ATI-Vital Signs PDF

CHAPTER 27 UNIT 2 Temperature HEALTH PROMOTION SECTION: HEALTH ASSESSMENT/DATA COLLECTION CHAPTER 27 Vital Signs PHYSIOLOGIC RESPONSES ● Vital signs are measurements of the body’s most basic functions and include temperature, pulse, respiration, and blood pressure. Many facilities also conside...

CHAPTER 27 UNIT 2 Temperature HEALTH PROMOTION SECTION: HEALTH ASSESSMENT/DATA COLLECTION CHAPTER 27 Vital Signs PHYSIOLOGIC RESPONSES ● Vital signs are measurements of the body’s most basic functions and include temperature, pulse, respiration, and blood pressure. Many facilities also consider pain level and oxygen saturation vital signs. (SEE CHAPTER 41: PAIN MANAGEMENT, CHAPTER 53: AIRWAY MANAGEMENT, MATERNAL NEWBORN CHAPTER 23: NEWBORN ASSESSMENT, AND NURSING CARE OF CHILDREN CHAPTER 2: PHYSICAL ASSESSMENT FINDINGS.) Temperature reflects the balance between heat the body produces and heat lost from the body to the environment. Pulse is the measurement of heart rate and rhythm. Pulse corresponds to the bounding of blood flowing through various points in the circulatory system. It provides information about circulatory status. Respiration is the body’s mechanism for exchanging oxygen and carbon dioxide between the atmosphere and the blood and cells of the body, which is accomplished through breathing and recorded as the number of breaths per minute. Blood pressure (BP) reflects the force the blood exerts against the walls of the arteries during cardiac muscle contraction (systole) and relaxation (diastole). Systolic blood pressure (SBP) occurs during ventricular systole, when the ventricles force blood into the aorta and pulmonary artery, and it represents the maximum amount of pressure exerted on the arteries when ejection occurs. Diastolic blood pressure (DBP) occurs during ventricular diastole, when the ventricles relax and exert minimal pressure against arterial walls, and represents the minimum amount of pressure exerted on the arteries. FUNDAMENTALS FOR NURSING ● ● The neurologic and cardiovascular systems work together to regulate body temperature. Disease or trauma of the hypothalamus or spinal cord will alter temperature control. The rectum, tympanic membrane, temporal artery, pulmonary artery, esophagus, and urinary bladder are core temperature measurement sites. The skin, mouth, and axillae are surface temperature measurement sites. HEAT PRODUCTION AND LOSS Heat productionresults from increases in basal metabolic rate, muscle activity, thyroxine output, testosterone, and sympathetic stimulation, which increases heat production. Heat lossfrom the body occurs through: ● Conduction:Transfer of heat from the body directly to another surface (when the body is immersed in cold water). ● Convection:Dispersion of heat by air currents (wind blowing across exposed skin). ● Evaporation:Dispersion of heat through water vapor (perspiration). ● Radiation:Transfer of heat from one object to another object without contact between them (heat lost from the body to a cold room). ● Diaphoresis:Visible perspiration on the skin. ASSESSMENT/DATA COLLECTION EXPECTED TEMPERATURE RANGES ● ● ● ● ● An oral temperature range of 36° to 38° C (96.8° to 100.4° F) is acceptable. The average is 37° C (98.6° F). Rectal temperatures are usually 0.5° C (0.9° F) higher than oral and tympanic temperatures. Axillary temperatures are usually 0.5° C (0.9° F) lower than oral and tympanic temperatures. Temporal temperatures are close to rectal, but they are nearly 0.5° C (1° F) higher than oral, and 1° C (2° F) higher than axillary temperatures. A client’s usual temperature serves as a baseline for comparison. CHAPTER 27 Vital Signs 135 CONSIDERATIONS PROCEDURES FOR TAKING TEMPERATURE Age ● Newborns have a large surface‑to‑mass ratio, so they lose heat rapidly to the environment. A newborn’s temperature should be between 36.5° and 37.5° C (97.7° and 99.5° F). By age 5, children should be able to maintain an average temperature of 37° C (98.6° F). ● Older adult clientsexperience a loss of subcutaneous fat that results in lower body temperatures and feeling cold. Their average body temperature is 35° to 36.1° C (95.9° to 99.5° F). Older adult clients are more likely to develop adverse effects from extremes in environmental temperatures (heat stroke, hypothermia). It also takes longer for body temperature to register on a thermometer due to changes in temperature regulation. Perform hand hygiene, provide privacy, and apply clean gloves. Hormonal changescan influence temperature. In general, temperature rises slightly with ovulation and menses. At ovulation, body temperature can increase by 0.3° to 0.6° C (0.5° to 1.0° F) above the client’s baseline. During menopause when the client is experiencing a hot flash, skin temperature can increase up to 4° C (7.2° F). Rectal Exercise, activity, and dehydrationcan contribute to the development of hyperthermia. Illness and injurycan cause elevations in temperature. Fever is the body’s response to infectious and inflammatory processes. Fever causes an increase in the body’s immune response by: ● Increasing WBC production. ● Decreasing plasma iron concentration to reduce bacteria growth. ● Stimulating interferon to suppress virus production. Recent food or fluid intake and smokingcan interfere with accurate oral measurement of body temperature, so it is best to wait 20 to 30 min before measuring oral temperature. Circadian rhythm, stress, and environmental conditions can also affect body temperature. Oral ● ● Gently place the oral probe (with cover) of the thermometer under the tongue in the posterior sublingual pocket lateral to the center of the lower jaw. Leave it in place until the reading is complete. AGE‑SPECIFIC: Use this site for clients who are 4 years of age and older. Note: Do not obtain oral temperature readings for clients who breathe through their mouth or have experienced trauma to the face or mouth. ● ● ● ● ● Rectal measurement of temperature is more accurate than axillary. Assist the client to Sims’ position with the upper leg flexed. Wearing gloves, expose the anal area while keeping other body areas covered. Spread the buttocks to expose the anal opening. Ask the client to breathe slowly and relax. Insert the rectal probe (with cover and lubrication) of the thermometer into the anus in the direction of the umbilicus 2.5 to 3.5 cm (1 to 1.5 in) for an adult. If you encounter resistance, remove it immediately. Once inserted, hold the thermometer in place until the reading is complete. Clean the anal area to remove feces or lubricant. Use the rectal site to verify the temperature for any reading obtained through another site that is greater than 37.2º C (99º F). SAFETY MEASURE: Do not obtain rectal temperatures for clients who have diarrhea, are on bleeding precautions (those who have a low platelet count), or have rectal disorders. AGE‑SPECIFIC: The American Academy of Pediatrics NURSING INTERVENTIONS recommends not measuring rectal temperatures on infants younger than 3 months. Note: Stool in the rectum can cause inaccurate readings. EQUIPMENT Electronic thermometersuse a probe to measure oral, rectal, tympanic, temporal artery, or axillary temperature. Electronic thermometers require the use of a probe cover or probe cleaning with each use (per the manufacturer) and can be set to play a signal when the reading is complete. Tympanic or temporal arterial temperatures require a device specifically for measuring temperature at that site. Axillary ● ● Place the oral probe of the thermometer (with cover) in the center of the client’s clean, dry axilla. Lower the arm over the probe. Hold the arm down, keeping the thermometer in position until the reading is complete. Disposable, single‑use thermometersare for oral, axillary, and rectal temperature measurement. They reduce the risk of cross‑infection. These can include single-use thermometer strips or patches that have an adhesive side, and can be applied to the forehead or abdomen. 136 CHAPTER 27 Vital Signs CONTENT MASTERY SERIES Tympanic ● ● ● ● ● Hypothermia Pull the ear up and back (for an adult) or down and back (for a child who is younger than 3 years old). Place the thermometer probe (with cover) snugly into the client’s outer ear canal and press the scan button. Leave it in place until the reading is complete. Carefully remove the thermometer from the ear canal and read the temperature. Ambient temperature can affect readings. Hypothermia is a body temperature less than 35º C (95° F). NURSING ACTIONS ● ● ● ● Provide a warm environmental temperature, heated humidified oxygen, warming blanket, and/or warmed oral or IV fluids. Keep the head covered. Provide continuous cardiac monitoring. Have emergency resuscitation equipment on standby. AGE‑SPECIFIC: The American Academy of Pediatrics advises against the use of electronic ear thermometers for infants 3 months old and younger due to the inaccuracy of readings. Note: Excess earwax can alter the reading. If noted, use the other ear or select another site for temperature assessment. ● ● Remove the protective cap and wipe the lens of the scanning device with alcohol to make sure it is clean. Hold the probe flat against the forehead and press the scan button. Continue holding the button and keeping the probe flush with the skin over the temporal artery. Then lift the thermometer and touch the probe to the skin behind the earlobe. Release the scan button to display the temperature reading. COMPLICATIONS Fever Usually not harmful unless it exceeds 39° C (102.2° F). Hyperthermia Hyperthermia is an abnormally elevated body temperature (greater than 40° C [104° F]) due to a failure of the thermoregulatory mechanisms of the body. NURSING ACTIONS ● ● ● ● ● ● ● ● ● ● PHYSIOLOGIC RESPONSES Autonomic nervous systemcontrols the heart rate. Parasympathetic nervous systemlowers the heart rate. Temporal ● Pulse Obtain specimens for blood, urine, sputum, or wound cultures as needed. Assess/monitor white blood cell counts, sedimentation rates, and electrolytes. Ensure prescribed cultures are obtained before administering prescribed antibiotics, to promote test accuracy. Provide fluids and rest. Minimize activity. Use a cooling blanket. Children and older adults are at particular risk for fluid volume deficit. Provide antipyretics (aspirin, acetaminophen, ibuprofen). Do not give aspirin to manage fever for children and adolescents who have a viral illness (influenza, chickenpox) due to the risk of Reye’s syndrome. Prevent shivering, as this increases energy demand. Offer blankets during chills and remove them when the client feels warm. Provide oral hygiene and dry clothing and linens. Keep environmental temperature between 21° and 27° C (70° to 80° F). FUNDAMENTALS FOR NURSING Sympathetic nervous systemraises the heart rate. ASSESSMENT/DATA COLLECTION EXPECTED HEART RATE RANGE ● ● The expected reference range for an adult client’s pulse is 60 to 100/min at rest. Assess the wave‑like sensations or impulses you feel in a peripheral arterial vessel or over the apex of the heart as a gauge of cardiovascular status. Rate: The number of times per minute you feel or hear the pulse. Rhythm: The regularity of impulses. A premature, late, or missed heart beat can result in an irregular interval between impulses and can indicate altered electrical activity of the heart. A regular pulse is the expected finding. Strength (amplitude or pulse volume): Reflects the volume of blood ejected against the arterial wall with each heart contraction and the condition of the arterial vascular system. The strength of the impulse should be the same from beat to beat. Grade strength on a scale of 0 to 4. ● 0 = Absent, unable to palpate ● 1+ = Diminished, weaker than expected ● 2+ = Brisk, expected ● 3+ = Increased, strong ● 4+ = Full volume, bounding Equality: Peripheral pulse impulses should be symmetrical in quality and quantity on both sides of the body at the same location. Assess strength and equality to evaluate the adequacy of the vascular system. An inequality or absence of pulse on one side of body can indicate a disease state (thrombus, aortic dissection). CHAPTER 27 Vital Signs 137 CONSIDERATIONS Dysrhythmia:An irregular heart rhythm, generally with an irregular radial pulse. PROCEDURE ● ● Pulse deficit:The difference between the apical rate and the radial rate. With dysrhythmias, the heart can contract ineffectively, resulting in a beat at the apical site with no pulsation at the radial pulse point. To determine the pulse deficit accurately, two clinicians should measure the apical and radial pulse rates simultaneously. Age:The expected pulse rate for a 1-week-old infant is 90 to 160/min, depending on activity level. The rate gradually decreases as the child grows older. From age 10 through adolescence, the expected pulse rate is 50 to 100/min, depending on activity. The strength of the pulsation can weaken in older adult clients due to poor circulation or cardiac dysfunction, which can make the peripheral pulses difficult to palpate. ● ● NURSING INTERVENTIONS EQUIPMENT A device (clock)that allows for counting seconds Stethoscope Perform hand hygiene and provide privacy. Locate the radial pulse on the radial‑ or thumb‑side of the forearm at the wrist. (27.1) ◯ Place the index and middle finger of one hand gently but firmly over the pulse. Assess the pulsation for rate, rhythm, amplitude, and quality. ◯ If the peripheral pulsation is regular, count the rate for 30 sec and multiply by 2. If the pulsation is irregular, count for a full minute and compare the result to the apical pulse rate. Measure the temporal, carotid, brachial, femoral, popliteal, posterior tibial or dorsal pedal pulses using the same technique. Locate the apical pulse at the fifth intercostal space at the left midclavicular line. (27.2) ◯ Use this site for assessing the heart rate of an infant, checking a heart rate prior to the administration of cardiac medications, or to validate the precise rate when a rapid (greater than 100/min) or irregular pulse is detected. ◯ Place the diaphragm of a stethoscope on the chest at the fifth intercostal space at the left midclavicular line. If the rhythm is regular, count for 30 sec and multiply by 2. If the rhythm is irregular or the client is receiving cardiovascular medications, count for 1 full min. COMPLICATIONS Tachycardia A rate greater than the expected range or greater than 100/min. FACTORS LEADING TO TACHYCARDIA ● ● ● 27.1 Pulse points ● Exercise Fever, heat exposure Medications: epinephrine, levothyroxine beta2‑adrenergic agonists (albuterol) Changing position from lying down to sitting or standing 27.2 138 CHAPTER 27 Vital Signs Apical pulse CONTENT MASTERY SERIES ● ● ● ● ● Acute pain Hyperthyroidism Anemia, hypoxemia Stress, anxiety, fear Hypovolemia, shock, heart failure, hemorrhage NURSING ACTIONS ● ● ● Monitor for pain, anxiety, restlessness, and manifestations of low cardiac output (fatigue, dizziness, hypotension, chest pain, low oxygen saturation). Monitor for potential adverse effects of medications. Protect the client from injury. Bradycardia A rate less than the expected range or slower than 60/min. FACTORS LEADING TO BRADYCARDIA ● ● ● ● ● ● ● Long‑term physical fitness Hypothermia Medications: digoxin, beta‑blockers (propranolol), calcium channel blockers (verapamil) Changing position from standing or sitting to lying down Chronic severe pain Hypothyroidism Relaxation NURSING ACTIONS ● ● ● Monitor for manifestations of low cardiac output (dizziness, hypotension, chest pain, syncope, diaphoresis, dyspnea, altered mental state). Monitor for potential adverse effects of medications. Protect the client from injury. Respirations ASSESSMENT/DATA COLLECTION EXPECTED RESPIRATORY RATE RANGE ● ● The expected reference range for an adult client’s respiratory rate is 12 to 20/min. Accurate assessment of respiration involves observing the rate, depth, and rhythm of chest‑wall movement during inspiration and expiration. Do not inform the client that you are measuring respirations so the client will remain relaxed and not alter the breathing pattern. Rate: The number of full inspirations and expirations in 1 min. Determine this by observing the number of times the client’s chest rises and falls. Depth: The amount of chest wall expansion that occurs with each breath. Altered depths are deep or shallow. Rhythm: The observation of breathing intervals. For adults, expect a regular rhythm (eupnea) with an occasional sigh. CONSIDERATIONS Age:Respiratory rate decreases with age. Newborns have an expected respiratory rate of 30 to 60/min and can experience short apneic spells during REM sleep (less than 15 seconds duration). Children 3 to 5 years old have an expected respiratory rate of 20 to 25/min. Sex:Males and children are diaphragmatic breathers, and abdominal movements are more noticeable. Women use more thoracic muscles, and chest movements are more pronounced when they breathe. Painin the chest wall area can decrease the depth of respirations. At the onset of acute pain, the respiration rate increases but stabilizes over time. PHYSIOLOGICAL RESPONSES Anxietyincreases the rate and depth of respirations. Chemoreceptors in the carotid arteries and the aorta primarily monitor carbon dioxide (CO2) levels of the blood. Rising CO2 levels trigger the respiratory center of the brain to increase the respiratory rate. The increased respiratory rate rids the body of excess CO2. For clients who have chronic obstructive pulmonary disease (COPD), a low oxygen level becomes the primary respiratory drive. Smokingcauses the resting rate of respirations to increase. PROCESSES OF RESPIRATION Ventilation: The exchange of oxygen and carbon dioxide in the lungs through inspiration and expiration. Measure ventilation with the respiratory rate, rhythm, and depth. Diffusion: The exchange of oxygen and carbon dioxide between the alveoli and the red blood cells. Measure diffusion with pulse oximetry. Perfusion: The flow of red blood cells to and from the pulmonary capillaries. Measure perfusion with pulse oximetry. FUNDAMENTALS FOR NURSING Body position:Upright positions allow the chest wall to expand more fully. Medications(opioids, sedatives, bronchodilators, and general anesthetics) decrease respiratory rate and depth. Respiratory depression is a serious adverse effect of these medications. Amphetamines and cocaine increase rate and depth. Neurologic injuryto the brainstem decreases respiratory rate and rhythm. Illnessescan affect the shape of the chest wall, change the patency of passages, impair muscle function, and diminish respiratory effort. With these conditions, the use of accessory muscles (the intercostal muscles) and the respiratory rate increase. Impaired oxygen‑carrying capacity of the bloodthat occurs with anemia or at high altitudes can result in increased depth and respiratory rate in order to compensate. CHAPTER 27 Vital Signs 139 Pulse oximetry NURSING INTERVENTIONS EQUIPMENT: A watch or clock that allows for counting seconds. PROCEDURE ● ● ● ● ● Perform hand hygiene and provide privacy. Place the client in semi‑Fowler’s position, being sure the chest is visible. Have the client rest an arm across the abdomen, or place a hand directly on the client’s abdomen. Observe one full respiratory cycle, look at the timer, and then begin counting the rate. Count a regular rate for 30 seconds and multiply by 2. Count the rate for 1 min if irregular, faster than 20/min, or slower than 12/min. Note depth (shallow, normal, or deep) and rhythm (regular or irregular). COMPLICATIONS Ineffective breathing patterns cause decreased diffusion of oxygen and decreased perfusion to the tissues, and require further data collection with possible rapid intervention. Alterations in ventilatory patterns include the following: Bradypnea: Regular breathing pattern with a rate less than 12/min. Hypoventilation: Shallow breathing pattern with an abnormally low rate. Apnea: periods where there is no breathing. Ongoing apneic spells can lead to respiratory arrest. Tachypnea: regular breathing pattern with a rate greater than 20/min. This is a noninvasive, indirect measurement of the oxygen saturation (SaO2) of the blood (the percent of hemoglobin that is bound with oxygen in the arteries is the percent of saturation of hemoglobin). ASSESSMENT/DATA COLLECTION EXPECTED PULSE OXIMETRY RANGE The expected reference range is 95% to 100%, although clients who have chronic lung disease might tolerate a level as low as 85%. The provider can prescribe an acceptable range for the client. CONSIDERATIONS The same factors that affect respiratory rate can affect pulse oximetry measurement. NURSING INTERVENTIONS EQUIPMENT: Pulse oximeter with digit probe, earlobe probe, or disposable sensor pad PROCEDURE ● ● ● ● ● Hyperventilation: Deep breathing pattern with an increased rate; leads to decreased levels of carbon dioxide and hyperoxygenation. Hyperpnea: Respiratory rate, depth, and work of breathing are increased; common during exercise. Cheyne-Stokes respirations: Irregular rate and depth of respirations that follow a cyclical pattern. The client will experience shallow breaths that progress to a normal pattern, and increased rate, then the rate begins to slow again, ending with an apneic period. Kussmaul respirations: Increased respiratory rate, regular pattern, but abnormally deep. Choose an intact, nonedematous site for probe or sensor placement. Place the digit probe on the client’s finger. Use earlobe or bridge of nose for clients who have peripheral vascular disease. A disposable sensor pad can be applied to the sole of an infant’s foot. When the readout on the pulse oximeter is stable, record this value as the oxygen saturation. Blood pressure PHYSIOLOGICAL RESPONSES The principal determinants of blood pressure are cardiac output (CO) and systemic (peripheral) vascular resistance (SVR). BP = CO × SVR Cardiac output ● ● ● CO is determined by ◯ Heart rate ◯ Contractility ◯ Blood volume ◯ Venous return Increases in any of these increase CO and BP Decreases in any of these decrease CO and BP Systemic vascular resistance ● ● ● 140 CHAPTER 27 Vital Signs SVR reflects the amount of constriction or dilation of the arteries, and diameter of blood vessels. Increases in SVR increase BP Decreases in SVR decrease BP CONTENT MASTERY SERIES ASSESSMENT/DATA COLLECTION CLASSIFICATIONS OF BLOOD PRESSURE 27.3 BP classifications according to the updated guidelines of the Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure SYSTOLIC BP (mm Hg) DIASTOLIC BP (mm Hg) NORMAL less than 120 and ELEVATED ● ● less than 80 120 to 129 and less than 80 STAGE 1 HYPERTENSION 130 to 139 or 80 to 89 STAGE 2 HYPERTENSION greater than or equal to 140 or greater than or equal to 90 Base the classification on the highest reading (systolic or diastolic). A client who has a BP of 124/92 mm Hg has stage 2 hypertension because the DBP places the client in that category. A client who has a BP of 146/82 mm Hg also has stage 2 hypertension because the SBP places the client in that category. If the client’s average SBP or DBP (following two BP measurements) is elevated, they should have readings performed on at least 2 other days. If the findings are elevated on at least three separate occasions over several weeks, the client has hypertension. Hypotensionis a blood pressure below the expected reference range (systolic less than 90 mm Hg) and can be a result of fluid depletion, heart failure, or vasodilation. Pulse pressureis the difference between the systolic and the diastolic pressure readings. Orthostatic (postural) hypotensionis a blood pressure that decreases when a client changes position from lying to sitting or standing, and it can result from various causes (peripheral vasodilation, medication adverse effects, fluid depletion, anemia, prolonged bed rest). Medications(opiates, antihypertensives, and cardiac medications) can lower BP. Cocaine, nicotine, cold medications, oral contraceptives, alcohol, and antidepressants can raise BP. Exercisecan cause a decrease in BP for several hours afterward. Obesityis a contributing factor to hypertension. Family historyof hypertension, lack of exercise, high sodium intake, and continuous stress can increase the risk of hypertension. NURSING INTERVENTIONS Implement interventions to ensure an accurate blood pressure measurement. The client should ● Not use nicotine or drink any caffeine for 30 min prior to measurement. ● Rest for 5 min before measurement. ● Sit in a chair, with the feet flat on floor, the back and arm supported, and the arm at heart level. The nurse should ● Use the auscultatory method with a properly calibrated and validated instrument. ● Not measure BP in an arm with an IV infusion in progress or on the side where the client had a mastectomy or an arteriovenous shunt or fistula. ● Average two or more readings, taken at least 2 min apart. (If they differ by more than 5 mm Hg, obtain additional readings and average them.) ● After initial readings, measure BP and pulse with the client standing. EQUIPMENT Auscultatory method ● CONSIDERATIONS Age Infants have a low BP that gradually increases with age. ● Older children and adolescents have varying BP based on body size. Larger children have a higher BP. ● Adults’ BP can increase with age. ● Older adult clients can have a slightly elevated systolic pressure due to decreased elasticity of blood vessels. ● Circadian (diurnal) rhythmsaffect BP, with BP usually lowest in the early morning hours and peaking during the later part of the afternoon or evening. Stressassociated with fear, emotional strain, and acute pain can increase BP. Ethnicity:African Americans have a higher incidence of hypertension in general and at earlier ages. ● Sphygmomanometer with a pressure manometer (aneroid or mercury) and a correctly sized cuff ◯ The width of the cuff should be 40% of the arm circumference at the point where the cuff is wrapped. ◯ The bladder (inside the cuff) should surround 80% of the arm circumference of an adult and the whole arm for a child. ◯ Cuffs that are too large give a falsely low reading, and cuffs that are too small give a falsely high reading. Stethoscope Automatic blood pressure devices Use when available for monitoring clients who require frequent evaluation. Measure BP first using the auscultatory method to make sure the automatic device readings are valid. Sex:Adolescent to middle‑age males have higher blood pressures than females of the same age. Postmenopausal clients have higher blood pressures than males of the same age. FUNDAMENTALS FOR NURSING CHAPTER 27 Vital Signs 141 COMPLICATIONS PROCEDURE (AUSCULTATORY METHOD) ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● 142 Perform hand hygiene and provide privacy. Initially measure BP in both arms. If the difference is more than 10 mm Hg, use the arm with the higher reading for subsequent measurements. This difference can indicate a vascular problem. Apply the BP cuff 2.5 cm (1 in) above the antecubital space with the brachial artery in line with the marking on the cuff. Use a lower extremity if the brachial artery is not accessible. Estimate systolic pressure by palpating the radial pulse and inflating the cuff until the pulse disappears. Inflate the cuff another 30 mm Hg, and slowly release the pressure to note when the pulse is palpable again (the estimated systolic pressure). Deflate the cuff and wait 1 min. Position the stethoscope over the brachial artery. Close the pressure bulb by turning the valve clockwise until tight. Quickly inflate the cuff to 30 mm Hg above the palpated systolic pressure. Release the pressure no faster than 2 to 3 mm Hg per second. The level at which you hear the first clear sounds is the systolic pressure. Continue to deflate the cuff until the sounds muffle and disappear and note the diastolic pressure. Record the systolic over the diastolic pressure (110/70 mm Hg). Assess orthostatic changes by taking the client’s BP and heart rate (HR) after the client has been in the supine position for 3 to 10 min. Next, have the client change to the sitting or standing position and immediately reassess BP and HR. Wait an additional 3 min and repeat BP and HR. The client has orthostatic hypotension if the SBP decreases more than 20 mm Hg and/or the DBP decreases 10 mm Hg or more with an increase in HR. Do not delegate this procedure to an assistive personnel. Recall that initial blood pressures can be higher due to the stress of the clinical setting. Deflate the cuff completely between attempts. Wait at least 1 full min before reinflating the cuff. Air trapped in the bladder can cause a falsely high reading. CHAPTER 27 Vital Signs Orthostatic (postural) hypotension NURSING ACTIONS ● ● ● ● Assess for dizziness, weakness, and fainting. Advise the client to sit or lie down if these manifestations occur. Instruct the client to activate the call light and not to get out of bed without assistance. Have the client sit at the edge of the bed for at least 1 min before standing up, and to move slowly when changing position. Assist with ambulation. Hypertension NURSING ACTIONS ● ● ● ● ● Assess/monitor for tachycardia, bradycardia, pain, and anxiety. Primary hypertension is usually without manifestations. Assess for identifiable causes of hypertension (kidney disease, thyroid disease, medication). Administer pharmacological therapy. Encourage the client to follow up with the provider. Encourage lifestyle modifications. ◯ Cessation of smoking or use of smokeless tobacco ◯ Weight control ◯ Modification of alcohol intake ◯ Physical activity ◯ Stress reduction ◯ Dietary modifications ■ Dietary Approaches to Stop Hypertension (DASH) diet ■ Restrict sodium intake. ■ Consume adequate potassium, calcium, and magnesium, which help lower BP. ■ Restrict cholesterol and saturated fat intake. CONTENT MASTERY SERIES Application Exercises 1. A nurse is caring for a client in the emergency department who has an oral body temperature of 38.3° C (101° F), pulse rate 114/min, and respiratory rate 22/min. The client is restless with warm skin. Which of the following interventions should the nurse take? (Select all that apply.) A. Obtain culture specimens before initiating antimicrobials. Active Learning Scenario A nurse is explaining to a group of newly licensed nurses the various factors that can affect a client’s heart rate. Use the ATI Active Learning Template: Basic Concept to complete this item. UNDERLYING PRINCIPLES: List at least five factors that can cause tachycardia and at least five factors that can cause bradycardia. B. Restrict the client’s oral fluid intake. C. Encourage the client to rest and limit activity. D. Allow the client to shiver to dispel excess heat. E. Assist the client with oral hygiene frequently. 2. A nurse is instructing an assistive personnel (AP) about caring for a client who has a low platelet count. Which of the following instructions is the priority for measuring vital signs for this client? A. “Do not measure the client’s temperature rectally.” B. “Count the client’s radial pulse for 30 seconds and multiply it by 2.” C. “Do not let the client know you are counting their respirations.” D. “Let the client rest for 5 minutes before you measure their blood pressure.” 3. A nurse is instructing a group of assistive personnel in measuring a client’s respiratory rate. Which of the following guidelines should the nurse include? (Select all that apply.) A. Place the client in semi‑Fowler’s position. B. Have the client rest an arm across the abdomen. C. Observe one full respiratory cycle before counting the rate. D. Count the rate for 30 sec if it is irregular. E. Count and report any sighs the client demonstrates. 4. A nurse is measuring the blood pressure of a client who has a fractured femur. The blood pressure reading is 140/94 mm Hg, and the client denies any history of hypertension. Which of the following actions should the nurse take first? A. Request a prescription for an antihypertensive medication. B. Ask the client if they are having pain. C. Request a prescription for an antianxiety medication. D. Return in 30 min to recheck the client’s blood pressure. 5. A nurse is performing an admission assessment on a client. The nurse determines the client’s radial pulse rate is 68/min and the simultaneous apical pulse rate is 84/min. What is the client’s pulse deficit? FUNDAMENTALS FOR NURSING CHAPTER 27 Vital Signs 143