Chapter 11 Vitals

________ and _________ had high blood pressure; nearly 1/3 don't know they have it.

1 and 3

Korotkoff Phases

1. first appearance of repetitive, clear tapping sounds that gradually increase (systolic pressure) 2. A brief period of softer and longer swishing sounds 3. The return of sharper sounds, which become crisper and louder thudding sounds 4. The distinct, abrupt muffling of sounds, which become softer and blowing quality 5. The point at which all sounds finally disappear completely (last sound is diastolic)

What is the normal adult respiration rate range?

14 to 20 breaths/min

Determining and Recording Blood Pressure: Blood pressure follow-up criteria

: dental personnel have an obligation to advise and refer for further evaluation. Diagnosis of hypertension would never be made or treatment started on the basis of an isolated reading. When the blood pressure is within the normal range (120/80), it needs to be rechecked within 2 years. Rechecking within 1 year is recommended for persons at increased risk for hypertension, such as family history, weight gain, obesity, African American, use of oral contraceptives, smoking, and excessive alcohol consumption. Lifestyle modifications are indicated for all levels of blood pressure classification. Consultation with a patient's physician is indicated prior to dental or dental hygiene treatment when either reading is ≥180/110.

Normal rate for adult and child

Adults. The adult range is from 14 to 20 per minute, slightly higher for women. Children. The respiratory rate decreases steadily during childhood. Averages are first year: 30 per minute; second year: 25 per minute; eighth year: 20 per minute; fifteenth year: 18 per minute.

Adult Pulse Range

Adults. There is no absolute normal. The adult range is 60 to 100 beats per minute (bpm), slightly higher for women than for men.

Normal Values for Body Temperature

Adults: The normal average temperature is 37.0°C (98.6°F) The normal range is from 35.5°C to 37.5°C (96.0°F to 99.5°F). Older adults: Over 70 years of age, the average temperature is slightly lower (36.0°C, 96.8°F). Children: no appreciable difference between boys and girls. Average temperatures are: first year: 37.3°C (99.1°F); fourth year: 37.5°C (99.4°F); fifth year: 37°C (98.6°F); twelfth year: 36.7°C (98.0°F).

When should you count pulse Beats 1 minute?

Always

When measuring a patient's blood pressure, where should the inflatable bladder of the blood pressure cuff be placed?

Brachial artery

Vitals assessment Alteration of patient appointment

Dental hygiene care planning and appointment sequencing are directly influenced by the findings. Abnormal findings may result in the appointment being rescheduled, or the treatment planned for that visit being altered.

Procedures for Observing Respirations: Factors to observe: depth, rhythm, quality, sounds, patient position

Depth. Describe as shallow, normal, or deep. Rhythm. Describe as regular (evenly spaced) or irregular (with pauses of irregular lengths between). Quality. Describe as strong, easy, weak, or labored (noisy). Poor quality may have an effect on body color; for example, a bluish tinge of the face or nailbeds may mean an insufficiency of oxygen. Sounds. Describe deviant sounds made during inspiration, expiration, or both. Position of patient. When the patient assumes an unusual position to secure comfort during breathing or prefers to remain seated upright, mark records accordingly.

Uncontrolled look pressure can lead to all except.....

Diabetes

Relation to DH care

Explain how vital signs can affect dental hygiene and dental treatment. Teach the patient to refrain from eating, drinking, or smoking before the vital signs are taken. During the process, explain each step as needed by the individual patient.

Too narrow a bladder will cause false _____________ readings

High

Which does NOT cause respiration to increase?

Hot Food

Factors to Teachthe Patient

How vital signs can influence dental and dental hygiene appointments. The importance of having a blood pressure determination at regular intervals. For the patient diagnosed as hypertensive, encourage regular continuing use of prescription drugs for control of high blood pressure. Even in the absence of symptoms, patients must remain on prescribed medications, unless and until ordered by their prescribing physician.

Factors that influence pulse rate

Increased pulse. Caused by exercise, stimulants, eating, strong emotions, extremes of heat and cold, and some forms of heart disease. Decreased pulse. Caused by sleep, depressants, fasting, quieting emotions, and low vitality from prolonged illness. Emergency situations.

Blood Pressure

Information about the patient's blood pressure is essential during dental and dental hygiene appointments because special adaptations may be needed. Blood pressure readings most usually are recorded with the medical history and other assessment data. Readings taken at the start of an appointment can be significantly higher than at the end of treatment. To establish a baseline reading and determine the need for patient referral for medical attention, several readings are needed, especially at the close of appointments when the patient is relaxed. Screening for blood pressure in dental offices has been shown to be an effective health service for all ages since many patients are unaware that they have hypertension.

Too wide a bladder may cause false ____________ readings

Low

Procedures for Observing Respirations: Determine rate

Make the count of respirations immediately after counting the pulse. Maintain the fingers over the radial pulse. Respirations must be counted so that the patient is not aware, as the rate may be voluntarily altered. Count the number of times the chest rises in 1 clocked minute. It is not necessary to count both inspirations and expirations.

Locations for measurement

Oral: patient needs to be able to breathe through the nose and hold lips closed; must not have sore mouth, very dry mouth, or recent oral surgery. Forehead: for disposable thermometer. Ear: with a tympanic device. Medical or hospital applications: also use axilla or rectum for assessment.

Thoraic outlet syndrome

Painful disorder of fingers, hand, and/or wrist from compression of the brachial nerve plexus and vessels b/ween neck and shoulder

A patient with a temperature over 100.8°F shows signs of which of the following?

Pyrexia

Sites for determining pulse

Radial pulse: at the wrist, palm down w/ 3 fingers Other sites convenient for use in a dental office or clinic are the temporal artery on the side of the head in front of the ear, or the facial artery at the border of the mandible. Carotid pulse: used during cardiopulmonary resuscitation. Brachial pulse: used for an infant.

Rationale for treatment planning

Recording vital signs contributes to the proper systemic evaluation of a patient in conjunction with the complete medical history.

Regular Irregular

Regular overall w/ skipped beats

Explanation Informed consent

Seat patient in upright position, at eye level for instruction. Explain the vital signs and obtain consent.

Difference between sign and symptom

Sign: Identify by healthcare professional Symptom: Observed by patient

Korotkoff sounds

Sounds that are heard as the pressure in the sphygmomanometer cuff is released Auscultation= listening for sounds within the body to evaluate the condition of her heart, vessels, lungs, or other organs. During BP determination, a stethoscope is used to listen to sounds created by the blood as it pushes its way through he constricted brachial artery. Auscultatory gap: period of abnormal silence that occurs between the Korotkoff Phases

Procedure for Determining Blood Pressure: Prepare the patient

Tell patient briefly what is to be done. Detailed explanations should be avoided because they may excite the patient and change the blood pressure. Seat patient comfortably, with the arm slightly flexed, with palm up, and with the whole forearm supported on a level surface at the level of the heart. Use either arm unless otherwise indicated, for example, by a handicap or a shunt for dialysis. Repeat blood pressure determinations should be made on the same arm, because the difference between arms may be as much as 10 mmHg. Take pressure on bare arm, not over clothing. Loosen a tight sleeve.

Selection of cuff size

The correct width (W) is 20% greater than the diameter of the arm where applied

Body temperature Pulse Respiratory rate Blood pressure

The four basic vital signs for adolescents and adults.

Respiration

The function of respiration is to supply oxygen to the tissues and to eliminate carbon dioxide. Variations in normal respirations may be shown by such characteristics as the rate, rhythm, depth, and quality and may be symptomatic of disease or emergency states.

Pulse

The intermittent throbbing sensation felt when the fingers are pressed against an artery. It is the result of the alternate expansion and contraction of an artery as a wave of blood is forced out from the heart. The pulse rate or heart rate is the count of the heartbeats. Irregularities of strength, rhythm, and quality of the pulse should be noted while counting the pulse rate.

Blood pressure cuff in position

The lower edge of the cuff is placed approximately 1 inch above the antecubital fossa. The stethoscope endpiece is placed over the palpated brachial artery pulse point approximately 1 inch below the antecubital fossa and slightly toward the inner side of the arm.

Equipment to Determine Blood Pressure

The mercury sphygmomanometer is the preferred instrument. A calibrated aneroid manometer or a validated electronic device can be used and may be practical for home use. Finger monitors have been shown to be inaccurate.

Children Pulse Rate

The pulse or heart rate falls steadily during childhood. In utero: 150 bpm; at birth: 130 bpm; second year: 105 bpm; fourth year: 90 bpm; tenth year: 70 bpm.

Factors to alter temperature

Time of day: Highest in late afternoon and early evening; lowest during sleep and early morning. Temporary increase: Exercise, hot drinks, smoking, or application of external heat. Pathologic states: Infection, dehydration, hyperthyroidism, myocardial infarction, or tissue injury from trauma. Decrease: Starvation, hemorrhage, or physiologic shock.

Over 28bpm accelerated is called

Trachypnea

Seat patient in ___________________at eye level for instruction.

Upright Position

Referral for medical evaluation

When vital signs are not within normal, advise the patient to check with the physician. Referral for medical evaluation and treatment is indicated.

Indications for taking temperature

While preparing the patient history and making the extraoral and intraoral examinations, the need for taking the temperature may become apparent, or the dentist may have requested the procedure in conjunction with current oral disease.

Maintenance of normal respirations

a respiration is one breath taken in and let out.

Apply cuff

apply the completely deflated cuff to the patient's arm, supported at the level of the heart. It has been shown that when the arm rests on the arm of a dental chair, higher than the heart, the diastolic pressure shows a small but significant increase. Place the portion of the cuff that contains the inflatable bladder directly over the brachial artery. The cuff may have an arrow to show the point that should be placed over the artery. The lower edge of the cuff is placed 1 inch above the antecubital fossa (figure on next slide). Fasten the cuff evenly and snugly. Adjust the position of the gauge for convenient reading but so that the patient cannot see the mercury. Palpate 1 inch below the antecubital fossa to locate the brachial artery pulse. The stethoscope endpiece is placed over the spot where the brachial pulse is felt. Position the stethoscope earpieces in the ears, with the tips directed forward.

posititon of arm to take pulse

arm resting on surface w/ palm down

Types of endpieces

bell shaped or flat (diaphragm); the bell shape is used for medical examinations, particularly for chest examination

Maintenance of blood pressure

blood pressure depends on the force of the heartbeat (energy of the heart); peripheral resistance; condition of the arteries; changes in elasticity of vessels, which may occur with age and disease; and volume of blood in the circulatory system.

Components of blood pressure

blood pressure is the force exerted by the blood on the blood vessel walls. When the left ventricle of the heart contracts, blood is forced out into the aorta and travels through the large arteries to the smaller arteries, arterioles, and capillaries. The pulsations extend from the heart through the arteries and disappear in the arterioles. During the course of the cardiac cycle, the blood pressure is changing constantly.

An unusually slow heartbeat (below 50) is

bradycardia

Temperature 37.6°C to 41.0°C (99.6°C to 105.8°F)

check possible temporary or factitious cause, such as hot beverage or smoking, and observe patient while repeating the determination. Review the dental and medical history. Postpone elective oral care when there are signs of respiratory infection or other possible communicable disease.

Care of earpieces

clean by rubbing with gauze sponge moistened in disinfectant.

Inflate the cuff

close the needle valve (air lock) attached to the hand control bulb firmly but so it may be released readily. Pump to inflate the cuff until the radial pulse stops. Note the mercury level at which the pulse disappears. Look at the dial, and pump to 20 or 30 mmHg beyond where the radial pulse was no longer felt. This is the maximum inflation level (MIL). It means that the brachial artery is collapsed by the pressure of the cuff and no blood is flowing through. Unless the MIL is determined, the level to which the cuff is inflated will be arbitrary. Excess pressure can be very uncomfortable for the patient.

Stethoscope (a listening aid that magnifies sound)

consists of an endpiece that is connected by tubes to carry the sound to the earpieces.

Sphygmomanometer (blood pressure machine)

consists of an inflatable cuff and two tubes, one connected to the pressure hand control bulb and the other to the pressure gauge. Cuff material: is made of a nonelastic material and is fastened by a Velcro overlap. The inflatable bladder is located within the material of the cuff. Size: the diameter of the arm, not the age of the patient, determines the size of the cuff selected. The four cuff sizes available are child size, regular adult, large adult, and thigh. The thigh size is needed for grossly obese persons. Dimension: refers to the cuff width that is used; needs to be 20% greater than the diameter of the arm to which it is applied (as seen in figure on slide). It needs to cover approximately two-thirds of the upper arm. When a cuff is too narrow, the blood pressure reading is too high; when the cuff is too wide, the reading is too low.

Types of thermometers

electronic with digital readout; it is covered with disposable protective sheath. Place under tongue; short time required. Read on the digital display. Tympanic, cover with protective sheath. Insert gently into ear canal. Short exposure (2 to 5 seconds) before record appears on digital unit. Mercury in glass: oral, blue tip; rectal, red tip. Used less because of danger for breakage with mercury spill that must be cleaned up using specified procedures. Sheath cover used for infection protection. It takes longer time before reading than other types; more difficult to see and read mercury column. Disposable single-use chemical strip. Apply to appropriate skin area, usually the forehead. Color changes denote temperature.

Factors that increase blood pressure

exercise, eating, stimulants, emotional disturbance, use of oral contraceptives; blood pressure increases with age and length of use.

Factors that decrease blood pressure

fasting, rest, depressants, quiet emotions, such emergencies as fainting, blood loss, and shock

Temperature variations

fever (pyrexia) with values over 37.5°C (99.5°F) hyperthermia with values over 41.0°C (105.8°F) hypothermia with values below 35.5°C (96.0°F).

As a routine assessment

for complete examination during a maintenance appointment; with other vital signs prior to administration of local anesthetic.

Baseline documentation

for the new patient's initial permanent record along with all vital signs.

Mercury manometer

has gauges that are marked with long lines at each 10 mmHg, with shorter lines at 2-mm intervals between each long line. The level of the column of mercury of the manometer is at eye level for accurate reading and must not be tilted.

Locate the radial pulse

hold the fingers on the pulse

Pulse pressure

is the difference between the systolic and diastolic pressures. The normal or safe difference is less than 40 mmHg.

Diastolic pressure

is the lowest pressure. It is the effect of ventricular relaxation. The normal diastolic pressure is less than 80 mmHg.

Systolic pressure

is the peak or the highest pressure. It is caused by ventricular contraction. The normal systolic pressure is less than 120 mmHg.

Factors that influence respirations

many of the same factors that influence pulse rate also influence the number of respirations. A rate of 12 per minute or fewer is considered subnormal for an adult; over 28 is accelerated; and rates over 60 are extremely rapid and dangerous. Increased respiration. Caused by work and exercise, excitement, nervousness, strong emotions, pain, hemorrhage, shock. Decreased respiration. Caused by sleep, certain drugs, pulmonary insufficiency.

Position the stethoscope endpiece

place the endpiece over the palpated brachial artery, 1 inch below the antecubital fossa, and slightly toward the inner side of the arm, hold lightly in place

Procedures for Observing Respirations: Record

record all findings in the patient's record.

Deflate the cuff gradually

release the air lock slowly (2 to 3 mm per second) so that the dial drops very gradually and steadily. Listen for the first sound: systole ("tap tap"). Note the number on the dial, which is the systolic pressure. This is the beginning of the flow of blood past the cuff. Continue to release the pressure slowly. The sound will continue, first becoming louder, then diminishing and becoming muffled, until finally disappearing. Note the number on the dial where the last distinct tap was heard. That number is the diastolic pressure. Release further (about 10 mm) until all sounds cease. That is the second diastolic point. In some clinics and hospitals, the last sound is taken as the diastolic pressure. Let the rest of the air out rapidly.

improper positioning if chair is too high....

shoulders up and elbows away from body

What is the 5th new vital sign?

smoking status—gives the opportunity to introduce early in the encounter with the patient the significance of smoking to general and oral health. The fact that smoking is the number one preventable cause of illness and death more than justifies including smoking status as a vital sign.

An unusually fast heartbeat (over 100 bpm in an adult) is called

tachycardia

Prepare the patient for determining pulse

tell the patient what is to be done. Have the patient in a comfortable position with arm and hand supported, palm down. Locate the radial pulse on the thumb side of the wrist with the tips of the first three fingers (see figure on next slide). Do not use the thumb because it contains a pulse that may be confused with the patient's pulse.

Sequence for determining pulse

the pulse rate is obtained following the body temperature. When the mercury in glass thermometer is used, the pulse can be counted while the thermometer is in the mouth.

Temperature over 41.0°C (105.8°F)

treat as a medical emergency. Transport to a hospital for medical care.

Determining and Recording Blood Pressure: Repeat for confirmation

wait 30 seconds before inflating the cuff again. More than one reading is needed within a few minutes to determine an average and ensure a correct reading

Suspicion of infection

when oral infection is known to be present; necrotizing ulcerative gingivitis or periodontitis; apical or periodontal abscess; acute pericoronitis; at any appointment when the patient reports illness or there is a suspected infection; for protection of the health of the healthcare personnel and patients or families who may be exposed secondarily; special significance during epidemics when community exposures are at risk; for patient's referral for medical care when indicated.

Count and record for determining pulse

when the pulse is felt, exert light pressure and count for 1 clocked minute. Use the second hand of a watch or clock. Check with a repeat count. While taking the pulse, observe the following: rhythm: regular, regularly irregular, irregularly irregular. Volume and strength: full, strong, poor, weak, thready. Record on patient's record the date, pulse rate, other characteristics. Caution: a pulse rate over 100 is considered abnormal for an adult.

Determining and Recording Blood Pressure: Record

write date and arm used. Record blood pressure as a fraction, for example, 120/80. When both diastolic points are recorded, they can be written as 120/80/72.