Kozier & Erb's Fundamentals of Nursing (9th Edition) - PDF

KOZIER & ERB’S Fundamentals of NURSING NINTH EDITION Concepts, Process, and Practice CHAPTER Vit...

KOZIER & ERB’S Fundamentals of NURSING NINTH EDITION Concepts, Process, and Practice CHAPTER Vital Signs: Blood Pressure Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved.  Vital Signs – Blood Pressure Arterial blood pressure: is a measure of the pressure exerted by the blood as it flows through the arteries. Two blood pressure measurements: Systolic Pressure – Contraction of the ventricles Diastolic Pressure – Ventricles at rest – Lower pressure present at all times Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved.  Systolic and Diastolic Blood Pressure Pulse pressure = difference between systolic and diastolic pressures Measured in millimeters of mercury (mm Hg) Recorded as fraction, e.g. 120/80 Systolic = 120, diastolic = 80 Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved. Determinants of Blood Pressure Arterial blood pressure is the result of several factors: Pumping action of heart Peripheral vascular resistance – Arteriosclerosis Blood volume Blood viscosity – Hematocrit Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved.  Factors Affecting Blood Pressure Age Exercise Stress Race Sex Medications Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved.  Factors Affecting Blood Pressure (cont'd) Obesity Diurnal variations Medical conditions Body temperature Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved. Table 29-4 Classification of Blood Pressure Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved.  Hypertension and Hypotension Hypertension: A blood pressure that is persistently above normal. Usually asymptomatic, contributes to heart attack – Primary or secondary Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved.  Factors associated with Hypertension: Thickening of the arterial walls. Inelasticity of the arteries. Lifestyle factors: – Cigarette smoking – Obesity – Heavy alcohol consumption – Lack of physical exercise, – High blood cholesterol levels – Continued exposure to stress. Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved.  Hypertension and Hypotension Hypotension: is a blood pressure that is below normal, that is, a systolic reading consistently between 85 and 110 mmHg. – Orthostatic hypotension (postural hypotension): blood pressure that decreases when the client changes from a supine to a sitting or standing position. – It is the result of peripheral vasodilation in which blood leaves the central body organs, especially the brain, and moves to the periphery, often causing the client to feel faint. Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved.  Hypotension can also be caused by: Hypotension can also be caused by analgesics such as meperidine hydrochloride (Demerol). Bleeding, Severe burns Dehydration. It is important to monitor hypotensive clients carefully to prevent falls. Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved. Manual blood pressure measurement is performed with a blood pressure cuff, a sphygmomanometer, and a stethoscope. The blood pressure cuff consists of a bag, called a bladder, that can be inflated with air. Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved.  Measuring Blood Pressure Sphygmomanometer – Aneroid or digital – Doppler ultrasound – Cuff and bladder sizes Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved.  Cuff and bladder sizes The width should be 40% of the circumference, or 20% wider than the diameter of the midpoint, of the limb on which it is used Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved.  Measuring Blood Pressure Sites – Commonly assessed in the client’s upper arm. (brachial artery) – May be measured on the forearm or wrist, usually using an electronic blood pressure monitor. Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved.  Measuring Blood Pressure – Thigh (popliteal artery) Assessing the blood pressure on a client’s thigh is indicated in these situations: The blood pressure cannot be measured on either arm (e.g., because of burns or other trauma). The blood pressure in one thigh is to be compared with the blood pressure in the other thigh. Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved. Blood pressure is not measured on a particular client’s limb in the following situations: The shoulder, arm, or hand (or the hip, knee, or ankle) is injured or diseased. A cast or bulky bandage is on any part of the limb. The client has had surgical removal of breast or axillary (or inguinal) lymph nodes on that side. The client has an IV infusion or blood transfusion in that limb. The client has an arteriovenous fistula (e.g., for renal dialysis) in that limb. Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved. Common Errors in Blood Pressure Measurement Bladder/cuff too narrow or too wide Arm unsupported; arm above heart level Insufficient rest before assessment or repeated assessment too quickly Cuff too loose or unevenly wrapped Cuff deflated too quickly/too slowly Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved. Common Errors in Blood Pressure Measurement (cont’d) Failure to measure in same arm Assessing while client eats, smokes, or is in pain Failure to identify auscultatory gap Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved.  Delegation of Blood Pressure Measurement May be delegated to UAP UAP reports abnormal readings Nurse interprets abnormal readings, determines response Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Copyright ©2012 by Pearson Education, Inc. Audrey Berman Shirlee Snyder All rights reserved.