Vital Signs /Clinical/ PDF

‫وزارة التـعليم العــالي والبحث العلمي‬ ‫جامعـــــت السهراء (ع) للبنــــاث‬ ‫كلـــيت التقنـياث الصحــيت والطبــيت‬ ‫أسس التمريض‬ ‫‪Vital Signs /Clinical/‬‬ ‫‪Assessing Pulse,‬‬ ‫‪Respiration, & Blood‬‬ ‫‪Pressure‬‬...

‫وزارة التـعليم العــالي والبحث العلمي‬ ‫جامعـــــت السهراء (ع) للبنــــاث‬ ‫كلـــيت التقنـياث الصحــيت والطبــيت‬ ‫أسس التمريض‬ ‫‪Vital Signs /Clinical/‬‬ ‫‪Assessing Pulse,‬‬ ‫‪Respiration, & Blood‬‬ ‫‪Pressure‬‬ ‫‪PREPARED BY: MARLEN HASHEM SALLOUM‬‬ ‫‪1‬‬  ‫وزارة التـعليم العــالي والبحث العلمي‬ ‫جامعـــــت السهراء (ع) للبنــــاث‬ ‫كلـــيت التقنـياث الصحــيت والطبــيت‬ ‫أسس التمريض‬ ASSESSING RADIAL PULSE Key Points:  Locate the pulse point properly.  Always count pulse for one full minute if dysrhythmias or other abnormality is present.  Have another nurse locate and count the radial pulse while you auscultate the apical pulse. Equipment: 1. Watch with a second hand or indicator. 2. Paper, pencil. 3. Vital signs record. Procedure: # Step Rational 1 Wash hands. Reduces transmission of microorganisms. 2 If necessary, draw curtain around bed Maintains privacy. and/or close door. 3 Obtain pulse measurement. 4 Assist client to assume supine position. Provides easy access to pulse sites. 5 If supine, place client’s forearm along side Relaxed position of lower arm or across lower chest or upper abdomen and extension of wrists permits with wrist extended straight. If sitting, full exposure of artery to bend client’s elbow 90 and support lower palpation. arm on chair. Slightly extend wrist with palms down. PREPARED BY: MARLEN HASHEM SALLOUM 2  ‫وزارة التـعليم العــالي والبحث العلمي‬ ‫جامعـــــت السهراء (ع) للبنــــاث‬ ‫كلـــيت التقنـياث الصحــيت والطبــيت‬ ‫أسس التمريض‬ 6 Place tips of first two fingers of hand Fingertips are most sensitive over groove along radial or thumb side of parts of hand to palpate arterial client’s inner wrist. pulsations. Nurse’s thumb has pulsation that may interfere with accuracy. 7 Lightly compress against radius, Pulse is more accurately obliterate pulse initially, and then assessed with moderate relax pressure so pulse becomes pressure. Too much pressure easily palpable. occludes pulse and impairs blood flow. 8 Determine strength of pulse. Note whether Strength reflects volume of thrust of vessel against fingertips is strong, blood ejected against arterial weak or thread. wall with each heart contraction. 9 After pulse can be felt regularly, look at Rate is determined accurately watch’s second and begin to count rate; only after nurse is assured pulse when sweep hand hits number on dial, can be palpated. Timing begins start counting with zero, then one, two, with zero. Count of one is first and so on. beat palpated after timing begins. 10 If pulse is regular, count rate for 30 A 30 second count is accurate for seconds and multiply by 2, rapid, slow, or regular pulse rates. 11 If pulse is irregular, count rate for 60 Inefficient contraction of heart seconds. Assess frequency and pattern if fails to transmit pulse wave, irregularity. interfering with CO2, resulting in irregular pulse. Longer time ensures accurate count. PREPARED BY: MARLEN HASHEM SALLOUM 3  ‫وزارة التـعليم العــالي والبحث العلمي‬ ‫جامعـــــت السهراء (ع) للبنــــاث‬ ‫كلـــيت التقنـياث الصحــيت والطبــيت‬ ‫أسس التمريض‬ 12 Wash hands. Reduces transmission of microorganisms. 13 Compare readings with previous Evaluates for change in condition baseline and/or acceptable range of and alterations. heart rate for client’s age. 13 Compare radial pulse equality and Differences between radial note discrepancy. arteries indicate compromised peripheral vascular system. Recording and reporting: Record PR with assessment site in nurses’ notes or vital signs flow sheet. Measurement of PR after administration of specific therapies should be documented in narrative form in nurses’ notes. Report abnormal finding to nurse in charge or physician. ASSESSING RESPIRATION Key Points:  Assess the client for factors that could indicate respiratory variations.  Without telling the client what you are doing, watch the chest movements in and out.  Count in each ventilatory movement as one respiration.  Count for 30 seconds or one full minute. PREPARED BY: MARLEN HASHEM SALLOUM 4  ‫وزارة التـعليم العــالي والبحث العلمي‬ ‫جامعـــــت السهراء (ع) للبنــــاث‬ ‫كلـــيت التقنـياث الصحــيت والطبــيت‬ ‫أسس التمريض‬ Equipment: -Watch with second hand. - Paper, pencil -Vital signs record. Observe the rate, rhythm, and depth of respiration. Normal respiration is regular in depth and rhythm. Place hands on chest when respirations are difficult to count. PREPARED BY: MARLEN HASHEM SALLOUM 5  ‫وزارة التـعليم العــالي والبحث العلمي‬ ‫جامعـــــت السهراء (ع) للبنــــاث‬ ‫كلـــيت التقنـياث الصحــيت والطبــيت‬ ‫أسس التمريض‬ Critical Decision Point: Clients with difficulty of breathing (dyspnea) such as those with congestive heart failure or abdominal ascites or in late stages of pregnancy should be assessed in positions of greatest comfort. Repositioning may increase the work of breathing, which will increase respiratory rate. Procedure: # Steps Rational 1 Draw curtain around bed and/or close Maintains privacy door. 2 Wash hands Prevents transmission of microorganisms. 3 Be sure client’s chest is visible. If Ensures clear view of chest wall necessary, move bed linen or gown. and abdominal movements. 4 Place client’s arm in relaxed position Client’s or nurse’s hand rises and across the abdomen or lower chest, or falls during respiratory cycle. place nurse’s hands directly over client’s upper abdomen. 5 Observe complete respiratory cycle Rate is accurately determined (one inspiration and one expiration). only after nurse has viewed respiratory cycle. 6 After cycle is observed, look at watch’ Timing begins with count of one. s second hand and begin to count rate: Respirations occur more slowly when sweep hand hits number on dial, than pulse; thus timing does not begin time frame, counting one with begin with zero. first full respiratory cycle. 7 If rhythm is regular, count number of Respiratory rate is equivalent to respirations in 30 seconds and number of respirations per multiply by 2. If rhythm is irregular, minute. Suspected irregularities less than 12, or greater than 20, count require assessment for at least 1 for 1 full minute. minute. 8 Note depth of respirations Character of ventilatory subjectively assessed by observing movement may reveal specific degree of chest wall movement while disease state restricting volume counting rate. Nurse can also of air from moving into and out objectively assess depth by palpating of the lungs. chest wall excursion after rate has PREPARED BY: MARLEN HASHEM SALLOUM 6  ‫وزارة التـعليم العــالي والبحث العلمي‬ ‫جامعـــــت السهراء (ع) للبنــــاث‬ ‫كلـــيت التقنـياث الصحــيت والطبــيت‬ ‫أسس التمريض‬ been counted. Depth is shallow, normal, or deep. 9 Note rhythm of ventilatory cycle. Character of ventilations can Normal breathing is regular and reveal specific types of uninterrupted alterations. 10 Replace bed linen and client’s gown. Restores comfort and promotes sense of well-being. 11 Wash hands. Reduces transmission of microorganisms. 12 Discuss findings with client as Promotes participation in care needed. and understanding of health status. 13 If respirations are assessed for the first Used to compare future time, establish rate, rhythm, and depth respiratory assessment. as baseline if within normal range. 14 Compare respirations with client’s Allows nurse to assess for previous baseline and normal rate, changes in client’s condition and rhythm, and depth. for presence of respiratory alterations. Recording and Reporting: Record respiratory rate and character in nurses’ notes or vital sign flow sheet. Indicate type and amount of oxygen therapy if used by client during assessment. Measurement of respiratory rate after administration of specific therapies should be documented in narrative form in nurses’ notes. Report abnormal findings to nurse in charge or physician. PREPARED BY: MARLEN HASHEM SALLOUM 7  ‫وزارة التـعليم العــالي والبحث العلمي‬ ‫جامعـــــت السهراء (ع) للبنــــاث‬ ‫كلـــيت التقنـياث الصحــيت والطبــيت‬ ‫أسس التمريض‬ ASSESSING BLOOD PRESSURE Key Points: 1. Blood pressure is the measurements of the pressure exerted by the blood on the walls of the arteries. The rate and force of the heartbeat determines the reading as the ventricles contract and rest. 2. Do not take BP reading on person’s arm if:  Is injured/diseased.  Is on the same side of body where a female has had a radical mastectomy.  Has a shunt or fistula for renal dialysis, or is site for an intravenous infusion. Equipment and Supplies:  Stethoscope  Blood pressure cuff of appropriate size  Sphygmomanometer – an aneroid or a mercury manometer may be available. The gauge should be inspected to validate that the needle or mercury is within the zero mark.  Alcohol swab  Paper, pencil, pen, V/S flow sheet or record form PREPARED BY: MARLEN HASHEM SALLOUM 8  ‫وزارة التـعليم العــالي والبحث العلمي‬ ‫جامعـــــت السهراء (ع) للبنــــاث‬ ‫كلـــيت التقنـياث الصحــيت والطبــيت‬ ‫أسس التمريض‬ Procedure: AUSCULTATION METHOD # Step Rational 1 Wash hands. Reduces transmission of microorganisms. 2 With client sitting or lying, If arm is unsupported, client may position client’s forearm, perform isometric exercise that can supported if needed, with palms increase diastolic pressure 10%. turned up. Placement of arm above the level of the heart causes false low reading. 3 Expose upper arm fully by removing Ensures proper cuff application. constricting clothing. 4 Palpate brachial artery. Position Inflating bladder directly over brachial cuff 2.5 cm (1 inch) above site of artery ensures proper pressure is applied brachial pulsation. Center bladder during inflation. Loose-fitting cuff of cuff above artery. With cuff causes false high readings. fully deflated, wrap evenly and snugly around upper arm. 5 Position manometer vertically at Accurate readings are obtained by eye level. Observer should be no looking at the meniscus of the mercury farther than 1 meter away. at eye level. The meniscus is the point where the crescent-shaped top of the mercury column aligns with the manometer scale. Looking up or down at the mercury results in distorted readings. 6 Palpate radial artery with Identifies approximate systolic pressure fingertips of one hand while and determines maximal inflation point inflating cuff rapidly to pressure for accurate reading. Prevents 30 mmHg above point at which auscultatory gap. If unable to palpate pulse disappears. artery because of weakened pulse, an ultrasonic stethoscope can be used. 7 Deflate cuff fully and wait 30 Prevents venous congestion and false seconds. high readings. PREPARED BY: MARLEN HASHEM SALLOUM 9  ‫وزارة التـعليم العــالي والبحث العلمي‬ ‫جامعـــــت السهراء (ع) للبنــــاث‬ ‫كلـــيت التقنـياث الصحــيت والطبــيت‬ ‫أسس التمريض‬ 8 Place stethoscope earpieces in ears Each earpiece should follow angle of ear and be sure sounds are clear, not canal to facilitate hearing. muffled, 9 Relocate brachial artery and place Proper stethoscope placement ensures bell or diaphragm (chest piece) of optimal sound reception. Stethoscope the stethoscope over it. Do not improperly positioned causes muffled allow chest piece to touch cuff or sounds that often result in false low clothing. systolic and false high readings. 10 Close valve of pressure bulb Tightening of valve prevents air leak clockwise until tight. during inflation. 11 Inflate cuff to 30 mmHg above Ensures accurate measurement of palpated systolic pressure. systolic pressure. 12 Slowly release valve and allow Too rapid or slow a decline in mercury mercury to fall at rate of 2 to 3 level can cause inaccurate readings. mmHg/sec. 13 Note point on manometer when First Korotkoff sound indicates systolic first clear sound is heard. pressure. 14 Continue to deflate cuff, noting Fourth Korotkoff sound involves distinct point at which muffled or muffling of sounds and is recommended dampened sound appears. as indication of diastolic pressure in children. 15 Continue to deflate cuff gradually, Beginning of fifth Korotkoff sounds is noting point at which sound recommended by American Heart disappears in adults. Association as indication of diastolic pressure in adults. 16 Deflate cuff rapidly and Continuous cuff inflation causes arterial completely. Remove cuff from occlusion, resulting in numbness and client’s arm unless measurement tingling of client’s arm. must be repeated. 17 If this is the first assessment of Comparison of BP in both arms detects client, repeat procedure on other circulatory problems (Normal difference arm. of 5 to 10 mmHg exists between arms). 18 Assist client in returning to Restores comfort and promotes sense of comfortable position and cover well-being. arm if previously clothed. 19 Discuss findings with client as Promotes participation in care and needed. understanding of health status. PREPARED BY: MARLEN HASHEM SALLOUM 10  ‫وزارة التـعليم العــالي والبحث العلمي‬ ‫جامعـــــت السهراء (ع) للبنــــاث‬ ‫كلـــيت التقنـياث الصحــيت والطبــيت‬ ‫أسس التمريض‬ 20 Wash hands Reduces transmission of microorganisms 21 Compare readings with previous Evaluates for changes in condition and baseline and/or acceptable value alterations. of BP for client’s age. 22 Compare BP readings in both Arm with higher pressure should be used arms. for subsequent assessment unless contraindicated. 23 Correlate BP with data obtained Blood pressure and heart rate are from pulse assessment and related interrelated. cardiovascular signs and symptoms. Recording and reporting:  Inform client of value and need for periodic re-assessment.  Record BP. Measurement of BP after admission of specific therapies should be documented.  Report abnormal findings to nurse in charge or physician. PREPARED BY: MARLEN HASHEM SALLOUM 11  ‫وزارة التـعليم العــالي والبحث العلمي‬ ‫جامعـــــت السهراء (ع) للبنــــاث‬ ‫كلـــيت التقنـياث الصحــيت والطبــيت‬ ‫أسس التمريض‬ REFERENCES: th 1. Kozier & Erbs, (2011). Fundamentals of Nursing. 9 Edition. th 2. Potter & Perry, (2009). Fundamentals of Nursing, 7 Edition, by Elsevier Faculty Development and Training. 3. Delaune S.C., & Ladner P.K. (2002). Fundamentals of Nursing/ Standards & Practice. 2nd Edition. Published by Delmar & Thomson Learning. 4. Gaylene Bouska Altman.(2005). Delmars Fundamental & Advanced Nursing Skills. 2nd Ed. Thomson and Delmar Learning. 5. Carol R. Taylor, (2009). Fundamentals of Nursing: The Art and Science of Nursing Care (Fundamentals of Nursing: The Art & Science of Nursing Care) 6. Kozier & Erb's, (2011). Fundamentals of Nursing with My Nursing Lab and Pearson e-Text (Access Card) (9th Edition) 7. Potter &Perry, (2009). Clinical Nursing Skills and Techniques, 7th Edition By Anne Griffin Perry, Patricia A. Potter. 8. Springhouse, (2006). Fundamentals of Nursing Made Incredibly Easy! (Incredibly Easy! Series). 9. Burton & Ludwig, (2010). Fundamentals of Nursing Care: Concepts, Connections & Skills. 10. Lippincott & Williams, (2006). Lippincott Manual of Nursing Practice: Handbook, 3rd edition. 11. Kaplan Nursing, (2002). Th Basics; Essential Conten for International Nurses. 2nd Edition. PREPARED BY: MARLEN HASHEM SALLOUM 12