Chapter 19: Vital Signs

body temp sites

* oral cavity * rectum * axilla * tympanic membrain * inguinal fold * forehead

Assessing the Apical Pulse

- Equipment: Watch w/ secondhand or digital timer, stehoscope, alcohol wipes -Can delegate to NAP if skills allow ----1st perform pre-procedure assessments ----- Inform NAP of special considerations -----Ask Nap to record and report pulse if outside of norma (60-100) Pre-procedure asseement: -Why is apical pulse indicate? (blood loss, cardiac/resp disease) -Assess factors that influence pulse( meds/actiity). wait 10-15 in pt recently active

What do fevers do?

- Kill or inhibits growth of microorganisms -Enhances phagocytosis -Causes breakdown of lysosomes and virally infected cells -Releases interferon which protects cells from viral infection They are a natural response and usually aren't a threat to clients

Auscultating BP

- Korotkoff Sounds: sounds of blood pulsating through arteries 1: Systolic: first tapping sound associated with pulse 2: Swishing sound as cuff is further deflated 3: Midway, sharp rhythmitic tapping sound 4: like 3rd but softer and fading 5th: Diastolic: silence

Breath sounds

- Normal resp are quiet - Abnormal (adventitious) sounds include: ---Wheezes: high pitched heard on expiration ---Rhonchi: low-pitched, gurgling sounds caused by secretions ---Crackles: caused by fluid in alveoli. Discontinuous, heard on inspiration. HIghpitched popping or low pitched bubbling ---Stridor: piercing, highpitched usually heard in infants with resp distress ---Stertor: snoring sound, common with mouth breathing

Hypoventilation

- Rate and depth of respirations are decreased and CO2 is retained or alveolar ventilation is comp'd. May be related to chronic obstructive pulonary disease, general anesthesia, resp failure.

Therapies for lowering blood pressure

-Aerobic exercise and resistance training in combo with medicine and diet. Insufficient evidence for using meditiation, yoga, relaxation therpy, stress reduction techniques and acupuncture

pulse quality

-Determined by the pulse volume and equality of pulses on both sides

Factors influencing respiration:

-Developmental level (newbor, toddler, adult) -Exercise -Pain (increased rate but decreased depth) -Stress -Smoking -Fever -Hemoglobin -Disease -Medications -Position

Chest and abdomen movement with breathing

-Difficulty moving air into/out of lungs cause resp change -Intercostal retration: visible sinking of tissue around and between ribs that occurs when additional breathing effort is needed -Substernal retraction: tissues are drawn beneath sternum -Suprasternal retraction: tissues are drawn in above the clavicle

Assessing Body Temperature

-Equipment: watch w/ second hand or digital clock/timer -can be delegated to NAP -Preprocedure: observe signs of resp distress (breathing faster/slower than normal, gasping, confusion, cyanosis) -determine baseline resp rate and resp charactoristics -assess things that may influence resp rate (pain, fever, activity) Procedure: Procedure Steps 1. Position the patient. With the patient in a sitting position (preferably), flex the patient's arm and place her forearm across her chest. Aids in counting the patient's pulse rate by making the rise and fall of the chest more discernible and by making the patient less aware that you are measuring the respiratory rate. The patient's awareness might alter the respiratory rate and/or pattern because respirations are partially under voluntary control. 2. Palpate and count the radial pulse; remember that number. 3. Then, keeping your hand on the patient's wrist, count the respirations. Allows you to count the respirations unobtrusively. 4. Observe the respiratory rate, rhythm, and depth. Rate: Normal for patient's age, fast (tachypnea), or slow (bradypnea) Rhythm: Regular or irregular Depth: Normal, shallow, or deep (e.g., Kussmaul's) All of these characteristics are necessary to evaluate respiratory status. Different pathologies affect each of these characteristics differently. 5. Count the number of breaths per minute. Begin timing the respirations with a count of 1, not 0 (the same as with pulse measurement). a. If the respiratory rhythm is regular, count the rate (one inhalation and one exhalation is one respiration) for 30 seconds, and multiply by 2. b. If the rhythm is irregular, count the rate for 1 full minute (60 seconds). Variations in rhythm may cause an inaccurate rate when counted for less than 1 minute.

Pyrexia

-Fever -Oral temp higher than 100 (37.8) or rectal for 101 (38.3).

Hypoxia

-Inadequate cellular oxygenation ---Signs: pallor/cyanosis, restlessness, apprehension, confusion, dizziness, fatigue, decresed level of consciousness, tachycardia, tachypnea, changes in BP -Cyanosis eval: tongue and oral mucosa are best indicators of hypoxia ----nails/lips/skin may be related to cold or reduced circulation -Chronic hypoxia causes clubbing (loss of nail angle) of fingers

Hyperthermia

-Like hyperpyrexia (fever), a body temp above normal. -However, elevated body temp is higher than the set point. -occurs because body cannot promote heat loss fast enough to balance heat producetion/high environmental temps

Blood Pressure

-Pressure of blood forced against arterial walls during cardiac contraction -Systolic Pressure: Peach pressure exerted against arterial walls and ventricles contract and eject blood -Diastolic Pressure: Minimum pressure exerted against arterial walls When heart is at rest

Thermoregulation

-Process of maintaining an internal temperature within a tolerable range. -Controlled by hypothalmus, body's thermostat.

Use apical pulse when:

-Radial pulse is weak/irregular -Rate is less that 60 or more than 100 -Pt on cardiac meds -Pt is an infant or child up to 3

What causes fever?

-foreign bodies stimulate phagocytes (wbcs) which eat them and secrete pyrogens -Pyrogens stimulate release of prostaglandins (set the hypothalmic thermostat to be raised higher). -Set point: reset value

Respiratory Rate

-number of breaths per minute. Count and observe by: ---Place hand of pt's chest or observing rise and fall of chest or abdomen ---use stethoscope and count inhalation and exhalation cycles - A familiar patient who's resp rate is not directly relevant to assessment can be counted to 30 sec and multiplied by 2. Everyone else is 1 min.

Arterial Oxygen Saturation (SaO2)

-percent of oxygen dissolved into arterial blood Measured by: 1.)Arterial Blood Gas (ABG) sampling: directly measures pressures of O2 and CO2 and blood pH (gases in arterial blood). It is invasive, painful, time consuming and expensive. 2.) Pulse oximetry: Measure O2 saturation (indicates O2 being carried by hemoglobin into arterial blood). Emits light and photosensor measure light passing through the site.

Assessing the Carotid Pulse

1. Palpate the carotid artery lightly. Place your fingers on the patient's trachea and slide them to the side into the groove between the trachea and the sternocleidomastoid muscle. Compressing or massaging the carotid arteries can stimulate the carotid bodies and significantly decrease the patient's heart rate and blood pressure. NEVER compress the carotid artery on both sides of the neck at the same time. 2. Assess the rate, rhythm, and quality, and compare bilaterally.

3 phases of fever:

1.) Initial phase (febrile onset): body temp is rising but did not reach new set point. May be sudden or gradual. person feels chilly/uncomfortabe 2.) Second phase (course): bod temp reaches its set point (max) and remains constant at this higher level. Person feels flushed and feels warm/dry. May stay here for days or weeks 3.) Third phase (defervescence/crisis): temperature returns to normal. Fever breaks. Person feels warm and lfushed due to vasodilation. Diaphresis (sweating) occurs

Body produces heat through 3 factors:

1.) Metabolism 2.) Movement of muscles 3.) nonshivering thermogenesis

How does the body regulate blood pressure?

3 factors: cardiac function, peripheral vascular resistance, blood volume

Febrile

A person with a fever ---A febrile: a person without a fever

Pulse sites;

Apical (apex of heart) Or Peripheral purlse (where artery can be pressed). -Radial, Brachial, carotid, temporal, etc

Heat Stroke

Body regulation fails, hyperthermia progress to temp above 103 . can reach temps of 106

Perfusion

Continuous supply of exygenated blood through blood vessels to all body cells

heat exhaustion

Core temp of 98.6 to 103. Signs incude weakness, nausea, vomiting, syncope, tachycardiia, tachypnea, muscle aches, headache, diaphoresis and flushed skin

Procedures: Taking Temperature

Delegate: Can be given to NAP if conditions and skill allow. Explain special considerations (PT had food or oral fluids, pt is confused), report to you if tempt is greater than 100. Preprocedure: Determine appropriate site (safety, comfort, accurate measurements) -----Oral: did pt smoke, eat or drink, chew gum? Wait 20-30 min -----Tympanic: assess for earwax or hearing aid -----Rectal: check record for diarrhea or impacted stool -----Axillary: check record for fever or hypothermia ----Skin: assess for conditions that require precise reading -----------some increase risk for client injury, others contribute to unreliable measurements Check previour record, note changes over time. Assess symptos and temperature alterations

Pulse Deficit

Different between radial and apical pulse. Differences may be due to heart irregularities and apex beats not being transmitted

Assessing Apical-Radial Pulse Deficit

Equipment Watch or clock with a second hand or second readout Procedure gloves, if indicated Stethoscope Alcohol or other antiseptic wipes to clean the stethoscope Delegation Instead of delegating measurement of an apical-radial pulse to a NAP, you would most likely ask the NAP to assist you in this procedure because it is best performed by two persons working together. Pre-Procedure Assessments Determine why assessment of pulse deficit is indicated. Conditions that require assessment of pulse deficit include digitalis therapy, blood loss, cardiac or respiratory disease, and other conditions that affect oxygenation status. Assess factors that may alter the pulse, such as activity and medications. Obtain another nurse to assist with the procedure. When performing the procedure, always identify your patient according to agency policy, using two identifiers, and be attentive to standard precautions, hand hygiene, patient safety and privacy, body mechanics, and documentation. Procedure Steps 1. Wipe the stethoscope with a 70% alcohol or benzalkonium chloride wipe before and after examining the patient. Cleaning can reduce the bacterial count by up to 100% and prevent the transmission of microbes. 2. Expose the left side of the patient's chest, minimizing patient exposure. Prevents distortion of sound from the patient's gown rubbing on the stethoscope and protects privacy. 3. Place the watch so that the second hand is visible to both nurses (if two nurses are performing the procedure). Using one watch increases accuracy of counts. 4. Nurse 1 palpates the 5th intercostal space at the midclavicular line for the apical pulse and holds the diaphragm of the stethoscope in place, using firm pressure. Aids in hearing high-pitched sounds and ensures good contact between the diaphragm of the stethoscope and the skin. 5. Nurse 2 palpates the radial pulse and assesses rate, rhythm, and quality. 6. Nurse 2 says "Start" when ready to begin and "Stop" when finished. Both nurses count the pulse simultaneously for 1 full minute. Count simultaneously to ensure accuracy. Counting for 1 full minute is necessary for an accurate assessment of any discrepancies that may exist between the two sites. 7. To obtain pulse deficit, subtract the radial rate from the apical rate. Apical Rate - Radial Rate = Pulse Deficit Evaluation Identify the presence of an apical-radial pulse deficit, and compare to previous findings. Assess other measures of cardiopulmonary status to identify a decline in the patient's condition. Look for trends. The presence of any apical-radial pulse deficit is abnormal. Patient Teaching Teach the patient about the significance of an apical-radial pulse deficit. Explain any necessary interventions. Home Care Assess the skill level of the person(s) who will be measuring the client's apical-radial pulse deficit in the home and provide instruction if necessary. Before leaving the home, clean the stethoscope as described in the Home Care section of Procedure 19-3. Documentation Document the apical-radial pulse deficit. Sample documentation MM/DD/YYYY 0900 Apical-radial pulse deficit is 4 beats/min. ——————— Jon Albertson, RN

Measuring Blood Pressure

Equipt: stethoscope and sphymomanometer Can delegate to NAP after pre-procedure assessments -inform site to use -inform special considerations (not to use certain arm) -record and report findings immediately -note which arm and pt position during measurement if bp is elevated -check record and activities that may influence reading Procedure Steps 1. Clean the stethoscope before and after the procedure. Although only a small percentage of microorganisms are pathogenic, cleaning can reduce the bacterial count by 94% to 100%. 2. Position the patient comfortably, ensuring that: a. The legs are uncrossed, the back is supported, and the feet are resting on the floor (if the patient is sitting in a chair); or that the patient is supine. This position allows for the most accurate reading. Crossing the legs may elevate the BP reading. b. The measurement arm is supported at heart level, slightly flexed, with the palm facing upward. The blood pressure will decrease if the arm is above the heart and increase if the arm is below the heart or not supported. 3. Fully expose the arm, being careful that clothing is not tight. Remove clothing rather than rolling up a sleeve. Note: There is some evidence to suggest that readings taken over sleeves do not affect blood pressure results, and that it may actually be preferable because of concerns about hygiene, privacy and religious beliefs (Pinar, Ataalkin, & Watson, 2010). While you are learning, and until there is more evidence, we advise that you will find it easier to hear the BP sounds on a bare arm. Clothing that is tight enough to restrict blood flow will alter the reading. 4. Place the cuff on the upper arm. a. Wrap the cuff snugly. b. Ensure that the cuff is totally deflated and palpate the brachial artery. c. Place the bottom edge of the cuff approximately 1 in. (2.5 cm) above the antecubital space. d. Place the center of the cuff bladder directly over the brachial artery (the center is often indicated with an arrow on the BP cuff). The center of the cuff bladder needs to be directly over the brachial artery to obtain an accurate reading. Loose application of the cuff results in overestimation of the pressure. 5. Place the stethoscope ear pieces in your ears, pointing slightly forward. When the earpieces point slightly forward, they direct sound into the ear canal, making the sounds more audible. 6. Palpate the brachial artery on the arm with the cuff. (Use the radial artery for this step if you prefer.) For correct stethoscope placement. 7. Inflate the cuff, as follows: a. Close the sphygmomanometer valve and inflate the cuff rapidly to about 80 mm Hg. b. Then palpate the pulse while you continue inflating in 10 mm Hg increments until you no longer feel the pulse. c. As you inflate the cuff, the artery is occluded as the pressure of the cuff exceeds the pressure in the artery. At that point, blood flow through the artery is halted, and no sound can be heard. Note the pressure at which the pulse disappears. d. Go to step 8 or the variation, as you prefer. Palpating the artery while inflating the cuff ensures that the cuff is inflated higher than the systolic BP. If the patient has an auscultatory gap, the systolic pressure can be mistakenly identified as lower than it actually is. Palpation is particularly important if the baseline systolic BP is unknown or if the patient is hypertensive. 8. Continue inflating the cuff to a pressure that is 20 to 30 mm Hg above the level at which the pulse disappeared. Move to Step 9. Helps ensure you will not miss an auscultatory gap or a faint first sound. Step Variation in Cuff Inflation Technique Do not continue palpating after the pulse disappears; instead, deflate the cuff rapidly. Wait 2 minutes, then place the stethoscope over the brachial artery and inflate the cuff to a pressure that is 20 to 30 mm Hg above the palpated level. Continue with steps 9 and 10. 9. Place the stethoscope over the brachial artery as follows: a. Be certain that the stethoscope tubing is not touching anything and that the diaphragm is not tucked under the edge of the cuff. When the tubing rubs against clothing, for example, it produces artifact sounds that make it difficult to hear the BP sounds. Placing the bell or diaphragm under the cuff can partially occlude the brachial artery, delaying the appearance of the Korotkoff sounds. b. Using the bell will enable you to hear BP sounds more accurately, especially at diastolic pressures. However, most people use the diaphragm because it is easily placed and because some stethoscopes do not have a bell. 10. Deflate the cuff slowly (2 to 3 mm Hg per second or per beat), listening for the Korotkoff sounds as you deflate. Deflating the cuff slowly increases patient discomfort and may alter the reading. Deflating the cuff faster may cause errors in hearing the Korotkoff sounds. a. As you deflate the cuff, blood begins to flow rapidly through the partially open artery, producing turbulence that you will hear through the stethoscope as a tapping sound. Note the point on the manometer at which you hear the first sound. This is the systolic BP. (If you are using an electronic BP device, read the digital screen when the numbers appear. Follow the manufacturer's instructions.) The 1st Korotkoff sound is the systolic pressure. b. Continue deflating the cuff and note the level at which the sounds become muffled and disappear. The artery is no longer compressed and sound will disappear. Record the point at which the sound disappears as the diastolic pressure. The 5th Korotkoff sound (the disappearance of sound) is the diastolic BP in adults. The 4th Korotkoff sound (the muffling of sounds) is the diastolic BP in children. The American Heart Association recommends recording the first sound, muffling, and last sound in children younger than 13 years, pregnant women, and people with high cardiac output or peripheral vasoconstriction. 11. If you need to repeat the measurement, deflate the cuff completely, and wait 2 minutes before reinflating it. Prevents venous congestion and false high readings. Procedure Variation A: Measuring Blood Pressure in the Forearm Place a properly sized cuff on the forearm, midway between the elbow and the wrist. Auscultate over the radial artery. Note that a forearm reading is not interchangeable with an upper arm reading. Procedure Variation B: Measuring Blood Pressure in the Thigh Use the thigh or the calf if the cuff will not fit either the upper or lower arm. NOTE: The thigh systolic measure may be 20 to 30 mm Hg higher than an arm BP reading. The diastolic reading is generally comparable. Place the patient in a prone position. If patient cannot be prone, place supine with knee slightly bent. Choose the correct cuff size. Wrap the cuff snugly around the thigh so that the lower edge of the cuff is approximately 1 in. (2.5 cm) above the popliteal fossa and the center of the cuff bladder is positioned directly over the popliteal artery (often indicated with an arrow on the blood pressure cuff). Palpate and auscultate over the popliteal artery. Procedure Variation C: Measuring Blood Pressure in the Calf Use the thigh or the calf if the cuff will not fit either the upper or lower arm. Place the patient supine. Choose the correct size cuff. Wrap the cuff snugly around the calf so that the lower edge of the cuff is approximately 2.5 cm above the malleoli or ankle. Place the stethoscope over either the dorsalis pedis or the posterior tibial artery. NOTE: Calf BP measurements are not equivalent to upper arm measurements in adults; they tend to produce a higher systolic BP. Procedure Variation D: Palpating the Blood Pressure Apply the cuff and palpate for the radial or brachial pulse. Begin to inflate the cuff. When you can no longer feel the pulse, inflate the cuff about 30 mm Hg more. As you release the valve and slowly deflate the cuff, note the reading on the manometer at which you once again feel the pulse. Record the palpated blood pressure according to the way it was assessed (e.g., "Palpated, low Fowler's, left arm 86/—" [or "86 systolic"]). Evaluation Compare the BP reading with previous readings. Look for trends. Is the BP slowly decreasing (e.g., impending shock) or slowly increasing (e.g., hypervolemia)? Look for a corresponding change in pulse rate, indicating potential hypoxemia. If this is the first BP measurement for the client, check readings in both arms. A difference of 10 mm Hg or less is normal. Report any significant changes in the BP reading. Patient Teaching Teach the patient about: Normal BP values (keep in mind that prehypertension is diagnosed at a lower level when using self-monitored readings). Significance of the BP reading. Further follow-up that may be necessary.

Evaluate and document Apical Pulse

Evaluation Are the findings within normal limits? Are there other factors supporting the findings? What are the trends over time? Is the skin pink, warm, and dry? Is there any cyanosis? Documentation Document the pulse rate, rhythm, and site. Sample documentation mm/dd/yyyy ———— 0800 ———— Apical pulse regular rhythm, and strong, rate of 64. ———— Janice Jonas, RN

Respiration

Exchange of oxygen and carbon dioxide in the body. 2 aspects: mechanical and chemical -Mechanial: active movement of air into and out of resp. system. -----Pulmonary ventilation: breathing -Chemical: ---External res: exchange of o2 and co2 between alveoli and pulm. blood supply ---Gas transport: transport of gasses through body ---Internal respiration: exchange of gases between capillaries and body tissues.

What influences body temp? Environmental

High temps can raise internal temps causing heat stroke, low temps can cause hypothermia

What influences body temp? Exercise

Increase metabolism can raise body temp to 101-104

Hyperthyroidism

Increase of thyroid hormone THYROXINE and increases BMR. Often feel warm Epinephrine and norepinephrine also increase BMR and contribute to warmth

Vasodilation

Increasing diameter of blood vessels. Sends blood to the body's surface from the core to help the body cool off

Mechanics of breathing

Inspiration: Impulses sent along phrenic nerve cause thoracic muscles and diaphragm to contract. Ribs move upward diaphragm moves downward and abd organs move down and forward. Air is drawn into lungs Expiration: Diaphragm and thoracic muscles relax, chest cavity decreases and lungs recoil forcing air out. Passive and takes 2-3 seconds.

Fever descriptions:

Intermittent: temp alternates between fever and normal w/o meds. Remittent: fluctuations of temp higher than average during 24 hr period (greater than 3.6 f or 2 c) Constant (sustained): temp may fluctuate slightly but is always above normal Relapsing (recurrent): short periods of fever alternating with normal temps, each lasting 1 to 2 days

Hypothyroidism

Low thyroxine level Less heat is produced, patients feel cold

Nonshivering thermogenesis

Metabolism of brown fat to produce heat. Used by infants.

Planning outcomes/evaluation : Pulse

NOC standardized outcomes include the following: Vital Signs Status is the only outcome that directly pertains to assessing the pulse. Other outcomes depend on the nursing diagnosis causing the pulse changes. For example, Ineffective Peripheral Tissue Perfusion can be monitored with the NOC label of Circulation Status. Some individualized goal/outcome statements you might write for pulse status follow: Apical pulse 60 to 80 beats/min when at rest. Pedal pulses 80 to 100 beats/min, 2 (on a scale of 0 to 3), and equal bilaterally.

Vasoconstriction

Narrowing of the blood vessels to conserve heat by taking heat away from periphery and back to the body's core.

Assessing heartrate:

Need a stethoscope: Bell (small part) for low frequency sounds, Diaphram (large part) for high frequency sounds. Palpate or ausculate the pulse. Select pulse site and lightly press the pt's artery against bone with index and middle finger. may need to use Doppler.

Blood Volume

Normal volume in body is 5 liters (5000 mL's) -hemorrgage reduces volume and BP falls -fluid retention/renal failure increases volume and BP increases

OLDCARTS

Onset, Location, Duration, Character, Aggravating factors, Relieving Factors, Treatment, Severity

Assess Brachial Pulse

Procedure Steps 1. Palpate the brachial artery. a. Using firm pressure, press in the inner aspect of the antecubital fossa until you palpate the brachial artery. b. If you have difficulty palpating the pulse, ask the patient to pronate the forearm (i.e., turn the palm of the hand downward). This brings the brachial artery over a bony prominence and makes the pulse easier to feel. 2. Assess pulse rate, rhythm, and quality, and assess bilaterally (see Procedure 19-2A). The brachial pulse is used most frequently to assess blood pressure and to identify the presence of a pulse during cardiopulmonary resuscitation (CPR) in an infant.

Assessing the Dorsalis Pedis Pulse

Procedure Steps 1. Palpate the dorsalis pedis pulse. a. Run your fingers up the groove between the great and first toes to the top of the foot. b. Palpate very lightly. The dorsalis pedis pulse is easily obliterated, so use very light pressure. The dorsalis pedis pulse is used to access circulation of the foot. Owing to atherosclerosis or hardening of the arteries, the dorsalis pedis may be difficult to palpate in older adults. 2. Assess pulse rate, rhythm, and quality, and assess bilaterally. 3. If you are unable to palpate the dorsalis pedis pulse, use a Doppler ultrasound device to assess the pulse and circulation to the lower extremity.

Assessing the Femoral Pulse

Procedure Steps 1. Palpate the femoral pulse by pressing deeply in the groin midway between the anterosuperior iliac spine and the symphysis pubis. The femoral artery lies very deep and requires significant pressure to palpate. You may need to use both hands to feel the pulse on an adult. 2. Assess pulse rate, rhythm, and quality, and assess bilaterally. The femoral pulse is used to determine the presence of a pulse during CPR and to assess circulation to the leg.

Assessing Popliteal Pulse

Procedure Steps 1. Palpate the popliteal pulse by pressing behind the knee in the middle of the popliteal fossa. The popliteal pulse can be difficult to feel. It is used only when specifically indicated because of absence of pedal pulses or for taking a thigh blood pressure. 2. Assess pulse rate, rhythm, and quality, and assess bilaterally. The popliteal pulse is used to assess circulation of the lower leg and auscultate a thigh blood pressure.

Assessing the posterior tibial pulse

Procedure Steps 1. Palpate the posterior tibial pulse by pressing on the inner (medial) side of the ankle below the medial malleolus. The posterior tibial pulse is usually palpated easily, but it may be deeper in some people. So, press down moderately and then increase pressure until you feel the pulse. It is relatively easy to obliterate. 2. Assess pulse rate, rhythm, and quality, and assess bilaterally. The posterior tibial pulse is used to assess circulation to the lower extremity; it is assessed along with the dorsalis pedis pulse.

Assessing Temporal pulse

Procedure Steps 1. Palpate the temporal pulse by pressing lightly lateral (outside area) and superior to (above) the eye. 2. Assess pulse rate, rhythm, and quality, and assess bilaterally as for the radial pulse (see Procedure 19-2A). The temporal pulse is easily accessible and is used frequently in infants.

Apical Pulse procedure

Procedure Steps 1. With the client supine or sitting, expose the left side of the chest, but only as much as necessary. Prevents distortion of sound from the patient's gown rubbing on the stethoscope, while also protecting the patient's privacy. 2. Wipe the stethoscope with a 70% alcohol or benzalkonium chloride wipe before and after examining the patient. Cleaning can reduce the bacterial count by up to 100%. 3. Palpate the 5th intercostal space at the midclavicular line for the apical pulse. The left ventricle of the heart and the point of maximum impulse lie in this area. The apical pulse is generally best heard at the point of maximum impulse (PMI), over the apex of the heart. a. To locate the 5th intercostal space, slide your finger down from the sternal notch to the angle of Louis (the bump where the manubrium and sternum meet). b. Slide your finger over to the left sternal border to the 2nd intercostal space. c. Now place your index or ring finger (depending on which hand you use) in the 2nd intercostal space, and count down to the 5th intercostal space by placing a finger in each of the spaces. d. Slide over to the midclavicular line, keeping your finger in the 5th intercostal space. The apical pulse is generally best heard at the PMI in the 5th intercostal space at the midclavicular line. The PMI is located over the apex of the heart. For an adult, this site is on the anterior chest at 3 inches (8 cm) or less to the left of the sternum, at the 4th, 5th, or 6th intercostal space at the midclavicular line. 4. Palpate the apical pulse (also called the point of maximal impulse [PMI]). The pulse area should be about the size of a quarter, without lifts or heaves. A larger than normal pulsation may indicate ventricular hypertrophy. 5. Warm the stethoscope in your hand for 10 seconds. Then place the diaphragm over the PMI, and listen to the normal S1 and S2 heart sounds ("lub dub"). Count each pair of sounds ("lub-dub") as one heartbeat. A cold stethoscope placed on the skin may startle the patient and increase the heart rate. Heart sounds result when blood moves through the valves of the heart. The first heart sound is louder at the apical area and should be audible when the pulse is auscultated. 6. Count the apical heart rate for 1 full minute. Ensures accuracy. Because the apical heart rate is needed as an assessment measure for the administration of some medications (e.g., digoxin), accuracy is essential. Some cardiac conditions cause either slow or irregular rates, both of which must be counted for a full minute to ensure accuracy.

What is the gold standard site for body temp?

Pulmonary artery This, esophagus and bladder accurately measure core temp but are not easilly accessed.

Analysis/Nursing Diagnosis : Pulse

Pulse changes are symptoms. Nursing diagnoses are useful for describing condition causing the pulse change. -Ineffective Tissue perfusion: diag used when pulse is absent or weak/cool, pale skin is present -Impaired skin integreity or tissue integity: used as secondary diag when ITP^ is present. If tissue is not adequatly perfused, ischemia and necrosis can occur -Deficient Fluid Volume may cause the pulse to be weak and thready. Excess Fluid Volume may cause the pulse to be bounding and full. Decreased Cardiac Output may cause tachycardia, bradycardia, or changes in pulse volume.

Pulse

Rhthmic expansion of an artery produced when a bolus of oxygenated blood is forced into it by contraction of the heart

Equipment for BP

Stethoscope, blood pressure cuff and sphygmomanometer or electronic blood pressure monitor Electronic BP Monitors use microphones to sense sounds or sensors to detect pressure waves Cuff size: Width of bladder will cover 2/3's of the length of the upper arm of adult and whole upper arm of child. Cuff width is 40% of the arm circumference and length of bladder encircles 80% of arm in adults.

What influences body temp? Emotions and stress

Stress, anxiety, excitement, nervous stimulate symp. nervous system, producing epinephrine and norpinephrine which trigger increase in metabolic rate

Convert Fahrenheit to centigrade (C)

Subtract 32 from F tempt and multiply by 5/9 (F-32) x 5/9 = C

Average Vital Signs

Temperature: Oral: 98 Rectal: 98.6 Pulse: Normal 60-100 beats/min Average: 80 beats/min Respirations: 12-20 breaths/min Blood pressure: Normal range 100-119 mm Hg systolic or 60-80 mm Hg diastolic Prehypertensive 120-139 mm Hg systolic or 80-89 mm Hg diastolic Average 110/70 mm Hg

Metabolism

The sum of all physcial and chemical processes and changes that take place in the body.

Site for BP

Usually use Brachial artery -Avoid assessing BP in an arm with an IV device, skin graft, cast, ect -Do not use paralyzed ar or side of breast or shoulder surgery -Can use lower extremities (forearm, thigh, calf) but systolic may be 20 to 30 mm Hg higher. Diastolic should be similar -Document site used

Insensible loss

Water loss by evaporation

What influences body temp? Gender

Woman's body temp varies with menstrual cycle and pregnancy. Low progesterone = lower body heat High progesterone= higher body heat Menopause cause temp fluctuations (HOT FLASHES)

Pulse Pressure

the difference between the systolic and diastolic pressures and reflects the stroke volume 120/80 120-80=40 40 is pulse pressure

Pulse rate

the number of pulse beats per minute while palpating or auscultating. Begin at 1 and not 0 Bradycardia: below 60 Tachycardia: above 100

Palpating Blood Pressure

-Can be used if BP is difficult to hear - Use palpation with auscultation for calculating proper cuff inflaction pressure before auscultating BP and deteting ausculatory gap

Teaching your client about Hypertension

*Teach the client and family about lifestyle changes for preventing and managing hypertension.* - Limit salt intake to 1 teaspoon per day (2,400 mg of sodium). - Consume a diet high in potassium (e.g., fresh fruits and vegetables such as bananas, potatoes, and acorn squash). - Consume a diet high in calcium (e.g., milk and milk products [yogurt], sardines, molasses, tofu). - Limit alcohol intake to 1 or 2 drinks per day for men; 1 for women. (One drink is a can of beer, one jigger of liquor, or a glass of wine. Wine is preferred.) - Maintain ideal body weight; lose weight if overweight. - For overall cardiovascular health, reduce saturated fat and cholesterol intake. - Eliminate smoking. - Aerobic excersize 30-45 minutes several days a week - Reduce stresss MOnitor pressure at home to see if mods are effective, at certain times, when experiencing headaches or dizziness

How Body Regulates Respiration:

-Breathing is regulated in response to changes of concentrations of O2 and CO2 in arterial blood. Primary stimulus for breathing is level of CO2 in the blood -Central chemoreceptors: located in resp centers are senstive to CO2 and pH (hydrogen ion) concentrations. Increases in either cause respirations -Peripheral chemoreceptors: locatd in carotid and aurtic bodies. Partial pressure of o2 in arterial blood (PaO2) is between 80 and 100. -Breathing is usually involuntary.

Skeletal Muscle Movement

-Catabolism of fats and carbs produces energy and heat -Sitting requires little muscle activity, but running increases body temp due to catabolism -If body senses a severe drop in temp, the hypothalamus would ake you shiver to produce heat. Can raise heat production by four times.

Factors influencing BP

-Developmental (newborn systolic 60-80 diastolic 40-50) -Gender: male slightly higher than female. Menopause=increase -Family History -Lifestlye: sodium, smoking, alcohol -Exercise -Body Position: higher if person is standing, if arm above heart level or unsupported, if pt's feet are dangling or crossed at knees -Stress -Pain: often causes increase but prologonge or severe pain can decrease -Race: african americans have higher bp than euroeans -Obesity: due to additional vascular supply required and increase in peripheral resistance -diurnal variations (sleep wake cycle) -Medications -Diseases: virculatory system or organs (kidneys) -Genetic variations/Genes:

Hyperpyrexia

-Fever above 105.8, can cause cellular damage which leads to confusion, delirium, seizures or coma. -Death results if body temp becomes higher than 109-112

Cough

-Forceful or violent expulsion of air during expiration. allergies, lung disease, resp. infection, heart condition -Constant or intermittent -Productive if secretions come up. Nonproduction/dry= no secretions -Hacking cough: series of dry coughs -Whooping cough: sudden cough that ends with whooping sound

Peripheral Resistance

-Friction between blood and vesel walls result in resistance to blood flow. Increase causes tmp increase in BP. Amount of fruction is due to blood viscosity (thickness), arterial ssize and arterial compliance -Blood Viscosity: determined by hematocrit (percentge of RBC's in plasma). Any increase in hematocrit (dehydration) increases viscosity and therefore BP. LOw hematocrit lowers viscosity and BP -Arterial size: smaller the radius of blood vessel, more resistance. -Arterial compliance: lack of elasticity create resistance and possible change in PB. -----Arteriosclerosis: Hardening of arteries is a common contributor to high BP in middle and older adults.

Respiratory effort

-Normal breathing= effortless -presense of disease (like asthma or pneumonia) creates labored breathing -Dyspnea: increased effort to breath, uncomfortable for pt and creates fear/fatigue -Orthopnea: difficulty breathing horizontally

How heat is exchanged between Body and Environment

-Radiation: loss through electromagnetic waves emitting from surfaces that are warmer than surrounding air. -Convection: Transfer of heat through currents of air or water -Evaporation: Water converts to vapor and is lost from the skin (perspiration) or mucus membranes (breath) -Conduction: Heat is transferred from warm to cool by direct contact

Hyperventilation

-Rapid and deep breathing cause excessive loss of CO2 (hypocapnia). May feel lightheaded/tingly. Caused by anxiety, infection, shock, hypoxia, drugs, diabetes, acid-base imbalance

Respiratory Rhythm

-Regular or Irregular -Cheyne-stokes: rare pattern involving fast shallow breathing followed by slow heavy breathing and moments without breath (apneas) -Biot's breathing: Groups of regular deep inspirations followed by regular or irregular periods of apnea.

Cardiac Function:

-Remember Cardiac output: volume of blood pumped per minute reflects functioning of heart. Increased output causes increase in BP, decrease causes decrease. -Increased Stroke Volume: conditions that cause this include increased blood volume (during pregnancy) and more forceful contraction of ventricles (during exercize) -Decreased Stroke Volume: Dehydration, active bleeding, heart damage (mycardinal infarction), very rapid heart rate (too fast for ventricles to fill)

Palpation with auscultation

-Use palpation with auscultation for calculating the proper cuff inflation pressure for BP and for detecting Ausculatory gap -Recognizing Asucultatory Gap: Hypertention: may note loss of sounds for up to 30 mmHg followed by return of sound. Palpating then auscultating ensures you will not miss the first sound.

How body regulates pulse:

1.) Left ventricle contractsand forces blood into the aorta, causing pressure and forces expansion of arteries and causes blood to move toward capillaries. Trough (low point) occurs when the artery contracts to push blood along. a.) Peak of the wave: systole (contraction of heart) b.) Trough period: diastole (rest phase) c.) Stroke volume: quantity of blood forced out by each contract of left ventricle. avers 70 mL in healthy adults d.) Cardiac output: total quantity of blood pumped per minute::: Cardiac output= strokes volume x pulse rate e.) ANS regulates heart rate. SYmpathetic increases heart rate. Parasympathetic decreases.

Normal Pulse Rate

60-100 bpm average; 70-80 bpm

Pulse Volume

Amount of force produced by the blood pushing through the arteries. Usualy the same for each beat. Refer to chart. Bilateral Equality: to determine if blood flow is adequate. Assess by comparing pulses on both sides. Absent or weak pulse: circulation may be comprimised. Assess for Pallor (paleness of skin compared to other part) or Cyanosis (bluish grayish discoloration)

Temp variations:

Axillary, oral, tympanic, rectal and temporal. axillary oral and rectal have a .8F difference between each site and the nurse should round up to a full degree. ex: ax: 98.1, oral 99.1, rectal 100.1

BMR

Basal metabolic rate: amount of energy required to maintain body at rest

Apnea

Cessation of breathing. Can only be tolerated for a few minutes. Brain damage can occur in longer than 4-6 minutes

What influences pulse rate?

Changes in blood volume, changes in elasticity of arterial walls, heart conditions, impaired nervous system, gender, food intake, stress, fever, disease, excersize positional changes, medications.

Assessment of BP: Direct and Indirect

Direct: Catheter is inserted into artery and attached to tubing connected to electric monitoring system. Usually used in critical care and surgery Indirect: (Non-invasive) accurate reading that can be performed in any setting

Delegating vital signs

Discern the situation. Can be assigned to student nurse or to NAP (nursing assistive personnel)

Equipment to measure temp

Electronic Thermometers Electronic Infrared Thermometers: detects heat in form of inrared energy given off by the body. Does not touch the actual site Disposable chemical thermometer: thin plastic strip, patch, or tape that produces color change at certain body temp. usually used for oral or axillary reading then disgarded.

Respiratory Assessment

Equipment: Watch w/ second hand or digital display, Steoscope for auscultating Data to collect: -resp rate -depth rhythm effort

Procedure: Assessing Peripheral Pulses

Equipment: Watch w/ second head, digital timer, pen, pencil, flow sheet or PDA Can be delegated to NAP if skills and condition allow. Tell NAP which site (radial, Brachial), special considerations (if they were active beforehand). Tell her to report if outside normal limits Pre-procedure: -Determine why assessment of pulses is indicated -Assess factors that can alter reading like meds or activity. wait 5 ti 10 min if pt was active

Evaluating Vital Signs

Evaluate vitals signs to now norms and trends of client. Not changes in conjuction to meds, diagnosis, procedure, environment, activity, etc.

What influences body temp? Developmental

Infants: lose 30% of body heat through head which is larger than the rest of their body. Puts them at risk for decreased body temp Older adults: Slower metabolism, lowered vasomotor control and loss of subcutaneous tissue makes it difficult for seniors to stay warm. Average temp for older adults is 95-96.8

Humidity

Moisture in the environment if environment is humid, less moisture evaporates from skin and less cooling occurs

Convert centigrade (C) to Fahrenheit

Multiply centigrade temp by 9/5 and add 32 (C x 9/5) + 32= F

Planning Interventions/implementation

NIC Standardized interventions inclde: -Dysrhythmia management: to monitor abnormal pulse -Vital Signs monitoring: used for general eval of clients who do not have identified issue with pulse Addressing dysrhythmias: -Monitor pt's VS -Monitor pt's activity tolerance -Collect and assess lab data -Help determine cause of dysrhythmia -administer antidysrhythmic medications -Provide emotional support

Procedure: Oral Temp

Procedure Steps 1. If you must use a glass thermometer, shake down the liquid if necessary. a. Stand in an open area away from tables and other objects. Prevents thermometer breakage. b. Hold the end opposite the bulb between your thumb and forefinger, and snap your wrist downward. c. Shake the thermometer until the reading is less than 96°F (36°C). The reading must be lower than the anticipated temperature measurement. 2. Slide the thermometer into a protective sheath. Provides a barrier to prevent transmission of microorganisms. 3. Place the thermometer tip under the tongue in the posterior sublingual pocket (right or left of frenulum). Puts the tip in close proximity to the major blood vessels under the tongue, allowing the thermometer to reflect the core temperature. 4. Have the patient close her lips around the thermometer, cautioning her not to bite down on it. Protects the thermometer from exposure to the air, which could alter the reading. Biting may break a glass thermometer, injuring the mouth. 5. Leave the thermometer in place for the recommended time. a. Glass thermometer: 5 to 8 minutes b. Electronic (digital) thermometer: Until it beeps c. According to agency policy Research findings differ on the optimal time for measuring an oral temperature, so follow agency policy. 6. Read the temperature. a. Glass thermometer: Remove the thermometer, position it at eye level, and rotate it until the markings are clear. b. Electronic thermometer: Read the digital display, then remove the thermometer. 7. After removing the thermometer, discard the cover. If there is no cover, wipe the thermometer with an antimicrobial or alcohol-based wipe. Wiping removes mucus that can make the markings on a glass thermometer difficult to read. 8. Clean and replace the thermometer. Follow agency policy. Prevents microbial growth on thermometers and recharges battery of electronic thermometers.

The Procedure - Tympanic Membrane Temperature:

Procedure Steps 1. Make sure the thermometer lens is intact and clean. Ensures an accurate reading. 2. Place a disposable cover tightly over the lens, making sure the clear film is smooth across the lens. Ensures an accurate reading and prevents cross-contamination. 3. Position the patient's head to one side. If you are right-handed, try to use the right ear; if you are left-handed, use the left ear. This allows you to better visualize the ear canal. 4. Straighten the ear canal or follow the manufacturer's instructions. As a rule: a. For an adult, pull the pinna up and back. b. For a child, pull the pinna down and back. Some tympanic thermometers require you to straighten the ear canal; others do not. Some instruct, for adults, to pull the ear up, backward, and slightly away from the head. Some models instruct, for a child, to pull the pinna straight back instead of down and back. The external auditory canal is curved upward in children younger than 3 years of age. In an adult, it is a slightly S-shaped structure. 5. Insert the probe into the ear canal gently and firmly, directing it toward the tympanic membrane and inserting far enough to seal the opening. Creates a seal to obtain an accurate reading without causing trauma to the ear canal. 6. Rotate the probe handle toward the jaw (for some thermometer models). Follow the manufacturer's instructions; not all models require this. Aims the lens toward the tympanic membrane. 7. Take the measurement. a. Press and release the button to obtain the reading. b. Follow the instructions for the specific tympanic thermometer being used. Some tympanic thermometers record the reading immediately; for some you must wait for about 3 seconds. 8. Remove the thermometer when you hear a beep and the display flashes. Note the reading in the display window. 9. Repeat the measurement in the other ear. A study of 132 adults found significant differences in temperature in the left compared with the right ear. In addition, the left ear tended to register a lower temperature than the right ear at temperatures below 36.7°C (98.1°F) and a higher temperature above 36.7°C (Heusch & McCarthy 2005) or when taken by a female (Helton & Carter, 2011). 10. Discard the probe cover (usually you will press an "eject" button to do this) and replace the thermometer in its charging base. Recharges the battery and protects the instrument.

Procedure: Chemical Strip Thermometer

Procedure Steps 1. Place the thermometer strip (paper or tape) on the patient's skin, generally on the forehead or abdomen. The thermometer strip must be in contact with the skin to work properly. 2. Leave the thermometer strip in place 15 to 60 seconds (or as the manufacturer directs). 3. Observe for color changes. Chemical strips have indicators that change colors to indicate temperature changes. 4. Read the temperature before removing the strip from the patient's skin. Ensures the most accurate reading. 5. Remove and discard the thermometer strip.

Pulse rhythm

The time interval between heartbeats (regular or irregular) Dysrhythmia: intervals between beats are irregular and vary ----Important to know if it's regularly irregular (forms a pattern) or Irregularly irregular (unpredictable ) -----May need additional assessment be ECG

Procedure: Aux temp

Procedure Steps 1. Position the client supine or sitting. 2. Dry the client's axilla, as needed. Moisture from perspiration alters the temperature reading. 3. Slide the thermometer into a protective sheath (depending on type of thermometer). A protective sheath provides a barrier to prevent transmission of organisms. 4. Place the thermometer tip in the middle of the axilla. 5. Position the client's upper arm down, with the lower arm across the chest. Puts the thermometer in close proximity to the axillary blood vessels, allowing it to better reflect the core temperature. 6. Hold the thermometer in place for the recommended time. a. Leave an electronic probe in place until it beeps. b. Leave a plastic, or glass if you must use it, thermometer in place for 8 minutes or according to agency policy (usually 5 minutes for children). Study findings differ for accuracy of temperature measurements at the axillary site. Follow agency policy. 7. Read the temperature. a. Electronic thermometer: Read the digital display; remove the thermometer. b. Glass thermometer: Remove the thermometer; hold at eye level, and rotate it until the markings are clear. Avoid using glass, if possible. 8. After removing the thermometer, discard the cover. If there is no cover, wipe the thermometer with a tissue. Removes any moisture that may have accumulated in 8 minutes' time. 9. Clean and replace the thermometer in the storage base, following agency policy. Prevents microbial growth on thermometers and recharges the battery.

Procedure: Rectal Temp

Procedure Steps 1. Slide the thermometer into a protective sheath. A protective sheath provides a barrier to prevent transmission of microorganisms. 2. Position an adult patient in Sims' position (on the side with the knees flexed). Drape the patient so that only the anal area is exposed. Step Variation Taking a Rectal Temperature for a Small Child Place a child in the prone position. You can lay the child face down across your lap or a parent's lap. Flexing the knees helps relax the muscles to ease insertion and aid in visualization. Draping provides privacy and decreases embarrassment. 3. Lubricate the tip of the thermometer by squeezing water-soluble lubricant onto a tissue and then applying it to the thermometer. Prevents injury to the rectal mucosa and eases insertion. Inserting the thermometer into the lubricant container would contaminate contents of the container. 4. Don a procedure glove on your dominant hand or on both hands if necessary. 5. With your nondominant hand, separate the patient's buttocks to visualize the anus. 6. Gently insert the thermometer approximately: Adult: 1 to 1.5 in. (2.5 to 3.7 cm) Child: 0.9 in. (2.5 cm) Infant: 0.5 in. (1.5 cm) The thermometer must be placed past the rectal sphincter. a. Have the patient take a deep breath. Insert the thermometer as he exhales. Taking a deep breath helps relax the anal sphincter. b. If you feel resistance, do not use force. Inserting the thermometer too far or forcing against resistance may injure the rectal mucosa. 7. Hold the thermometer in place until it beeps. (For a plastic or glass if you must use it, thermometer, hold the thermometer 3 to 5 minutes.) The thermometer must be held in place to prevent inadvertent injury to the patient. An electronic thermometer will beep when a constant temperature is reached. Research differs on the optimal time for measuring a rectal temperature, so follow agency policy. 8. Remove the thermometer, discard the cover, and read the digital display. 9. Remove the procedure glove(s) and discard in a biohazards container. 10. Follow agency policy for cleaning and storing thermometers. Prevents microbial growth on thermometers and recharges electronic thermometer battery.

Assessing radial pulse

Procedure Steps 1. With the patient sitting or supine, flex the patient's arm and place the patient's forearm across his chest. 2. Palpate the radial artery. The radial site is the most frequently used to calculate the patient's heart rate because it is generally the easiest site to use. a. Place the pads of your index or middle fingers (or both) in the groove on the thumb side of the patient's wrist, over the radial artery. b. Press lightly but firmly until you are able to feel the radial pulse. Start with light pressure to prevent occluding the pulse and gradually increase the pressure until you feel the pulse. The fingertips are the most sensitive parts of the hand to palpate arterial pulsations. Avoid using the thumb, because it has its own pulsation and may interfere with the accuracy of your count. 3. Note the rhythm and quality of the pulse. Note whether the thrust of the pulse against your fingertips is bounding, strong, weak, or thready. The rhythm and quality of the pulse are a reflection of the patient's cardiac output. The strength of the pulse reflects the volume of the blood that is ejected against the arterial wall with each contraction of the heart. An irregular or weak pulse indicates decreased cardiac output. A bounding pulse indicates increased cardiac output. 4. Count the pulse: a. Count for 60 seconds the first time you take a patient's pulse. After that, you can count a pulse with a regular rhythm for 15 seconds and multiply by 4, or count for 30 seconds and multiply by 2 to get the beats per minute. If you do not know the patient well, count for a full minute to be certain to detect irregularities. See Step 4c rationale. b. Begin timing with the count of I—starting with the first beat that you feel. c. Count an irregular pulse for I full minute (60 seconds). Research is conflicting. Some studies indicate that a 60-second count is most accurate; others say that accuracy is not affected by a 30-second, or even a 15-second, count if the pulse is regular. You must count an irregular pulse for 1 full minute to be accurate. 5. For an admission assessment or peripheral vascular check, palpate the radial pulses on both wrists simultaneously. Note any difference in the quality of the pulse between arms. Is the pulse on one side weaker than that on the other? Palpating simultaneously enables the recognition of small differences in the peripheral circulation.

Procedure: Temporal Artery Temp

Procedure Steps NOTE: If the patient has been lying down, do not measure the temperature on the side that was lying on the pillow. Do not measure if a cap or hair has been covering the area over the temporal artery. These can prevent heat dissipation and produce a falsely high reading. 1. Remove the protective cap from the instrument; clean the lens/probe according to the manufacturer's instructions. 2. Place the probe flat on the center of the forehead, midway between the eyebrow and the hairline. 3. Press and hold the button while you stroke the thermometer medially to laterally across the forehead; keep the lens/probe flat and in contact with the skin and slide in a reasonably straight line until you reach the hairline. 4. Still holding the button, touch the thermometer lens/probe behind the ear lobe, in the soft depression below the mastoid. This step is necessary for an accurate reading if there is any moisture at all on the patient's forehead. 5. Release the button for the temperature reading.

Patient pulse: data to collect

Rate, Rhythm and quality

Taking an accurate Blood Pressure

To improve your technique and accuracy of measurement, use the following tips in addition to Procedure 29-6: Do not be influenced by the client's previous BP measurements. Explain the procedure, particularly on admission or when changing the routine. Reduces patient anxiety. Wait 30 minutes before assessing BP after client has ingested caffeine or smoked. Do not assess BP while the client is in pain. Apply the cuff over bare skin, if possible. Controversy surrounds this issue, so follow the manufacturer's instructions and agency policy. Advise clients who are home monitoring to apply the cuff over bare skin. Instruct the client not to talk during BP measurement. You should not talk either. Keep environmental noise and client movement to a minimum. Hold the stethoscope lightly but completely against the skin; do not put your thumb on top of the bell or diaphragm. Try not to allow the tubing to brush against your clothing or the bed. Use the same limb for each measurement, unless you are comparing arms or averaging readings from both arms. For the initial reading, measure the BP in both arms and use the arm with the higher reading for subsequent measurements. If you obtain an elevated reading, confirm in the other arm. Do not draw conclusions based on one reading. Take two or more readings, at least 2 to 5 minutes apart, and average them. If the readings differ by more than 5 mm Hg, obtain and average additional readings.

Hypothermia

abnormally low body temperature less than 95

Tidal Volume (TV)

amount of air inhaled or exhaled with each breath under resting conditions

Respiratory Depth

how much your lungs expand to take in air (300 to 500 mL for healthy adult). -Deep: large volume of air and fully expanding chest/abdomen -Shallow: chest barely rises or is difficult to observe -Normal: between shallow and deep

What influences body temp? Circadian rhythm

physiological 24 hour cycle can make temp fluctuate from 1 to 2 degrees. Lowest in the am and highest in late afternoon.