Vital Signs- Pulse & Blood Pressure
An adult has tachycardia when the pulse rate is ______ to ______ beats/min
100 to 180
A nurse is assessing the respiratory rate of a sleeping 28-day-old infant. What would the nurse document as a normal finding?
30 to 60 breaths/min
Bradycardia is a pulse rate below ________/min in an adult.
60 beats
Normal ranges for Blood Pressure:
90-130 /60-80
Identify factors that could influence the pulse rate...
Age, biological sex, physical activity, fever, stress, medication use, and the presence of disease.
____________ measurement is also the preferred method of pulse assessment for infants and children less than 2 years of age
Apical pulse
Which tasks may the nurse safely delegate to unlicensed assistive personnel (UAP)? Select all that apply.
Assessment of axillary temperature and radial pulse can normally be delegated to UAP.
________ refers to the force of the moving blood against arterial walls.
Blood pressure
_____ is when the pressure falls as the heart relaxes.
Diastole
When the stroke volume decreases, such as when the blood volume is decreased because of hemorrhage, the _____________ increases to try to maintain the same cardiac output.
Heart rate
How do you determine if a pt has a pulse deficit? How can you obtain a pulse deficit?
If there is a difference between the apical and radial pulse rates, subtract the radial pulse from the apical pulse rate to obtain the pulse deficit.
__________ stimulation of the SA node via the vagus nerve decreases the heart rate
Parasympathetic
Peripheral pulses result from what?
Peripheral pulses result from a wave of blood being pumped into the arterial circulation by the contraction of the left ventricle.
The difference between the systole and diastolic pressures is called the _______________.
Pulse pressure
Does pulse increase or decrease with age? why?
Pulse rate decreases with age due to decreased metabolic rate.
What are characteristics of peripheral pulse?
Rate, rhythm and amplitude (quality; strong, weak)
________ is when the pressure rises as the ventricle contracts.
Systole
______________ decreases cardiac filling time, which, in turn, decreases stroke volume and cardiac output.
Tachycardia
The "lub dub" sound is actually what?
The apical pulse is the result of closure of the mitral and tricuspid valves ("lub") and aortic and pulmonic valves ("dub"). The combination of the two sounds is counted as one beat.
Define peripheral pulse
The peripheral pulse is a throbbing sensation that can be palpated (felt) over a peripheral artery, such as the radial artery or the carotid artery
What does the pulse deficit indicate?
The pulse deficit indicates that all of the heartbeats are not reaching the peripheral arteries or are too weak to be palpated
The nursing concepts that apply to vital signs are _____ and _____.
Thermoregulation and perfusion.
Well-conditioned athletes may have a significantly decreased pulse rate, why?
This is due to greater efficiency and strength of the heart muscle from regular cardiovascular exercise.
Who has a slightly high pulse rate, women or men?
Women have a slightly higher pulse rate
Some factors that may contribute to a falsely decreased BP include:
a cuff that is too wide, releasing the valve too rapidly, and using cracked or kinked tubing.
A/n _________ is assessed when giving medications that alter heart rate and rhythm.
apical pulse
The pulse is regulated by the ___________ nervous system through the _______ node, the pacemaker of the heart.
autonomic, Sinoatrial (SA) node
As the heart rate increases, _____________ usually also increases. (except when tachycardic)
cardiac output
The nurse should immediately report bradycardia associated with .....
difficult breathing, changes in level of consciousness, decreased blood pressure, electrocardiogram (ECG) changes, and angina (heart pain)
A cuff that is too narrow may cause a falsely _________ BP
elevated
The younger a person is, the _______ their heart rate will be (up until about age 5).
faster
The nurse knows that a client who is being taught to perform home blood pressure monitoring (HBPM) understands the teaching plan when he makes which statement about the size of the BP cuff? The cuff should:
fit snug around the upper arm with room to slip a fingertip under the cuff and should be 1 in (2.5 cm) above the crease of the elbow.
An elevated body temperature causes ________________ due to increased metabolic demands and compensatory mechanisms to increase heat loss.
increased pulse rate
Common sources of stress associated with increased pulse rate include ______, _____, and _____.
pain, fear, and anxiety.
The _____________ describes the quality of the pulse in terms of its fullness and reflects the strength of left ventricular contraction.
pulse amplitude
The pulse rate is normally _______ during sleep in men and in people who are thin.
slower
The pulse tends to become _______ with aging
slower
___________ stimulation of the SA node increases the heart rate and force of contraction
sympathetic