Vital Signs - Respiration & Blood Pressure 2023/2024 PDF

Vital Signs Assessing Respiration and Blood Pressure NUR 102 Second semester 2023/2024  Mechanism of Breathing  Respiration is the act of breathing  Measured in breaths/min  Respiration = inspir...

Vital Signs Assessing Respiration and Blood Pressure NUR 102 Second semester 2023/2024  Mechanism of Breathing  Respiration is the act of breathing  Measured in breaths/min  Respiration = inspiration and expiration – Inspiration or inhalation = breath in (intake of air into the lung) – Expiration or exhalation = breath out (breathing out of gases from the lung to the atmosphere)  1 breath = 1 inhalation & 1 exhalation  Ventilation: movement of air in & out of the lungs 2  Respiration  Two types of breathing: – Costal (thoracic) breathing: external intercostal muscles & accessory muscles (observed by the movement of the chest) – Diaphragmatic (abdominal) breathing: contraction and relaxation of diaphragm (observed by the movement of abdomen)  Two types of breathing 1. Costal (thoracic) breathing 2. Diaphragmatic (abdominal) breathing 4  Mechanisms and Regulation of Breathing  Normal breathing is automatic and effortless  A normal adult inspiration lasts (1 to 1.5 seconds) expiration lasts (2 to 3 seconds)  Expiration twice more than Inspiration 5  Assessing Respiration  The Nurse should be aware of the following: 1. The client’s normal breathing pattern 2. The influence of the client’s health problems on respirations 3. Any medications or therapies that might affect respiration 4. The relationship of the client’s respirations to cardiovascular function  Resting respirations should be assessed  Assess the rate, depth, rhythm, quality and effectiveness of respiration Assessing Respiration  Rate  Depth  Rhythm  Quality and effectiveness of respiration.  Characteristics of Respiration 1. Rate: breath per min  Eupnea: normal rate and depth (12-20 )  Bradypnea: 20 : abnormally fast respiration.  Apnea: Absence of breathing  Assessing Depth (Volume) 2. Depth: Movement of chest  Normal: normal Volume of air inhaled and exhaled (Tidal volume =500ml)  Deep respiration: large volume of air is inhaled and exhaled, inflating most of lungs (more than 500ml)  Shallow Respiration: small volume of air inhaled and exhaled inflating minimal size of lung tissue ( less than 500 ml)  Hyperventilation: very deep, rapid respiration  Hypoventilation: very shallow respiration  Assessing Rhythm 3. Respiratory rhythm: regularity of inspiration and expiration (Regular or irregular)  Assessing Quality 4. Respiratory quality or character: aspects of breathing that are different from normal. Normal breathing is silent, effortless breathing. Two of these aspects are effort breathing sound.  Labored breathing: need effort (substantial effort)  Abnormal breathing sounds (wheeze …you can hear) 11  The effectiveness of respiration is measured in part by the uptake of oxygen from the air into the blood (O2 Saturation) and the release of CO2 from the blood  Pulse oximeter: pulse rate and O2 saturation; the amount of Hg in arterial blood that is saturated with O2 Factors Affecting Respiration I- Factors that increasing RR: 1. Exercise (Increase metabolism) 2. Stress 3. Increased environmental Temp 4. Low O2 concentration 5. Fever 6. Health status such as anemia II- Factors decreasing Resp. Rate: 1. Decreased environmental Temp. 2. Certain medication 3. Increased intracranial pressure 4. Body position affect amount of air that can inhaled Nursing Diagnosis  Ineffective breathing pattern  Blood Pressure Determinations of blood pressure (Bp) Factors affecting blood pressure Hypertension Hypotension Assessing blood pressure  Blood Pressure  Arterial blood pressure: is a measure of the pressure exerted by the blood as it flows through the arteries. 1. Systolic Pressure: Is the pressure of blood as a result of contraction of the ventricles, that is the pressure of the height of blood wave. 2. Diastolic pressure: Is the pressure when the ventricles are at rest, then is the lower pressure present  Pulse pressure: Is the difference between Diastolic and Systolic pressure (40 mmHg) but can be as high as 100 during Exercise.  Pulse pressure may increase due to arteriosclerosis or decrease due to heart failure. Blood Pressure (Bp) = Systolic/Diastolic= 120/80 mmHg. Measured in millimeters of mercury (mm Hg) 120/80 Systolic Pressure Diastolic Pressure  Contraction of left  Heart at rest ventricle  Bottom or second  Top or first number number  Determinant of Blood Pressure  Bp is a result of many Factors: 1. Pumping action of the heart: Determining Cardiac output (weak= ↓ Bp, strong = ↑ Bp) 2. Peripheral Vascular Resistance: due to decrease arterioles and capillaries capacity, compliance of the arteries (elasticity) 3. Blood Volume: (↓ with hemorrhage or dehydration = ↓ Bp. ↑ with rapid IV infusion = ↑Bp 4. Blood Viscosity: Bp ↑ when blood is thick  Factors affecting Blood Pressure 1. Age: the pressure rises with age 2. Exercise: 3. Stress: increase heart rate, cardiac output and vasoconstriction due to stimulation of sympathetic nervous system. 4. Race: African American is more than European American 5. Gender: female less than male but after menopause, women will have higher Bp than before 6. Medication 7. Obesity: predispose to hypertension 8. Diurnal variation: lowest in early morning, highest late afternoon, early evening. 9. Medical conditions: any condition affect CO, Blood Volume, Blood viscosity and compliance of the arteries.  Hypertension  Is a blood pressure that is persistently above normal.  It is usually asymptomatic and may cause MI  Two Types: 1. Primary Hypertension: Unknown cause 2. Secondary Hypertension: Known cause  Patient considered hypertensive when Diastolic more than 90 mmHg or Systolic more than 140 mmHg for more than two readings  Hypotension  Is blood pressure below normal (systolic is 85-110 mmHg)  Orthostatic Hypotension: falling of Bp due to sitting or standing. Result from peripheral vasodilatation in which blood leaves the central body organs.  Other causes: Analgesia, bleeding, sever burns, and dehydration When assessing orthostatic hypotension 1. Place patient in supine position for 10 min 2. Record pulse and blood pressure 3. Assist the patient to slowly sit or stand 4. Immediately recheck the pulse and BP in the same sites as previously. 5. Repeat the pulse and blood pressure after 3 min 6. Record the results A rise of pulse of 15-30 beats/min or a drop of BP of 20 mmHg systolic or 10 mmHg diastolic indicates orthostatic hypotension  Assessing Blood Pressure  Bp is measured by blood pressure cuff, sphygmomanometer and stethoscope Types of sphygmomanometer:  Aneroid  Mercury  Electronic/ digital Cuff size  The cuff should be in correct width and length for pt arm  The width of the bladder should be 40% of the arm circumference  The length of the bladder affect accuracy of measure ( it should cover 2\3 of the arm circumference) Sites for measuring BP  Upper arm ( brachial artery)  Thigh (Popliteal artery) Method of measuring BP:  Direct (invasive as arterial line)  Indirect (by auscultatory or palpatory method) Blood pressure is not measured using pt arm when:  The shoulder, arm or hand is injured or diseased  A cast over the arm  Arm with intravenous fluid  Arm near mastectomy  Arm with arteriovenous fistula Measured from thigh:  When we can’t use arm  When we want to compare upper and lower extremity pressure  Sound heard during BP measurement called Korotkoff's sound  5 Phases of this sound  Common error in assessing Bp  Bladder cuff too narrow (high)  Bladder cuff too wide ( low)  Arm unsupported ( high)  Insufficient rest before measurement ( high)  Repeating Bp rapidly (high)  Deflating cuff too quickly or too slowly( low systolic (SBP) and high diastolic (DBP)  Arm above heart level (low)  Assessing immediately after a meal or smoking (high)