No Pressure: Introduction to Vital Signs PDF

No Pressure: Introduction to Vital Signs Danielle Candelario, PharmD, BCPS, AE-C Associate Professor...

No Pressure: Introduction to Vital Signs Danielle Candelario, PharmD, BCPS, AE-C Associate Professor Rosalind Franklin University of Medicine and Science [email protected] Disclaimer: There may be several Fill-in-the-Blank throughout. I will do my best to point them out – but I may overlook it. Please ask me to pause or re-state the information. 1  Learning Objectives After today’s lecture, student pharmacists should be able to … 1 2 3 4 5 6 Recall the appropriate Identify Describe and Describe and Describe the operator Define the American steps for preparing a contraindications to demonstrate the demonstrate the and patient factors that College of Cardiology patient for a vital signs blood pressure appropriate technique appropriate technique can artificially affect the (ACC) Categories for assessment. assessment in a for automatic blood for a heart rate heart rate and blood Blood Pressure and particular arm. pressure assessment assessment. pressure. Heart Rate. utilizing a digital device. 2  Interpretatio Lecture Roadmap n and Case Application Introduction to Vital Signs Setting the Stage and and Preparing the patient Hypertensio n Heart Rate Blood Technique Pressure Technique What are Vital Signs? Blood Pressure (BP) Heart Rate Pain (HR) Oxygen (O2) Respiratory saturation Rate (RR) Temperature The vital signs are the signs of life! 44  High Blood Pressure is the “Silent Killer”  Most of the time, high blood pressure has no obvious symptoms to indicate that something is wrong.  Can go undetected for a long time and can cause long- term damage.  The best ways to protect our patients is to educate them on knowing your numbers and making changes that matter. 5 American Heart Association. Why High Blood Pressure is a “Silent Killer”. American Heart Association. 2017, Nov. 30.https://www.heart.org/en/health-topics/high-blood-pressure/why-high-blood-pressure-is-a-silent-killer. Accessed Jan. 9, 20223.  The “Silent Killer”  High blood pressure develops slowly over time and can be related to many causes High blood pressure can not be cured. It can be managed effectively through lifestyle changes and when needed, medications  In the US, hypertension accounts for more cardiovascular (CVD) deaths than any other modifiable CVD risk factor (diabetes, smoking, obesity). In the population-based ARIC (Atherosclerosis Risk in Communities) study, 25% of the cardiovascular events (CHD, coronary revascularization, stroke, or HF) were attributable to hypertension. In 2012, hypertension was the second leading assigned cause of end stage renal Whelton P., Carey R., Aronow W., et al. disease (ESRD), behind diabetes 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guidelinemellitus for the Prevention,(DM), and accounted Detection, Evaluation, for and Management of High Blood34% Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2018 May 15;71(19):e127-e248. 6 of incident ESRD cases in the US population doi: 10.1016/j.jacc.2017.11.006.  By the Numbers  20 mm Hg higher systolic blood pressure (SBP) and 10 mm Hg higher diastolic blood pressure (DBP) are each associated with a doubling in the risk of death from stroke, heart disease, or other vascular disease.  In a study of >1 million adult patients ≥30 years of age,  Higher systolic and diastolic BP were associated with increased risk of CVD incidence and angina, myocardial infarction (MI), Heart Failure (HF), stroke, peripheral artery disease (PAD), and abdominal aortic aneurysm. Whelton P., Carey R., Aronow W., et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2018 May 15;71(19):e127-e248. 7 doi: 10.1016/j.jacc.2017.11.006.  Consequences of High Blood Pressure Damage from high BP can build over time  The excess strain and resulting damage from high blood pressure causes the coronary arteries to become stiff and narrowed from plaque Plaque is a buildup of fat, cholesterol and other substances also known as atherosclerosis.  As arteries harden with plaque, blood clots are more likely to form. When an artery becomes blocked due to plaque buildup or a blood clot, the flow of blood through the heart muscle is interrupted, starving the muscle of oxygen and nutrients. The process of the heart ‘dying’ is a heart attack or myocardial infarction. 8 American Heart Association. ”Health Threats from High Blood Pressure. American Heart Association. 2017, Nov. 30.https://www.heart.org/en/health-topics/high-blood-pressure/health-threats-from- high-blood-pressure. Accessed Jan. 9, 20223.  Interpretatio Lecture Roadmap n and Case Application Introduction to Vital Signs Setting the Stage and and Preparing the patient Hypertensio n Heart Rate Blood Technique Pressure Technique  Where can a pharmacist incorporate blood pressure assessments into their practice? 10 Setting the Stage for the Assessment Practitioner Introduction 1. Introduce yourself 2. Confirm patient’s identity with 2 identifiers 3. State your purpose of session and estimate length of time 4. Confirm allergies, current medications, OTC, herbals and vitamins Hi my name is […], My name is […], student pharmacist student pharmacist and I would like to and I will take your take your Blood Vital Signs and Pressure and Heart review the readings Rate today and with you. discuss the readings 11 11 Contraindications to BP Assessment  Measurement of BP is generally benign however, there are circumstances in which obtaining readings from a particular arm may NOT be appropriate. Patients with a side affected ___________________ or renal fistula should avoid having readings taken on that side. If intravenous (IV) catheter in one arm, use the other arm to prevent potential damage to the catheter and interruption of administration of medication. Presence of an arterial–venous shunt, recent axillary node dissection, or Pro-Tip: any “Have deformity you everhistory or surgical been told thatmy a medicalwith interferes provider thataccess proper you orshould blood not have flow your to the blood upper pressure checked in a particular arm arm. because of …” 12 Prepare for an accurate assessment Proper patient posture means… ❖ Seated in a stable chair ❖ His or her back supported ❖ Arm supported with cuff at heart level ❖ Feet must be flat on the floor (uncrossed) Patient must be in position for at least __________ ! Pro-Tips: Let me tell you about the time I messed this all 13 13 Ensure an Accurate Measurement Environment Shhhhhh Heart Level Make sure Neither the patient nor the Rest the arm on a table room is quiet observer should talk during the above the patient’s waist. and measurement. Instruct your Position the arm so that comfortably warm patient not to talk (nicely) the brachial artery is at heart level Check for factors Free the that Arm Influence the Make sure the arm is free of reading See next 14 14 clothing slide Factors that Influence Blood Pressure Factor and Pulse Comment Age Rises until puberty, then declines over time. Gender Male versus female average blood pressure. Exercise BP increases with activity. Stature/Position Pooling of blood effects the heart’s response. Fever Peripheral vasodilation. Emotions/Mood Vasoconstriction in response to stress. Medications/Substances What medications affect blood pressure? Pain/Stress/Anxiety Sympathetic nervous system response increases vasoconstriction. Obesity Patients with obesity are predisposed to high BP. Blood Volume Lower blood volume = lower blood pressure. Diurnal Variations Morning versus evening readings can vary. Smoking Nicotine causes vasoconstriction 15 15 Ensure an Accurate Measurement Continued How do we identify the most common factors that influence BP? Ask questions! 1. Have you had any caffeine in the past 30 minutes? 2. Have you had any nicotine in the past 30 minutes? 3. Have you eaten within the past 30 minutes? How do these factors influence the BP 4. Have you beenreadings? seated/resting for at least 5 minutes? 16 16 Evaluation of the Patient Assess lifestyle and identify other cardiovascular risk factors or concomitant disorders that may affect prognosis and guide treatment. ❖ Have you ever been diagnosed with high blood pressure? ❖ Do you currently take any medications to help lower your blood pressure? ❖ If so, did you take your dose(s) today? ❖ Do you have diabetes or chronic kidney disease? ❖ How often do you take your blood pressure? ❖ What is your typical blood pressure? 17 17  Interpretatio Lecture Roadmap n and Case Application Introduction to Vital Signs Setting the Stage and and Preparing the patient Hypertensio n Heart Rate Blood Technique Pressure Technique Pulse Rate (Heart Rate) 19  Pulse ❖ Pulse rate is the measurement of the heart rate or the number of times the heart pushes blood through the arteries. As the heart pushes blood through the arteries, the arteries expand and contract with the flow of blood. Pumping action of Blood the heart causes creates a pressure PULS blood to pound wave with each E against heartbeat artery walls ❖ Taking a pulse not only measures the heart rate but can also indicate rhythm and strength of the pulse. 20 20 Heart Rate ❖Arteries are palpated (felt) to determine the heart rate (i.e. “pulse”) Located close to the surface of the skin ❖Beats per minute (BPM) are recorded Normal = _______ BPM Bradycardia: _____ BPM Tachycardia: _____BPM 21 Take 5: Fill in the remaining pulse sites Apical (Apex) Popliteal Dorsalis Posterior Pedis Tibial 22 Find your radial pulse 23  Measuring the Heart Rate Use the pads of two or three middle fingers on the hand to take the radial pulse. Before measuring, have an analog clock or timer nearby. 1. Position the patient’s hand palm-side up. 2.Place two fingers 2 cm (~1 in) down from the base of the thumb and press lightly. 3.Feel for the pulse and ensure it is noticeable. 4.Count the number of beats felt over 30 seconds and multiply by 2 to determine the patient’s pulse. Doctor taking pulse. Freepik. https://www.freepik.com/free-photo/crop-doctor-checking-pulse-patient_3019442.htm. 24 24 Rawlings-Anderson K, Hunter J., Monitoring Pulse Rate. Nurs Stand. 2008 Apr;22(31):41-3. Measure the Heart Rate In addition to the rate, you should evaluate the rhythm and strength. i. Strength: Weak or strong pulses ii.Rhythm: Note any differences in pattern or irregularities i. Normal Sinus Rhythm Atrial Fibrillation If there are any irregularities present, further evaluation must be performed. Example questions to consider to identify next steps: 1. Evaluate history of irregularity 2. Evaluate control of the irregularity 3. Evaluate patient symptoms (i.e. CP, palpitations, dizziness, SOB) https://www.fibricheck.com/heart-rate-versus-heart-rhythm/ 25 Considerations For Measuring Heart Rate Why should you not use your thumb to take a pulse? Your thumb has a pulse and can therefore be easily confused with the patient’s heart rate. When should you count the beats over a full 60 seconds? When the patient is expected to have an irregular heartbeat rhythm. Example: Atrial Fibrillation 26 Documentation of HR Findings Heart rate should be documented as: 64 BPM, RRR Note the Remember to rhythm: multiple reading by 2 Regular or if counting for 30 irregular seconds 27 Provider’s Impact on Pulse Measurement What influence does the operator have on pulse measurements? 28 Create the Heart Rate Checklist 1. 2. 3. 4. 5. 6. 29  Interpretatio Lecture Roadmap n and Case Application Introduction to Vital Signs Setting the Stage and and Preparing the patient Hypertensio n Heart Rate Blood Technique Pressure Technique  Blood Pressure is the force of blood as it pushes against the arterial walls Force against resistance creates pressure! ❖ During each cardiac contraction the heart pumps blood into the arterial tree. ❖ The pressure within the cardiac cycle reaches a systolic peak and a diastolic trough that are measured and reported as the blood pressure. ❖ Blood pressure is reported as systolic/diastolic pressure and reported in mmHg. 31 Divisions of the Cardiac Cycle Systolic Versus Diastolic 32  Divisions of the Cardiac Cycle Systolic ❖The maximum pressure that is felt on the arteries during left ventricular contraction (or systole). ❖Regulated by stroke volume (i.e. the volume of blood ejected with each heartbeat). 33 Divisions of the Cardiac Cycle Diastolic ❖ The resting pressure that the blood exerts between each ventricular contraction. 34  Goal of Measuring Blood Pressure The goal of identifying, treating, and monitoring a patient’s blood pressure is to reduce the risk of cardiovascular disease and its associated morbidity and mortality. 35 Types of Blood Pressure Monitors Blood Pressure can be assessed via: Mercur Digital/ Aneroid y Automatic Covered in Skills VII 36 Types of Blood Pressure Monitors Digital/ Automatic  Digital Blood Pressure Monitors use the Oscillometric method of measurement  This means the monitor detects the blood’s movement through the brachial artery and converts the movements into a digital reading  Also means NO STETHOSCOPE 37  Getting to Know a Blood Pressure Device 38  Meet a Digital BP Monitor Main Unit Unit Display  Irregular Heartbeat Symbol If this appears, monitor detected an irregular rhythm.  Heartbeat Symbol Flashes during measurement. Omron Instruction Manual. Available: https://omronhealthcare.com/wp-content/uploads/bp710_im_eng_09152010.pdf 39 The Anatomy of a Blood Pressure Cuff Cuff Index Bladder Line Artery Mark Air Tube 40  Different Cuff Sizes Available AliExpress. https://www.aliexpress.us/item/2251832686812810.html?src=bing&albslr=202723429&isdl=y&gatewayAdapt=glo2usa4itemAdapt&_randl_shipto=US. 41  Selecting the Correct Cuff Size ❖ Bladder width of at least 40% of the arm circumference. (66- 75% of the acromion- olecranon distance). ❖ Bladder length of at least 80% of the arm circumference. ❖ The index line should fall within the “range”. Bhardwaj S. BLK Pediatric Practice. March 14, 2021. https://blk-pediatric-practice.com/2021/03/14/correct-cuff-size-for-bp/#:~:text=How%20to%20select%20correct%20cuff%20size%20for%20measuring,12%20x 42 %2022%20%203%20more%20rows%20.  Why is Cuff Size Important? Data from the National Health and Nutrition Examination Survey (2007–2010) indicated that 52% of men and 38% of women with hypertension require a cuff size different from a standard adult-sized BP cuff. Inappropriate cuff sizing can lead to errors in measurement! If the cuff is too ___________________ large… = If the cuff is too ___________________ small… = 43 Shimbo D., Artinian N., Basile J., et al. Joint Policy Statement From the American Heart Association and American Medical Association. Circulation. 2020, Jul;142:e42-e63. https://doi.org/10.1161/CIR.0000000000000803.  Appropriate Placement of Cuff 1. Center the bladder of the cuff over the brachial artery. 2. Place the lower edge of the cuff approximately 2 cm (~1 inch) above the antecubital space (elbow crease). 3. Wrap the cuff smoothly and snugly around the arm. 2 fingers should fit under the cuff 4. Again, instruct the patient not to speak during the measurement. Other Considerations: May get better placement if you stand to place the cuff on Avoid pushing cuff up and rotating cuff while it is on the arm 44  Taking a Blood Pressure Measurement 1. Make sure the air plug is securely inserted in the main unit. 2. Affix the blood pressure cuff to the patient’s arm – with the blood pressure cuff ~1 inch above the antecubital space. 1. The cuff must be positioned with the air tube facing down. 2. The patient must not rest their arm on the air tube. 3. The artery indicator should be over the brachial artery. 3. Press the START/STOP button and the cuff will inflate automatically. The cuff will automatically determine the ideal inflation level. To stop the inflation, push the START/STOP button at any time. 45 Taking a Blood Pressure Measurement 4. Inflation will stop automatically and the cuff will deflate as numbers and the Heartbeat Symbol flash on the display. 5. When the measurement is complete, the arm cuff will completely deflate and the BP and HR will be displayed. 6. Press the START/STOP button to turn off the monitor. Will turn off after five minutes. 46 Take 5: Troubleshooting Device Errors Device errors can and will happen from time to time! Identifying errors is a part of proper measurement technique. bp710_im_eng_09152010.pdf (omronhealthcare.com) Using the digital manual on D2L, identify the errors below? 47 Documentation of BP Findings Example: BP Reading should be documented with numbers, position and arm. 132/84 mmHg, seated, Left Standing Sittin Laying Stick figures can be g used in written documentation 48  Complexities of Blood Pressure “True blood pressure” is measured over days & White coat Masked Provider influence weeks hypertension hypertension on measurement Home monitoring Constitutes 15- Affects ~ 10% of See next slide. = best. 20% of Stage 1 the population. Caution: Wrist hypertension and arm diagnosis. Blood pressure is monitoring may normal in the introduce errors. Blood pressure is office and Averaging several elevated in the elevated in measurements is office. ambulatory best. setting. BP should be based on an average of readings on ≥2 occasions for clinical decision 49 making. Provider Influence on BP Measurement What operator factors impact the blood pressure reading? 50  Impact of Inaccurate Readings Patient has … Reading May Be Off By … Crossed legs 2-8 mmHg Cuff over clothing 5-50 mmHg Cuff too small 2-10 mmHg Talking 10 mmHg Unsupported arm 10 mmHg Unsupported back/feet 6 mmHg American Heart Association. Measure Accurately. https://targetbp.org/blood-pressure-improvement-program/control-bp/measure-accurately/#practice-assessment-tool. 51 Accessed Jan 9, 2023.  Blood Pressure Checklist 1. Select the most appropriately sized cuff Ensure the index line falls within the range 2. Appropriately place the cuff 1 inch above the antecubital space. Snug but not too tight 3. Plug in the air tube to the monitor 4. Instruct patient to report discomfort and remain silent during assessment 5. Press START/STOP button 6. Remove BP cuff 7. Document BP appropriately (mmHg, location, L/R) 8. Verbalize reading and correctly identify BP category 52  Interpretatio Lecture Roadmap n and Case Application Introduction to Vital Signs Setting the Stage and and Preparing the patient Hypertensio n Heart Rate Blood Technique Pressure Technique  American College of Cardiology (ACC) Classification of BP in Adults ** These classifications are for patients WITHOUT a diagnosis of Hypertension ** Individuals with SBP and DBP in 2 categories are designated to the higher BP category American College of Cardiology. New ACC/AHA High Blood Pressure Guidelines Lower Definition of 54 Hypertension. 2017, Nov. https://www.acc.org/latest-in-cardiology/articles/2017/11/08/11/47/mon-5pm-bp- You need to refer a patient who has extremely high blood pressure reading > 180/120 mmHg OR patient is feeling dizzy or lightheaded (i.e. symptomatic 55 Interpretation of Blood Pressure Readings Let’s practice our interpretation skills with some patient cases! 56 Patient Case 1 Patient GM is 63-year-old female requesting a blood pressure reading from her local pharmacy. After sitting for 5 minutes with her feet flat on the floor, GM confirms she has not eaten, used nicotine, or had any caffeine within the last 30 minutes. She does not take any medications for her blood pressure but wants to take any measures she can to avoid having high blood pressure. (1)Based on her results, where does GM fall for staging? (2)Does GM qualify for diagnosis of hypertension? 57 Patient Case 2 Patient PK is a 48-year-old male visiting the pharmacy for a medication pick-up. PK expresses discomfort, sweating, and explains that they are feeling a crushing chest pain. You suggest the patient be seated with you so that you can check their blood pressure and help identify any problems. (1)Where would PK be staged for his blood pressure? (2)Should PK be referred to urgent care? 58  Summary of Today’s Lecture ❖ Hypertension is an observable disease state and it is important to practice accurate routine monitoring to reduce the risk of cardiovascular disease progression/development. ❖ Patient factors and provider technique greatly affect the accuracy of vital sign measurement. ❖ Competent device navigation and utilization is key to ensuring an accurate blood pressure measurement. ❖ Always → treat your patient and not just the number 59 59 No Pressure: Introduction to Vital Signs Danielle Candelario, PharmD, BCPS, AE-C Associate Professor Rosalind Franklin University of Medicine and Science [email protected] 60