Vital Signs: Pulse & Blood Pressure (PDF)

Vital Signs: Pulse and Blood Pressure Jojo Wong Learning Outcomes After the lecture and practical session, you will be able to: 1. Describe normal ranges of blood pressure & pulse. 2. Demonstrate the skills for assessing blood pressure & pulse. 3. Document...

Vital Signs: Pulse and Blood Pressure Jojo Wong Learning Outcomes After the lecture and practical session, you will be able to: 1. Describe normal ranges of blood pressure & pulse. 2. Demonstrate the skills for assessing blood pressure & pulse. 3. Document the findings of blood pressure & pulse. 4. Discuss factors that affect blood pressure & pulse, & accurate measurement of them. 5. Identify and report abnormal findings of blood pressure & pulse. Taking vital signs is a vital part of Nursing! Not merely the performance of skills, but involves the interpretation of findings and clinical judgment.  Vital Signs  Include body temperature, pulse, respiration, and blood pressure  Reflect the physiological function of the body  Deviations from normal may indicate alteration in health status  When to assess vital signs? for basic  On admission – obtain baseline data patient information  Before and after surgery or procedure to check for abnormaliries  Before and after taking certain medication  Client presents or reports symptoms  Following incident or injury  When to assess vital signs?  According to ward policy &  Based on the needs of the client Q=every Qid=4 times per day bd=twice a day tds= 3 times a day qd= once a  Pulse  Reflects the amount of blood ejected with each heartbeat  Is a sign for inferring heart function, blood flow & blood vessel condition (e.g. patency, elasticity) Perry, Potter, Ostendorf & Laplante (2021). Factors affecting the pulse  Age – As age increase, the pulse rate gradually decrease overall.  Sex – After puberty, the average male’s pulse rate is slightly lower than the female.  Fever – the pulse rate increase in response to the lowered blood pressure that results from peripheral vasodilation associated with elevated body temperature and increased metabolic rate.  Stress – in response to stress, sympathetic nervous stimulation increases the overall activity of the heart.  Exercise  Medication (Digoxin)  Hypovolemia Assessing an arterial pulse  Palpation method: - Use finger pads (index, middle, & ring fingers of one hand) to feel pulse wave & count for one full minute Assessing an arterial pulse  Doppler ultrasound: - For pulses difficult to palpate Assessing an arterial pulse  Auscultation method: - Usually use for assessing apical pulse. Press diaphragm of stethoscope firmly against chest wall until “lub-dub” sound being clearly Perry, Potter, Ostendorf & Laplante (2021).  Common Sites for assessing pulse  Apical pulse (at apex of the heart) - at 5th intercostal space just medial to the mid- clavicular line  Peripheral pulse (a pulse site is where a large artery adjacent to a bone & close to the skin surface) - 8 common sites pulse locations  Common Sites for assessing an arterial pulse 1. Temporal Pulse  Over temporal bone of head, above & lateral to eye 2. Carotid Pulse  Along medial edge of sternocleidomastoid muscle in neck 3. Brachial Pulse  Medially in antecubital space 4. Radial Pulse  On thumb side of inner aspect of wrist Common Sites for assessing an arterial pulse 5. Femoral Pulse  At midway along groin 6. Popliteal Pulse  Behind knee 7. Posterior Tibial Pulse  Inner side of ankle, below medial malleolus 8. Dorsalis Pedis (Pedal) Pulse  On upper surface of foot, between extension tendons of great & first toe Reasons for using specific pulse site Pulse Site Reasons for use Radial Readily accessible Temporal Used when radial pulse is not accessible Carotid Used during cardiac arrest/ To determine circulation to brain Apical Routinely used for infants and children up to 3 years of age/ Determine discrepancies with radial pulse. Used in conjunction with some medications Brachial Used to measure blood pressure/ Used during cardiac arrest for infants Femoral Used in cardiac arrest/ Determine circulation to leg Popliteal Used to determine circulation to lower leg Posterior tibial Used to determine circulation to the foot Dorsalis pedis Used to determine circulation to the foot  Pulse Assessment Include:  Pulse Rate  Pulse Rhythm  Pulse Volume  Pulse Rate  Is number of pulse beats counted in one minute  Normal: 60-100 beats per minute (b.p.m.)  Tachycardia (pulse rate > 100) tachy = fast  Bradycardia (pulse rate < 60) brady = slow  Pulse Rhythm  Refers to pattern of time intervals between pulse beats - regular / irregular - regularly irregular / irregularly irregular  Arrhythmia - If detected, the apical pulse should be assessed  Pulse Volume Pulse strength (force of each beat)  0 Absent  1 Weak pulse; readily obliterated with pressure; pulse may come & go (weak)  2 Difficult to palpate; may be obliterated with pressure (moderate)  3 Full, can be obliterated with greater pressure (strong)  4 Bounding, increased, hyperactive pulse; easily palpated & cannot be obliterated  Assessing pulse Necessary Equipment  Watch with a second hand ± small pillow For assessing apical pulse, add the following equipment:  Stethoscope  Alcohol swab  Rubbish bag  A tray (for putting in all the equipment)  Assessing pulse Preparation  Ascertain measurement need & check client’s identity - ask client & check client’s wrist band against client’s records (e.g. MEWS chart)  Assess presence of factors that may influence the findings  Explain procedure to client  Check client’s physical & psychological readiness for the procedure  Prepare necessary equipment (check & disinfect as needed)  Wash hands  Provide privacy as needed  Assessing pulse Implementation  Gently press your index, middle, and ring fingers on the radial artery, inside the patient's wrist  Feel a pulse with only moderate pressure; excessive pressure may obstruct blood flow distal to the pulse site Why not thumb? the thumb itself has a pulse rate as well, use middle or index finger instead  Assessing pulse Implementation  Select and locate pulse point (pedal –may be after lower limb surgery; apical for infants)  Assess pulse rate, rhythm, volume  Response to the client’s verbal and non-verbal cues  Assessing an apical pulse Implementation  Place the diaphragm over the apex of the heart (at 5th intercostal space just medial to mid-clavicular line)  Assessing pulse Aftercare  Mainly after assessing apical pulse - Client (clothing, position) - Environment (curtain, client’s necessary items) - Equipment (disinfect stethoscope, discard rubbish, put away equipment)  Document pulse  Document date & time  Document pulse rate in nearest integer  Document on flow sheet by using a red pen & making a (for peripheral pulse) or  a x (for apical pulse)  Can also document result on client’s progress sheet including site for taking pulse, pulse rate, rhythm, & volume  MAR: below digoxin (AR: 55bpm)  https://www.ncbi.nlm.nih.gov/books/NBK538431/ 21/9/24 nconscious ain erbally responsive lert level of consciousness X = heart rate  Blood Pressure (BP) Is the force exerted by the blood against the vessel walls 140/90mmHg  Millimeters of mercury (mmHg) Indicate the height to which the blood www.cdc.gov pressure can sustain the column of mercury Determinants of BP  BP = CO x R  BP: blood pressure  CO: cardiac output  R: peripheral vascular resistance  Cardiac Output  blood pumped by the heart (stroke volume) during 1 minute (heart rate); CO = SV x HR  Peripheral vascular resistance  resistance that the blood encounters as it is being pumped through the peripheral circulation  Diastolic pressure: the level of pressure before the next ventricular compression and the minimal pressure exerted against the arterial wall at all times www.renewedlifecorp.com Systolic pressure: is the peak pressure occurring during the heart’s contraction as blood is forced under high pressure into the aorta Blood Pressure Ranges Source: American  Hypotension Heart Association