Download Chapter 17

Fundamentals of Nursing Care: Concepts, Connections, & Skills
Chapter 17
Vital Signs
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Six Vital Signs






Blood pressure (BP)
Temperature (T)
Pulse (P)
Respiration (R)
Oxygen saturation (SpO2)
Pain
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Six Vital Signs





TPR
BP
Pulse oximetry (pulse ox) or oxygen saturation
Pain
Be sure to collect a full set of vital signs
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Significance of the Five Objective
Vital Signs
 Reveal how certain systems are functioning
 Provide data regarding patient’s overall
condition
 Provide a baseline against which subtle
changes can be measured
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Significance of Vital Signs
 Monitor patient’s physiological condition
 Identify new problems
 Determine if an intervention should be
performed
 Determine if prior interventions were effective
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Priceless
 Vital signs are only of value when they are
accurate!
 Only a piece of the puzzle
 Must assess the whole person
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
When to Assess Vital Signs






Admission to hospital
Each visit to a clinic or emergency room
Each home health or hospice visit
Every 8 hours or according to hospital policy
According to physician’s orders
When a patient complains of feeling unusual
or different
 When you suspect a change in condition
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
When to Assess Vital Signs (cont.)
 When administering medications
 Before, during, and after blood product
transfusion
 Before, during, and after surgical and
diagnostic procedures
 Every 4 hours when one or more vital signs
are abnormal
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
When to Assess Vital Signs (cont.)
 A second time when an assessment finding is
different from the last assessment
 Every 5 to 15 minutes if patient condition
unstable
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Guidelines for Assessing Vital Signs
 Use an organized and systematic approach
 Use the appropriate equipment for each
patient
 Be familiar with normal ranges for different
ages
 Compare vital signs with previous vital sign
range for that specific patient
 Know the patient’s medical history, meds,
therapies
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Guidelines for Assessing Vital Signs
(cont.)
 Understand and interpret the vital sign
findings
 Record and communicate significant vital sign
changes to the physician and next shift nurse
 Minimize environmental effects on vital signs
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
When to Reassess Vital Signs






After administering IV medications
Change in level of consciousness
Unstable postoperative condition
Uncontrolled bleeding
Pale, cold, and clammy skin
Whenever you detect or suspect a change in patient
condition
 Whenever a serious condition is suspected
 Whenever your instinct says to reassess
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Terminology Related to Body
Temperature





Afebrile: without fever
Febrile: fever
Hyperthermia: fever
Hypothermia: temperature below normal
Pyrexia: fever, commonly above 105°F (40.5°C)
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Temperature
 Body temperature
 Difference between the amount of heat the body
produces and the amount of heat that is gained or
lost to the external environment
 Core temperature
 Temperature of the deeper structures and tissues
 Normally slightly warmer than superficial body
tissue
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Temperature
 Core temperature
 Most important measurement to maintain
 Determines the conditions brain, heart, and
internal organs to survive
 Sterile thermometer probe inserted into the
pulmonary artery, heart, or urinary bladder
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Thermogenesis
 Production of heat
 Heat is produced
 Digestion
 Absorption
 Breakdown and synthesis of proteins
 Intake of food--↑metabolism--↑heat
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Thermogenesis
 Shivering
 ↑ heat production four to five times normal
 Exercise
 ↑ up to 50 times normal
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Thermoregulation
 Hypothalamus
 Elevated temp
 Blood vessels dilate—blood brought to skin
surface—radiation
 Sweat produced—evaporation
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Thermoregulation
 Below normal temp
 ↑ heat production—cause muscles to shiver
 Constrict blood vessels—redirect blood flow to
vital organs
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Factors Affecting Body Temperature







Environment
Time of day
Gender
Physical activity and exercise
Medications
Stress
Food or drink
 Illness
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Routes Used for Taking
Temperature






Oral—elongated tip
Tympanic
Axillary—elongated tip
Skin—strip applied to skin
Temporal artery
Rectal—round, red tip
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Routes
 Body temperature most accurate at a site with
a good blood supply
 Oral
 Can not eat, drink, or smoke 15 to 30 minutes
prior to measurement
 Plastic sheath
 Place under tongue
 Non-mercury
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Oral Route
 Do Not Use for




Infants
Small children
Confused
Unconscious
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Routes
 Axillary
 Placed under arm in axillary site
 Hold in place 5 to 8 minutes unless electronic
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Axillary Route




Must be continually held in place
Temperature may be slightly lower
Can be used on unconscious patient
Non-invasive
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Routes
 Tympanic




Infrared device
Adult—pull pinna up and back
Child <3—pull pinna down and back
Gently insert—pointing tip toward the mandible
on the opposite side of the face
 Must be facing tympanic membrane
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Tympanic Route
 Walls of ear canal are cooler than tympanic
membrane
 Cannot be used for patients with ear
infections or after ear surgery
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Routes
 Skin
 Disposable strip
 Apply to clean, dry skin
 Perspiration can affect reading
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Routes
 Rectal





Plastic sheath
Lubricate the tip of the thermometer
Insert 1-1½” (adult) ½ -1” (child) ½” (infant)
Leave in place 2 minutes, unless electronic
Not recommended as a route of choice due to risk
of intestinal perforation
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Rectal Route
 Position patient properly
 Risk of body fluid exposure
 Contraindications to use




Severe hemorrhoids
Rectal surgery
Immunocompromised
High risk for bleeding
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Rectal Route
 Must hold in place continuously
 Embarrassing—provide privacy
 Clean area after removal
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Routes
 Temporal artery
 Special thermometer
 Scans temporal artery
 Press scan button—place probe on a dry forehead
and slowly move across the width of the forehead
and temple then lift off skin and touch neck just
behind the earlobe
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Normal Body Temperature by
Route






Oral 98.6 F (37 C)
Tympanic 98.6 F (37 C)
Rectal 99.6 F (37.5 C)
Axillary 97.6 F (36.4 C)
Range: 97° to 99.6°F or 36.1° to 37.5°C
ALWAYS document route temperature was
obtained
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Fahrenheit-Celsius Conversion
Formula
 C = (F – 32⁰) X 5/9
 (102⁰ F – 32⁰) 70 X 5 350/9 = 38.9⁰C
 F = (C X 9/5) + 32
 (38.9⁰ C X 9 350.1/5 70 + 32 = 102⁰F
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Conversion Formula






°F -32/1.8 = °C
100.4°F – 32 = 68.4/1.8 = 38°C
°C x 1.8 + 32 = °F
34°C x 1.8 = 61.2 + 32 = 93.2
103.6°F
37°C
95°F
35.6°C
104°F
38.8°C
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Elevated Temperature
 Natural response
 Immune system functioning properly
 Most physicians will not attempt to reduce
fever until it elevates above 102⁰F (38.9⁰C)
 Elevations above 105⁰F (40.5⁰C) can result in
damage to body cells
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Signs and Symptoms






Flushed, warm skin
Dry mucous membranes
Glassy or droopy eyes
Increased irritability or restlessness
Photophobia
Thirst
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Signs and Symptoms






Headache or myalgia
Lethargy or drowsiness
Diaphoresis
Anorexia
Confusion, especially in children and elderly
Seizures in infants and children
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Nursing Care
 Assess vitals at least q2h—more often
depending upon the degree of abnormality
 Provide allowed fluids—prevent
dehydration—observe for s/s of dehydration
 Offer small frequent meals rather than large
meal
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Nursing Care




Provide mouth and skin care
Encourage limited activity and rest
Minimal coverings unless shivering
Apply cool compresses or ice packs (covered)
forehead, neck, axillae, groin
 Keep gowns and linen clean and dry
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Nursing Care
 Administer antipyretic medication as ordered
 Salicylates
 Acetaminophen
 Ibuprofen
 May need to provide supplemental oxygen to
meet the body’s increased metabolic needs
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Hypothermia




Body temperature below 96⁰ F (34.4⁰ C)
Slows body metabolism
May be deliberate
Mild hypothermia
 Warm blankets, clothes, ingestion of warm drinks
 Cover head
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Hypothermia
 More severe hypothermia






Additional measures
Heating blankets
Hot water bottles
Warmed IV fluids
Warm baths
Return to normal temperature slowly
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Terminology Related to
Abnormal Pulses
 Bradycardia: heart rate below 60 bpm
 Tachycardia: heart rate above 100 bpm
 Pulse deficit: the difference between the
apical and radial pulse when the radial pulse is
slower than the apical pulse
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Pulse




How many chambers in the heart?
Oxygenated blood leaves which ventricle?
Stroke volume? Cardiac output?
Pulse—arterial fluid wave palpated as a gentle
pulsing, tapping or throbbing sensation at
various points over the body
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Circulation
 http://www.youtube.com/watch?v=PgI80UeAMo
 http://www.youtube.com/watch?v=tBQa8IBzP
6I
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Pulse
 Corresponds to the contractions or beats of
the heart
 Count a pulse by the number of beats or
pulsations per minute
 Central or primary pulse site?
 Contraction is the strongest at the
__________ of the heart
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Pulse
 Apical pulse is most accurate
 Can hear both heart sounds
 Information about valves and contraction of
the atria and ventricles
 Unable to detect the above with peripheral
pulses
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Pulse
 Listen for a full minute
 Normally hear two sounds
 S1 and S2
 Lubb/dupp
 Together the two sounds represent one
complete heartbeat
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Terminology Related to Normal
Apical Pulse
 S1: as the ventricular contraction begins, the
tricuspid and bicuspid valves (AV valves) slam
shut; the first heart sound; the longer, lowerpitched sound; the lubb of “lubb dupp”
 S2: as the ventricles begin relaxation, the
pulmonary and aortic valves (semilunar
valves) close; a shorter, sharper sound; the
dupp of “lubb dupp”
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Apical Pulse
 Assessing pulse rate in children <3
 When radial pulse is weak or irregular
 Prior to administering heart rate altering
medication
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Pulse
 www.youtube.com/watch?v=xS3jX1FYG-M
 www.youtube.com/watch?v=7j_LniUd2Po
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Pulse
 Apical pulse = peripheral pulse
 If not
 Heart not pumping effectively
 Blood flow not strong enough to consistently
deliver a fluid wave to the more distant pulse sites
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Pulse
 Irregular heart beat
 Apical pulse rate faster than the radial pulse rate
 Pulse deficit
 Radial pulse is slower than the apical pulse rate
 Ex. Apcial 88 Radial 82 Pulse deficit 6
 Number of heart contractions to weak to produce
a fluid wave strong enough to be felt at radial site
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Pulse Assessment
 Rate
 60 to 100
 <60 referred to as ___________________
 >100 referred to as ____________________
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Factors Affecting Pulse Rate
 Age




Newborn—120-160 bpm
1-2 years—90 to 120 bpm
3-18 years—80 to 100 bpm
Adults—60 to 100 bpm
 Emotions
 Stimulate SNS, ↑pulse rate
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Factors Affecting Pulse Rate
 Medications—can either speed up or slow
down pulse rate
 Caffeine and nicotine—speed up the rate
 Exercise—speeds up the rate—well
conditioned athletes may have a pulse rate
< 60
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Factors Affecting Pulse Rate
 Meditation, rest, and sleep—lower pulse rate
 Circadian rhythm—slowest predawn to dawn
and faster as the day progresses
 Decreased blood volume
 Hemorrhage or dehydration
 Pulse rate increases
 Attempt to transport oxygen to tissues faster
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Pulse Assessment
 Factors affecting pulse rate
 Increased fluid—fluid overload pulses full and
bounding, sometimes faster
 ↑ temp—heart rate ↑ (10 bpm for each degree)
 As body cools—each degree slows pulse 10 bpm
 Hypoxia--↑ pulse rate
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Pulse Assessment
 Cardiovascular disease—varies on disease or
disorder—can increase, decrease, or cause
irregularity
 ↑ intracranial pressure—typically lowers the
pulse rate and may cause irregularity
 Table 17-4, pg. 358
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Pulse Assessment
 Rhythm
 If all beats are evenly spaced—rhythm is regular
 If differences in the interval lengths—rhythm is
irregular
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Peripheral Pulse Sites








Temporal: used when radial not accessible
Carotid: used in cardiac arrest
Brachial: measured BP
Radial: used for pulse rate assessment
Femoral: determines leg circulation
Popliteal: determines leg circulation
Posterior tibialis: determines foot circulation
Dorsalis pedis: determines foot circulation
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Peripheral Pulse Assessment
 Strength:
 Absent or 0
 Weak or 1+ (may also be thready) can be
obliterated with slight pressure—lose it
 Strong or 2+ easily detected—can be obliterated
with moderate pressure--normal
 Bounding or 3+ very strong and full—does not
obliterate even with moderate pressure
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Peripheral Pulse Assessment
 Equality:
 Equal strength bilaterally
 Weaker than opposite side
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Pulse Assessment
 Non-palpable peripheral pulse
 Palpate the next proximal pulse in that
extremity
 If non-palpable, move to the next proximal
pulse
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Non-palpable Peripheral Pulse
 Also assess




Color
Temperature
Sensation
Capillary refill
 Following assessment—obtain doppler
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Term for Normal Respirations
Eupnea: evenly spaced respirations of normal
depth, between the rate of 12 and 20 breaths
per minute
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Abnormal Respiratory Terms
 Apnea: respirations cease or are absent
 Bradypnea: respiratory rate below
12/minute
 Tachypnea: respiratory rate above
20/minute
 Dyspnea: labored or difficult breathing
 Stertorous: noisy, snoring, labored
respirations that are audible without a
stethoscope
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Abnormal Respiratory Terms (cont.)
 Hypoxemia: decreased oxygen level in
blood
 Hypoxia: decreased oxygen level in
tissues
 Orthopnea: difficulty breathing unless
in upright position
 Stridor: an audible high-pitched crowing
sound that results from partial
obstruction of the airways
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Respiration
 Exchange of oxygen and carbon dioxide
 Breathing in—inhalation or inspiration
 Breathing out—exhalation or expiration
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Respirations
 Be inconspicuous
 Placement of hands
 Assess radial pulse and keep same position
while counting respirations
 If respirations abnormal—assess for a full
minute
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Factors to Assess Regarding
Respiratory Rate





Rate per minute
Depth
Rhythm
Pattern
Respiratory effort
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Respirations
 Rate




One inspiration + one expiration= a respiration
Observe the rise and fall of the chest
Count the number of respirations
Normal rate—12 to 20
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Respirations
 Depth
 Observe the amount of chest expansion with each
breath
 The volume of air that is inhaled
 Subjective
 Shallow, normal, or deep
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Respirations
 Rhythm and pattern
 Regular or evenly spaced intervals between
respirations
 If not evenly spaced—irregular
 Discuss irregular respirations noted in Table 17-7,
pg. 362
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Abnormal Respiratory Pattern
 Cheyne-Stokes respirations
 Respirations begin shallow, gradually increase in
depth and frequency then begin to decrease in
depth and frequency until slow and shallow—
followed by a period of apnea (can last 10 to 50
seconds)
 Then starts over again……
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Cheyne-Stokes Respirations
 Ominous sign





Coma
Heart failure
Head injury
Drug overdose
Impending death
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Abnormal Respiratory Pattern
 Biot’s Respirations
 Respirations are faster, deeper and irregular with
periods of apnea
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Biot’s Respirations
 Meningitis
 Central nervous system disorders
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Abnormal Respiratory Pattern
 Kussmaul’s Respirations
 Respirations increased in rate and depth with
long, strong, blowing or grunting exhalations
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Kussmaul’s Respirations
 Diabetic ketoacidosis
 Renal failure
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Respirations
 Respiratory effort
 Amount of work required to breathe
 Effortless and performed without thinking
 If working hard to breathe—startled, wide-eyed,
anxious
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Respirations
 Exertional dyspnea
 Speaking, eating, repositioning, or ambulating
 Use of accessory muscles—neck and
abdominal
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Abnormal Breath Sounds
 Wheezes—musical, whistling—audible or
auscultation
 Crackles or rales (fine or coarse)—air moving
over secretions--fluid
 Rhonchi—continuous low pitched, rattling,
bubbling, snoring…
 Stridor (sometimes heard without use of a
stethoscope)
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Abnormal Breath Sounds
 www.youtube.com/watch?v=QPBZOohj2a0
 http://www.easyauscultation.com/crackleslung-sounds
 http://emedicine.medscape.com/article/1894
146-overview
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Terminology Related to Blood Pressure
 Diastolic pressure: measurement of the pressure
exerted by the blood on the artery walls while the
heart ventricles are not contracting (at rest); the
lower of the two pressures; the bottom number
of the BP
 Systolic pressure: measurement of the pressure
exerted by the blood on the artery walls while the
heart ventricles are contracting; the highest of the
two pressures; the top number of the BP
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Terminology Related to Abnormal
Blood Pressure
 Hypertension: the systolic BP consistently over
140 mm Hg or the diastolic BP consistently
over 90 mm Hg
 Hypotension: the BP suddenly falls 20 mm Hg
to 30 mm Hg below the patient’s normal BP or
falls below the low normal of 90/60 mm Hg
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Terminology Related to Abnormal
Blood Pressure (cont.)
 Orthostatic hypotension or postural
hypotension: when position changes result
in a systolic pressure drop of 15 to 25 mm
Hg or the diastolic pressure falls 10 mm Hg
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Blood Pressure
 Measurement of the pressure or tension of
the blood pushing against the walls of the
arteries
 The amount of pressure is determined by a
combination of the following four circulatory
qualities
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Four Circulatory Qualities
 Strength of the heart contraction or pumping
action of the heart
 Blood viscosity or thickness
 Blood volume
 Peripheral vascular resistance or elastic recoil
ability of the blood vessel walls
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Factors Affecting Blood Pressure







Age, race, obesity
Exercise, rest, level of hydration
Circadian rhythm
Anxiety
Medications
Nicotine and caffeine
Hemorrhage, increased intracranial pressure
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
BP Measurement
 Systolic
 Measurement of the force exerted by the blood
against the walls of the arteries during the
contraction of the heart ventricles
 Diastolic
 Measurement of the pressure exerted by the
blood on the artery walls while the heart is resting
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
BP Measurement
 Measured in millimeters of mercury (mm/Hg)
 Written as a fraction
 132/74
 Systolic—132
 Diastolic—74
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
BP Measurement
 Pulse pressure
 Measurement of the difference between the
systolic and diastolic pressures
 Subtract the smaller number from the larger
 Usually 30 to 50
 Pulse pressure <30 or >50 is abnormal
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
BP Measurement
 Adult normal range
 90/60 to 120/80
 Systolic >120—pre-hypertension
 Refer to Table 17-1, pg. 347
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
BP Management
 Hypertension
 Systolic readings consistently >140 or diastolic
consistently >90
 Medical diagnosis of hypertension
 BP elevation must be documented on at least two
or more separate occasions
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
BP Equipment
 Stethoscope
 BP cuff—sphygmomanometer
 Aneroid
 Electronic pressure manometer
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
BP Equipment
 Cuff size makes a difference
 Cuffs available in child, small and large adult
 Correct size is necessary for an accurate
reading
 Too large ________________
 Too small ________________
 Width should cover approx. 2/3 upper arm
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Assessment Sites
 Normally upper arm with stethoscope over
the brachial artery at the antecubital site
 Lower arm with stethoscope over the radial
artery
 If necessary—midthigh with stethoscope over
the popliteal artery—Figure 17-4, pg. 348
 Systolic may be 10 to 40 mm/Hg higher
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Korotkoff Sounds
 First sound: clear, rhythmic tapping sound,
gradually increasing in intensity
 Second sound: soft, swishing or murmuring
sound, representing turbulent blood flow
 Third sound: sharper, crisper rhythmic sound
 Fourth sound: softening or muffling of
rhythmic sound
 Fifth sound: silence
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
BP Measurement
 First sound—Systolic
 Point at which you last hear any sound—
documented as diastolic
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
BP Measurement
 Blood Pressure Sounds
 http://www.practicalclinicalskills.com/bloodpressure-course-contents.aspx?courseid=102
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
BP Measurement





How high to pump?
2 to 3 mm/Hg per second
Be careful—auscultatory gap
Inflate enough
Listen 10 to 15 mm/Hg after hearing last
sound
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
BP Measurement
 Do not use if






Mastectomy or removal of lymph nodes
Shunt for dialysis
Casts, braces, dressings
Recent vascular surgery or trauma to area
CVA
PICC line or IV
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Orthostatic Hypotension




Hypotension occurring with position change
When stand from a lying or sitting position
Dizziness, lightheadedness, or faint
Mild or prolonged
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Orthostatic Hypotension
 Normally
 Stand—blood pools in legs—body senses ↓--HR
↑--blood vessels constrict to ↑BP
 Possible causes—dehydration, heart disease,
diabetes, nervous system disorders, medications,
blood loss
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Orthostatic Hypotension




Lying—Sitting—Standing
Within 1 to 3 minutes
BP and pulse rate
If systolic drops 20 mm/Hg or diastolic drops
10 mm/Hg
 If HR rises > 20 bpm
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Effects of Hypertension
on the Body
 Gradual loss of elasticity in arterial walls
results in less stretch and recoil
 Heart has to work harder to pump blood
through the cardiovascular system
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Risk Factors for Hypertension






Family history
Smoking
Chronically high stress level
Moderate to heavy alcohol consumption
Obesity
Elevated cholesterol levels in blood
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Treatment
 Lifestyle changes
 ↓ dietary salt and fat intake
 Weight loss
 Smoking cessation, reduce or stop excessive
alcohol intake
 Stress reduction
 ↑ physical activity and exercise
 Medications
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Damage Caused by
Untreated Hypertension
 Brain, in the form of a stroke
 Heart, in the form of congestive heart failure
or myocardial infarction (heart attack)
 Kidneys, resulting in kidney failure
 Retinas of the eyes, resulting in loss of vision
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Oxygen Saturation
 Pulse oximeter
 Assessment sites
 Fingertip, earlobe, bridge of the nose or when
circulation adequate, the toe
 Infants?
 Pulse saturation—SpO2
 Intermittent or continuous
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Oxygen Saturation
 Assessment site





Adequate blood flow
Clean and dry—moisture interferes with accuracy
No artificial nails
No dark fingernail polish
Patient movement interferes with accuracy
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Characteristics of Pain
to Be Assessed
 Site or location
 Characteristics
 Constant or intermittent?
 Sharp, dull, stabbing, cramping, or burning
 Severity of pain using a pain scale that is
appropriate for age and comprehension
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Neuro Check






Assessing neurological system
Monitoring neurological system
Pupils—PERRL
Level of Consciousness—LOC
Verbalization
Facial symmetry
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Neuro Check
 Upper extremity strength
 Assess right and left side—equal in strength?
 Lower extremity strength
 Assess right and left side—equal in strength?
Copyright © 2011 F.A. Davis