 seconds)
how to find radial pulse
Adults, children > 3 years
Most easily accessible
Located inside of wrist on thumb side
Place pads of index and middle finger on the artery and apply gentle pressure
Too much pressure and you will obliterate the pulse!
grading pulses
4 - bounding 3 - full, increased 2 - expected 1 - diminished, barely palpable 0 - absent, not palpable
Rhythm pulse
regular, irregular
irregularly irregular
bradycardia
slow heart rate (lower than 60)
Tachycardia
Fast heart rate (higher than 100)
Asystole
No pulse, dead
Arrhythmia
Irregular rhythem
what is blood pressure
In Amy’s words: “How hard your heart needs to work in order to pump blood throughout the body; the top # is maximum force exerted when beating & bottom # is amount of force exerted at rest”
The force exerted on the walls of an artery under pressure from the heart
The peak of maximum pressure with ejection is systolic BP
Minimum pressure exerted when the heart relaxes is the diastolic BP (Stephen & Skillen, 2021, p 107).
why does size matter in a blood pressure kit
To tight – false high
To loose – false low
best practice - BP
5mins, sitting and being quiet
Elevated (by support) around heart level
Feet flat (touching ground), uncrosses
If they can’t get up – can raise bed
normal BP
120/80
Reasons errors in measurement occur BP
Stethoscope applied too firmly/loosely against antecubital fossa
Arm too high or too low
Repeating measurements too quickly (how long in between?)
Inflated too low/high
Cuff too wide/narrow
Cuff wrapped too loosely or unevenly
Cuff deflated too quickly/slowly
Arm held up unsupported
Examiner hearing compromised
