Ch. 18 Vital Signs: Session 1
Abnormal blood pressure: Prehypertension
Systolic: 120-139 Diastolic: 80-89
basal state
When the patient has fasted and not exercised in 12 hours
hemo-
blood
mmHg
millimeters of mercury
Hypercardia
stimulus to breath.
autonomic nervous system
the part of the peripheral nervous system that controls the glands and the muscles of the internal organs (such as the heart). Its sympathetic division arouses; its parasympathetic division calms.
Pulse Quality
the rhythm (regular or irregular) and force (strong or weak) of the pulse. 0 no pulse detected. 1+ thready, weak pulse; easily obliterated w pressure; pulse may come and go. 2+ pulse difficult to palpate; may be obliterate with pressure. 3+ normal pulse 4+ bounding, hyperactive pulse; easily palpated and cannot be obliterated. If you cannot feel a pulse, get out a doppler machine. A 4+ pulse Know that a bounding pulse can be normal in an older pt bc of a decrease in arterial wall elasticity A 1+ pulse can be due to hypovolemia, lack of fluid, dehydration. A 2-3+ pulse are considered the norm.
Respiration rate: Kussmaul
-Rapid, deep, labored breathing. Increase depth and rate (above 20 bpm). fun fact: A type of hyperventilation associated with diabetic ketoacidosis.how
What can affect a patient's respirations?
-age (from childhood to adulthood results in increased lung capacity. as lung capacity increased, lower respiratory rates are sufficient to exchange air. older adults have a decrease in lung elasticity) -medications (albuterol can be used to dilate bronchioles, increasing person's ability to move air in/out of lungs, narcotics would decrease) -stress (stress or strong emotions can stimulate sympathetic nervous system causing increase in rate and depth of respirations) -exercise (tissue consume and process more oxygen during exercising. exercise provides extra carbon dioxide and heat that the body must eliminate, the body responds to these needs by increasing the rate and depth of respirations) -pain (increase) -infection (increase) -fever (increase) -altitude (decrease in atmospheric pressure w altitude, oxygen content of the air decreases) -gender (decrease in men bc normally have a larger lung capacity so they may have lower respiratory rate)
What can affect a patient's blood pressure?
-age (older pt's have increased systemic vascular resistance, reflecting arterial narrowing and decreased vessel elasticity due to atherosclerotic vessel disease) -autonomic nervous system -pain (increase) -stress (increase) -caffeine (increase) -exercise (increase) -hypovolemia (decrease in circulating volume, either from blood or fluid loss, results in lower blood pressure. excess fluid, such as in congestive heart failure or renal failure, can cause elevated blood pressure readings) -medications (ex diuretics decrease blood volume) -normal fluctuations (fluctuates from minute to minute in response to various stimuli)
How is pain assessed?
0-10 pain scale. PQRST Symptom Analysis: Provocative/Palliative - What causes the pain? What makes it better or worse? Quality/Quantity - How does the symptom feel, look or sound? How much of it are you experience now? Region/Radiation - Where is the symptom located? Does it spread? Severity - How does the symptom rate on 0-10 pain scale? Timing - When did the symptom begin? How often does it occur? Is it sudden or gradual? Is it always there or just when you sit up or sit down?
Respiration (Vitals)
1. Rate 2. Rhythm 3. Quality MUST CHECK RATE FOR 1 FULL MINUTE IF IRREGULAR Bradypnea (< 12 breaths/minute) Tachypnea (>20 breaths/minute)
proper cuff size
5 sizes (peds, youth, standard adult, large, x-large or thigh) bladder length 80% and width 40% of arm circumference.
Documenting vital signs
>T. P. R., BP - Most times the VS will be documented on a graphic sheet. >When it is necessary to document in the nurse notes, simply write the information found. For example, 98.6, 86, 18, 124/76. >*DO NOT WRITE* T-98a. P-86, R-18, BP-124/76. This is the standard order of VS. All medical personnel will understand this set of numbers is the VS. When documenting in chart, remember it's part of the pt's legal doc & used as communication tool btwn the interdiscplinary teams. Document objectively, clear, and concise. Should be accurate and paint a clear picture what is going on with your pt.
Oxygen Saturation Point (SO2)
A measure of the capacity of oxygen transport. This is the percentage of hemoglobin binding sites in the bloodstream occupied by oxygen (oxyhemoglobin)
Respiration rate: Biot's respirations
AKA Ataxic breathing. Cyclic breathing pattern characterized by shallow breathing alternating with period of apnea.
Tachycardia
Abnormally fast rapid heartbeat >100 bpm in adults.
Pulse rates
Adults 60-100 (av. 72) can be lower in athletes and older persons Children 80-120 Infants 100-160 NOTE: if an accurate count is not taken, the pulse can be described as Regular: a normal pulse occurring at regular intervals Irregular: Intervals between beats are irregular Rapid: Faster than normal rates (Tachycardia- over 100 in adults) Slow: slower than normal rates (Bradycardia- below 60 in adults) Strong: full and normally strong Weak: may be difficult to find and palpate Bounding: abnormally strong Thready: Rapid and wear, and so rapid and so wear it feels like a thread being pulled under your finger (Some EMTs: feels like squishing a bug under your finger) Palpate pulses bilaterally (except for carotids) to compare quality (provides info about local blood flow, ex: partial occlusion/blockage of right femoral artery would result in weaker femoral, popliteal, pedal, and posterior tibial pulses on right compared to left)
Tidal volume
Amount of air that moves in and out of the lungs during a normal breath (6~8 L/min)
Proper inflation of cuff
An inflated cuff slows the return of venous blood from the extremity back to heart. Increased venous pressures are transmitted back to the arterial side of the circuit, leading to corresponding rise in arterial pressures. Slow, prolonged, or frequent cuff inflation promotes venous congestion. Inflate the cuff rapidly when taking a reading and deflate it completely after measurement. At least 1-2 min should elapse before sequential cuff inflation on any one limb. Elevating the arm above the head between cuff measurements speeds venous return to the heart.
hemoglobin
An iron-containing protein in red blood cells that reversibly binds oxygen.
forearm
Antebrachial
A nurse attempts to count the respiratory rate of a client via inspection and finds that the client is breathing at such a shallow rate that it cannot be counted. What is an alternative method of determining the respiratory rate for this client?
Auscultate lung sounds, count respirations for 30 seconds, and multiply by 2. Explanation: Sometimes it is easier to count respirations by auscultating the lung sounds for 30 seconds and multiplying the result by 2. Palpating the posterior thorax excursion detects vibrations in the lungs. Pulse oximeter and arterial blood gas results assess respiratory effectiveness, not respiratory rate.
Proper cuff size of blood pressure
Base cuff size on the circumference of the limb that ur using. The width of the cuff bladder should be at least 40% of circumference of the midpoint of the limb. An average adult arm requires a bladder with a 12-14cm width. The bladder length should be 80-100% of the limb circumference, or about twice bladder width. Apply the cuff snugly around the limb, and center the bladder over the artery. Using a cuff that is too small or loosely applied results in falsely high readings. Using a cuff that is too large results in falsely low readings.
What are the sites a nurse can use to obtain a patient's blood pressure?
Blood pressure can be measured in either upper or lower extremity. For accurate data interpretation, make note the site of the blood pressure measurement. Upper Extremity - usually in upper arm. wrap cuff around part of limb and auscultate or palpate blood flow at brachial artery. Blood pressure may also be determined by auscultation or palpation of the radial artery in wrist with appropriately sized cuff applied to antebrachial/forearm. Lower Extremity - if pt has arteries in upper extremity that cannot be palpated (whether covered by dressings or splints) or if pt has a vascular access device or has had a mastectomy (removal of breast). Thigh pressure measurement requires a large, appropriately sized cuff.
What factors are affect a patient's pulse oximetry?
Blood pressure generally needs to be >80 SBP. Vascular impingement from any cause. AV fistula can decrease distal flow. Elevation with respect to the heart. Compression by the probe. Cardiac arrest (don't use during arrest) Heart Rate extremes <30 or >200. Nail polish. Make sure ur putting pulse oximetry on a place with good perfusion. AVOID areas of edema, nail polish, or blue fingers. if so, you can put it on the forehead, nose, earlobes, toes. Make sure ur always assessing pt...the pulse oximetry could show 70 and before calling code Make sure pt is that pulse oximetry isn't on floor. See if pt is talking to you.
Temperature (Vital Signs)
Body maintains a steady temperature through a thermostat, or feedback mechanism, regulated in the hypothalamus of the brain. Normal resting oral temperature is 98.6°F with a normal range from 97-99°F. Oral, rectal, axillary, tympanic, temporal. Abnormal: The thermostatic function of the hypothalamus may become scrambled during illness or Central Nervous System (CNS) disorders. Factors affecting body temp: -age (newborns have unstable body temp bc their thermoregulatory mechanisms are immature, some old pts may have body temp less than 97.6°F bc baseline body temp may drop as an individual ages) -environment (outside temp, humidity, length of exposure) -time of day (temp is usually lower in early AM bc ur in rest-and-digest phase, temp is higher in late PM) -exercise (body temp increases bc of increased breakdown of carbohydrates and fats to provide energy) -stress (stimulates sympathetic nervous system circulating levels of epinephrine and norepinephrine increase, which are the fight or flight hormones) -hormones (progesterone, female hormone secreted at ovulation, increased body temp). Smoking causes vasoconstriction, which increases temp. Ice water will decrease temp. Coffee and chewing gum prior to taking temp. You may want to wait 15-30 min before taking temp if they have been eating or drinking anything.
When should vital signs be documented?
Directly after they have been taken back. This is called point of care. Document right away. If abnormal, every 30 min until evaluated by a physician. If initial vital signs are normal, subsequent vital signs should be taken every 4 hours for the first 24 hours after admission. After the first 24 hours if vital signs are stable and within normal limits, every 6 hours thereafter.
What are some contraindication to taking a patient's blood pressure?
Do not measure BP in any arm with a venous access device, esp an internal arteriovenous fistula, a peripheral vascular access for hemodialysis, or a PICC line. Also, do not measure BP if pt has had mastectomy (breast removal) bc BP monitoring on the same side can further impede circulation, contributing to lymphedema.
When documenting, make sure you put site of vital sign VS
Ex: 101°F (AX) or 126/78 (RUA)
internal respiration
Exchange of gases between cells of the body and the blood. The use of oxygen, the production of carbon dioxide, and the exchange of O2 and CO2 between cells and blood.
Blood Pressure (Vitals)
Force that blood exerts against the walls of the blood vessels - in general 120/80 or below Systolic: 90-120 (maximum pressure during ventricular systole) Diastolic: 60-80 (minimum pressure just before systole) Systole is contraction of the heart muscles, especially the ventricles. Diastole - after the contraction of the heart muscle...when the chambers are filling back up with blood.
Cardiac Output
Heart rate x stroke volume, the overall performance of the heart. Output of blood by the heart per 1 minutes, average 5.5 L/min.
Resting state of blood pressure
Ideally, measure baseline BP w pt in a resting state, after they have been sitting quietly for 5 min or more. The pt should be in a warm, quiet environment w the back supported and feet flat on the floor, if sitting. BP increases when legs are crossed at the knee. At least 30 min should elapse btwn smoking, exercising, or eating and measuring BP. Sometimes, BP must be measured when the patient is anxious or in pain, but these readings may differ from those made if the patient were in a basal state.
Appropriate sites to check temperature
If pt just got out of surgery or facial procedures, they may have orders that state do not take oral temp. Tympanic and Temporal are the most accurate checking sites because they're closer to the hypothalamus (body's core temp). Axillary is the least accurate. Most facilities are documenting in celsius so know to go from fehrenheit to celius it is (F-32)/1.8=C
How can errors occur in blood pressure measurement?
Inaccurate readings of blood pressure, falsely low or high readings.
What are some behavioral responses to pain?
Many different behaviors are associated with pain; some aggravate it and others alleviate it. Pts w pain notice that certain activities can cause pain to be noticed or increased. Patients often avoid such activities, but this avoidance may not be in their best long-term interest. Emotional responses to pain, such as fear & anxiety, increase muscle tension, which increases perception of pain intensity. Fear of the unknown also may worsen pain because of tension and anxiety the patient brings to the situation. Verbal and nonverbal responses
Proper positioning
Measure BP w the arm at heart level. Elevating the arm above heart level results in a falsely low measurement; positioning the arm below heart level results in a falsely high reading. If the patient is sitting or standing, support the forearm horizontally at level of heart (generally considered the level of the fourth intercostal). Failure to support the arm causes the patient to contract the arm muscles, elevating the BP. When the patient is supine, the arm may need to be elevated to heart level on a pillow.
Oxygen saturation: Normal reading
Normal blood oxygen levels in humans are considered 95-100 percent.
Afrebrile
Normal temperature.
Can vital signs be delegated to unlicensed assistive personnel?
Nurses often delegate temperature taking to unlicensed assistive personnel (UAP). Nurses use critical thinking to interpret temp measurements, document the results, and report abnormal values. Whenever possible, measure and record temp measurements at the same site, using the same device, so that fluctuations may be interpreted accurately. Yes, RN can delegate vital signs to tech. The RN are ALWAYS responsible for making sure if vital signs are being done and should recheck them if the RN thinks they're not accurate.
Inaccurate readings of blood pressure
Occurs if needle not at zero, faulty valves or leaky tubing, examiner digit preference, forgetting measurement. Recommendations to help with these: recalibrate or service equipment, replace equipment, do not round up or down, record immediately in the room.
When should a height and weight be collected?
On admission
When does pain occur?
Pain is always subjective experience that occurs whenever the patient says it occurs. Initially, pain minimizes injury and warns of disease. Persistent pain has no purpose. Sometimes subjective data doesn't match objective data...for ex: if pt says pain is 10/10 but they're having a pizza party and u think that it doesn't match what you're seeing..it is what the pt says it is. Sometimes pt that deal with chronic pain on daily Their pain may be at a 10 but they're able to function and have those parties.
PICC line
Peripherally Inserted Central Catheter (PICC)
Who is responsible for ensuring accurate assessment and documentation?
RN
Who interprets vital signs?
RN, health care, other members of the interdisciplinary team.
Diastole
Relaxation of the heart and filling with blood. We get concerned about the bottom number because this is when the heart is relaxed.
Phase V of Korotkoff Sounds
SILENCE last audible sound is diastolic pressure
stroke volume formula
SV = EDV - ESV End Diastolic Volume (volume of blood remaining in each ventricle after systole) End Systolic Volume (Amount of blood remaining in each ventricle at the end of systole (contraction)
How do you obtain a patient's height?
Shoes off, inches or centimeters. Either standing or supine.
How do you obtain a weight?
Should be obtained on the same scale, same time of day, and with the patient wearing the same clothing. A standing scale is used for ambulatory pts. A stretcher scale is used for non-weight bearing pts (for the weight to be accurate on stretcher scale, must be covered in same linens each time)
Stroke volume
The amount of blood ejected from the heart in one contraction; the amount/volume of blood pumped out by a ventricle with each heartbeat the amount of blood pumped by the left ventricle LV
Oxygen saturation: Abnormal reading
The lower the oxygen level, the more severe the hypoxemia. This can lead to complications in body tissue and organs. Normally, a PaO2 reading below 80 mmHg or a pulse ox below 95% is considered low. It's important to know pt's baseline oxygen saturation (in case they have chronic respiratory problems, they may have low 90s or high 80s)
How should I obtain my patient's respirations?
The respiration rate is the number of breaths a person takes per minute. The rate is usually measured when a person is at rest and simply involves counting the number of breaths for one minute by counting how many times the chest rises. Respiration rates may increase with fever, illness, and other medical conditions. When checking respiration, it is important to also note whether a person has any difficulty breathing. Assess respirations during every vital signs evaluation. Establish a set of normal baseline measurements of rate, rhythm, depth and quality for each pt so comparisons can be made. Perform respiratory assessment without patients being aware you are doing it so they don't alter their breathing. Assess respiratory rate after or before taking radial pulse, while holding the pt's wrist. One way to do this is check pulse for 30 seconds then check chest rise (respirations) for the next 30 seconds. 0
pulse
The rhythmic expansion and recoil of arteries resulting from heart contraction. Top to bottom: Temporal Carotid Apical Brachial Radial (most common bc easily accessible) Femoral Popliteal Posterior tibialis Dorsalis pedis Be sure to check bilaterally for all EXCEPT carotid bc u could cut off blood flow, which leads to cutting off oxygen flow to brain.
Pulse (Vital Signs)
The stroke volume force flares the arterial walls and generates a pressure wave, which is felt in the periphery as the pulse. Palpating the pulse gives the rate and rhythm of the heartbeat and local data on the condition of the artery. Adult is 60-100. Factors affecting pulse: -age -autonomic nervous system (stimulation of the vagus nerve in the parasympathetic nervous system results in decrease of pulse rate below 100. conversely, stimulation of sympathetic nervous system results in increased pulse rate. sympathetic nervous system activation occurs in response to various stimuli including pain, anxiety, exercise, fever, ingestion of caffeinated beverages, and changes in intravascular volume). -medications (ex: beta blockers decrease heart rate) -pain -caffeine -shock -bleeding/hypovolemia (increase pulse bc heart is working harder to compensate for losing fluid volume, BP goes down)
Pulse rhythm
The time interval between heartbeats
Vital signs
Vital signs: temperature, pulse, respiration, and blood pressure, oxygen saturation, pain Measurements of the body's most basic functions and useful in detecting or monitoring medical problems. Vitals signs are an important part of the assessment bc we need to determine what is going on w our patients. Vitals signs yield info regarding pt's health status. Vitals signs can be the first indication that something has changed or something new is going on with our pt. ex: can tell if our pt has infection, losing fluid volume or bleeding internally. Ex: if a pt is losing fluid volume (hypovolemia), the pt's heart rate will increase and BP will decrease. It can tell us if our unconscious pt is in pain (ex: if we notice facial grimacing, increase in HR or BP, this will incidate our pt is in pain) This is why it's important to know baseline vital signs, it may indicate there's something wrong w our pt.
Why is obtaining an accurate weight so important?
Weight measurement can provide important information regarding nutritional status along with vital assessment. Ex: heart failure causes weight gain and edema. Rapid weight gain or loss (e.g., 10 lb in 2 weeks) usually results from the gain or loss of body fluid rather than body fat. Make sure to look for patterns! Watch for trends in gain or loss. May vary daily due to change in fluid.
Stimulus to breath
When partial pressure of carbon dioxide (Pco2) exceeds the upper limit of normal in the bloodstream (greater than 45 mmHg). The rise in carbon dioxide stimulates the respiratory center to increase the rate and depth of respirations to remove excess carbon dioxide. Therefore, the patient's stimulus to breathe is no longer an increase in carbon dioxide levels, but from a low oxygen level sensed by peripheral chemoreceptors.
Who can document vital signs?
Whoever takes the pt can should document them bc data needs to be documented right away.
Oxygen saturation
a clinical measurement of the percentage of hemoglobin that is bound with oxygen in the blood
Assessing pain: Wong-Baker FACES
a pain assessment tool that uses six caricatures of a child's face representing no hurt to biggest hurt a child could ever have.
contraindication
a reason something is not advisable or should not be done
Abnormal blood pressure: Hypertension
abnormally high blood pressure; Greater than 140/90
Abnormal blood pressure: Hypotension
abnormally low blood pressure; less than 100/60
hypothermia
abnormally low body temperature Death can occur if core temp is 77°F or 113°F The hypothalamus will detect low body temp, it'll send signal to increase heat conduction by shivering or vasoconstriction. An decrease in metabolism will decrease body temp.
Respiration rate: Bradypnea
abnormally slow breathing; 12 bpm ( less than 12 bpm)
Bradycardia
abnormally slow heartbeat <60 bpm in adults. *make sure you're paying attn to the arrows of less than and greater than!!!* NOTE: A well-trained athlete may have a resting pulse of less than 50 bpm.
Respiration rate: Apnea
absence of breathing; temporary cessation of breathing
Pulse Pressure
difference between systolic and diastolic pressure. The normal range of pulse pressure is between 40 and 60 mm Hg. Pulse pressure tends to increase after the age of 50. This is due to the stiffening of arteries and blood vessels as you age.
pulse deficit
difference between the apical and peripheral/radial pulses. (tells about heart's ability to perfuse the body adequately) Apical pulse should always be compared with the radial pulse. ... If the radial pulse is less than the apical pulse, a pulse deficit exists. Pulse deficit signals a decreased left ventricular output and can occur with conditions, such as atrial fibrillation, premature beats and congestive heart failure. When a pulse deficit is present, the radial pulse is always lower than the apical pulse rate. Document and report to provider any new finding of a pulse deficit so that evaluation and f/u can occur. Apical pulse and Point of Maximal Impulse PMI) is at the 5th intercostal space, left midclavicular line. Listen for one full minute. PMI you can palpate.
How does the nurse obtain a patient's blood pressure?
different equipment that can be used to measure BP: sphygmomanometer, stethoscope, Doppler ultrasound, and automated devices. When using automatic blood pressure devices for serial blood pressure recording, check cuffed limb frequently to ensure adequate arterial perfusion and venous drainage between measurements.
Respiration rate: Dyspnea
difficult or labored breathing
external respiration
exchange of gases between lungs and blood. Taking O2 into the body and eliminating CO2 from the body.
Which condition will lead to an increase in cardiac output?
exercise Explanation: Cardiac output increases during exercise and decreases during sleep. When cardiac output is decreased, blood pressure decreases. Hemorrhage and dehydration can result in decreased cardiac output and decreased blood pressure.
frebrile
fever
Pyrexia
fever; raised body temperature. Death can occur if core temp is 77°F or 113°F The hypothalamus will detect high body temp, send signal to decrease body temp by sweating or vasodilation. An increase in metabolism will increase body temp. Heat is lost through radiation, conduction, convection, and evaporation.
Phase I of Korotkoff Sounds
first appearance, faint, clear, tapping sounds...SYSTOLIC PRESSURE
Characteristics of pulse
frequency, rate, rhythm, strength, quality
What are some physiologic responses to pain?
increased heart beat or respiratory rate, increased BP, diaphoresis, decreased O2 levels, metabolic responses
Core Temperature
internal body temperature (to the core)
pulse oximetry
noninvasive technique that measures the oxygen saturation (SaO2) of arterial blood. oxygen saturation is assess through infared light. noninvasive method of measuring oxygen in the blood by using a device that attaches to the fingertip
Physiologic
normal function of the body
Respiration rate: Eupnea
normal respiration/breathing.
False low readings of blood pressure
occurs if environmental noise, hearing deficit, earpieces fitting poorly, stethoscope tubing too long, failing to pump cuff up high enough, cuff too large, arm above heart level, releasing valve too rapidly, reading taken at inspiration of selected high-risk pts, COPD, pulmonary embolus, hypovolemic shock. Recommendations: turn down TV or radio; stop talking; avoid moving stethoscope or tubing; position earpeices snugly in ear canal; using hearing-amplified stethoscope or hearing aid; angle ear pieces fwd to fit snugly in ear, shorten tubing (12-15in); palpate systolic pressure to avoid missing auscultatory gap; measure arm circumference-bladder width should be 40-50% and length should be 80-100% of arm circumference; reposition arm at level of heart, generally the fourth intercostal space; practice slow release of 2-3 mmHg/s; consistently try to record BP at end expiration.
False high readings of blood pressure
occurs if measuring BP when a pt has just eaten, is in pain, anxious, or had a full bladder; cold hands or stethoscope; viewing meniscus from below eye level; cuff too small; wrapping cuff unevenly or loosely; deflating cuff too slowly; venous congestion; unsupported arm; back unsupported, legs dangling; arm below heart level. Recommendations: try to assess BP during basal state or adjust interpretation accordingly; warm hands and stethoscope before measuring BP; view meniscus from eye level; measure arm circumference-bladder width should be 40-50% and length should be 80-100% of arm circumference; rewrap cuff snugly; practice steady deflation of cuff at 2-3 mmHg/s; wait two minutes before reinflating to retake BP; elevate arm to promote redistribution of blood; support arm on table to prevent muscle contraction; provide support for legs and back; reposition arm at heart level, usually at the fourth intercostal space.
Respiration rate: Cheyne-Stokes respiration
pattern of breathing characterized by a gradual increase of depth and sometimes rate to a maximum level, followed by a decrease, resulting in apnea. a pattern of alternating periods of hypopnea or apnea, followed by hyperpnea
-tension
pressure
diaphoresis
profuse sweating
-globin
protein
heat loss
radiation, conduction, convection, evaporation
Respiration rate: Tachypnea
rapid breathing; 20 bpm (greater than 20 bpm)
Abnormal blood pressure: Orthostatic (postural) hypotension
rapid lowering of the blood pressure as a result of changing positions. Significant drop in BP numbers when pt changes position. Ex: pt laying flat and they need to use restroom. nurse is getting them out of bed and pt complains their dizzy and weak. when nurse gets them up and they're having those same symptoms. This could be a clue that they have Orthostatic hypotension in various positions (laying down, sitting, standing). with each postural change, we wait two minutes and note the change of BP. If systole drops 20 and diastole drops 10 then pt is suffering from orthostastis hypotension.
pulse rhythm can be
regular or irregular; a premature or late heartbeat can result in an irregular interval and can indicate abnormal electrical activity of the heart
Korotkoff sounds
sounds heard while taking the blood pressure. series of sounds that correspond to changes in blood flow through an artery as pressure is released
Where does the pulse come from?
stimulated by the sinoatrial SA node, a contraction of the left ventricle LV ejects blood into the aorta, which then expands and contracts, causing a pulse wave/pulsation to travel along the blood vessels...so SA node initiates the beats of the heart
pathway of the heart
superior vena cava inferior vena cava right atrium tricuspid valve right ventricle pulmonary semilunar valve pulmonary artery lung capillaries pulmonary vein left atrium mitral (bicuspid) valve left ventricle aorta semilunar valve aorta
venous access device
surgically implanted port that permits repeated access to central venous circulation
Auscultatory Gap
temporary disappearance of sounds usually heard over the brachial artery, occurring when the cuff pressure is high and is gradually reduced, with the sounds again heard at a lower level of pressure (usually occurring in patients who have hypertension). Absense of Korotkoff sounds between phase I & II; failure to identify can underestimate systolic and/or overestimate diastolic.
A nurse is assessing the blood pressure of a team of healthy athletes at the heath care facility. Which observation can be made by the nurse and athletes by measuring the blood pressure?
the ability of the arteries to stretch Explanation: Measuring the blood pressure helps to assess the efficiency of the client's circulatory system. Blood pressure measurements reflect the ability of the arteries to stretch, the volume of circulating blood, and the amount of resistance the heart must overcome when it pumps blood. Measuring the blood pressure does not help in assessing the thickness of blood, oxygen level in the blood, or the volume of air entering the lungs.
Systole
ventricular contraction
vascular
vessels that carry blood
