8.2 PULSE AND RESPIRATION.pdf

Sri Rahaya Nafitri Abdul Razak (U6240037) 8. ASSESSMENT OF PATIENTS 8.2. PULSE & RESPIRATION  The pulse is a wave of blood created by contraction of the left ventricle of the heart.  Pulse wave represents the stroke volume output or the...

Sri Rahaya Nafitri Abdul Razak (U6240037) 8. ASSESSMENT OF PATIENTS 8.2. PULSE & RESPIRATION  The pulse is a wave of blood created by contraction of the left ventricle of the heart.  Pulse wave represents the stroke volume output or the amount of blood that enters the arteries with each ventricular contraction.  Compliance of the arteries is their ability to contract and expand.  Cardiac Output (CO): the amount of blood ejected by the heart with each ventricular contraction  Peripheral pulse: a pulse located in the periphery of the body (e.g. foot, hand, neck)  Apical pulse: a central pulse located at the apex of the heart The purpose of assessing a peripheral pulse 1. To establish baseline data for subsequent evaluation 2. To identify whether the pulse rate is within normal range 3. To determine the pulse volume and whether the pulse rhythm is regular 4. To determine the equality of corresponding peripheral pulses on each side of the body 5. To monitor and assess changes in the client's health status 6. To monitor clients at risk for pulse alterations, e.g.: those with a history of heart disease or experiencing cardiac arrhythmias, haemorrhage, acute pain, infusion of large volume of fluid or fever 7. To evaluate blood perfusion to the extremities Factors Affecting the Pulse I. Age  As age increases, the pulse rate gradually decreases overall. II. Sex  After puberty, the average males pulse rate is slightly lower than the females. III. Exercise  The pulse rate normally increases with activity. The rate of increase in the professional athlete is often less than in the average person because of greater cardiac size, strength, and efficiency. IV. Fever  The pulse rate increases. a) In response to the lowered blood pressure that results from peripheral vasodilation associated with elevated body temperature. b) Because of the increased metabolic rate. V. Medications  Some medications decrease the pulse rate, and others increase it. E.g.; cardiotonic (e.g.; digitalis preparations) – decrease the heart rate. Epinephrine increases it. VI. Hypovolemia / dehydration  Loss of blood from the vascular system increases the pulse rate.  In adults, the loss of circulating volume results in an adjustment of the heart rate to increase blood pressure as the body compensates for the lost blood volume. VII. Stress  In response to stress, sympathetic nervous stimulation increases the overall activity of the heart.  Stress increases the rate as well as the force of the heartbeat.  Fear and anxiety as well as the perception of severe pain stimulate the sympathetic system. VIII. Position  When a person is sitting or standing, blood usually pools in dependent vessels of the venous blood return to the heart and a subsequent reduction in blood pressure and increase in heart rate. IX. Pathology  Certain diseases such as some heart conditions or those that impair oxygenation can alter the resting pulse rate. PULSES SITES  NO. Pulse Sites Description Reason for Using Specific Pulse Site 1. Temporal where the temporal artery passes over  used when radial pulse is not accessible. the temporal bone of the head. The site is superior (above) and lateral to (away from the midline of) the eye. 2. Carotid at the side of the neck where the  used during cardiac arrest/shock in adults, carotid artery runs between the used to determine circulation to the brain. trachea and the sternocleidomastoid muscle. 3. Apical at the apex of the heart. In adults, its  routinely use for infants and children up to 3 located on the left side of the chest, y/o. about 8cm (3inch) to the left of the  sternum (breastbone) at the fifth  Used to determine discrepancies with radial intercostal space (area between the pulse. Used in conjunction with some meds. ribs). In older adults, the apex may be further left if conditions are present that have led to an enlarged heart. Before 4 y/o of age, the apex is left of the midclavicular line (MCL); between 4 & 7 y/o, it is at the MCL. For child 7 to 9 y/o of age, located at the fourth or fifth intercostal space. 4. Brachial at the inner aspect of the bicep  used to measure Bp. muscles of the arms or medially in the  Used during cardiac arrest for infants antecubital space. 5. Radial where the radial artery runs along the  readily accessible radial bone, on the thumb side of the inner aspect of the wrist. 6. Femoral where the femoral artery passes  used in cardiac arrest/shock. alongside the inguinal ligament.  Used to determine circulation to a leg 7. Popliteal where the popliteal artery passes  used to determine circulation to the lower behind the knee. leg 8. Posterior tibial on the medial surface of the ankle  used to determine circulation of the foot where the posterior tibial artery passes behind the medial malleolus. 9. Dorsalis pedis where the dorsalis pedis artery passes  used to determine circulation to the foot over the bones of the foot, on an imaginary line drawn from the middle of the ankle to the space between the big and second toes. Assessing the Pulse  A pulse is commonly assessed by palpation (feeling) or auscultation (hearing)  The middle three fingertips are used for palpating all pulse sites by applying moderate pressure except apical pulse.  A stethoscope is used for apical pulses.  A Doppler Ultrasound Stethoscope (DUS) is used for pulses that are difficult to assess.  The nurse should be aware of the following: a) Any medication that could affect the heart rate. b) Ensure patient rested 10 -15 minutes c) Any baseline data about the normal heart rate. E.g.; a resting heart rate of a physically fit athlete will be below 60 beats/min. d) Position of patient. E.g.; sitting. In some patients, the rate changes with the position because of changes in blood flow volume and autonomic nervous system activity.  What to obtain, when assessing the pulse: Rate, rhythm, volume, arterial wall elasticity, and presence or absence of bilateral equality.  The pulse rhythm is the pattern of the beats and the intervals between the beats.  Characteristic of a normal pulse: equal time elapses between beats. Abnormal pulse  Tachycardia means an excessively fast heart rate, over 100 beats/min in an adult.  Bradycardia means a heart rate in an adult of less than 60 beats/min.  Dysrhythmia / arrhythmia means a pulse with an irregular rhythm. Pulse Volume  Pulse volume also called the pulse strength or amplitude, refers to the force of blood with each beat.  Usually, the pulse volume is the same with each beat.  It can range from absent to bounding.  A normal pulse can be felt with moderate pressure of the fingers and can be obliterated with greater pressure.  A forceful or full blood volume that is obliterated only with difficulty is called a full or bounding pulse.  A pulse that is readily obliterated with pressure from the fingers is referred to as weak, feeble, or thread.  The elasticity of the arterial wall reflects its expansibility or its deformities.  A healthy, normal artery feels straight, smooth, soft, and pliable.  Older adults often have inelastic arteries that feel twisted (tortuous) and irregular on palpation. Apical Pulse Assessment Purposes / Indication i. To obtain the heart rate of an adult with an irregular peripheral pulse or unavailable. ii. To monitor patient with known cardiovascular, pulmonary, and renal diseases. iii. Prior administering medications that affect heart rate, e.g.: Digoxin. iv. To monitor pulse of newborns, infants, and children up to 2 to 3 years old. Location a) Palpate the angle of Louis (the angle between the manubrium, the top of the sternum, and the body of the sternum) b) Fifth intercostals space towards the medial to mid-clavicle line (MCL). RESPIRATION  Respiration is the act of breathing.  Inhalation or inspiration refers to the intake of air into the lungs.  Exhalation or expiration refers to breathing out or the movement of gases from the lungs to the atmosphere.  Ventilation is also used to refer to the movement of air in and out of the lungs. Types of breathing i. Costal (thoracic) breathing - normal ii. Diaphragmatic (abdominal) breathing - abnormal Describe mechanics and Regulation of Breathing  During inhalation, diaphragm contracts(flatten), ribs move upwards and outward, sternum moves outward, thorax enlarged and permitting lungs to expand.  During exhalation, diaphragm relaxes, ribs move downwards and inwards, sternum move inwards, decreasing size of the thorax as the lungs compressed.  Normal breathing is automatic and effortless.  Normal adult inspiration 1-1.5 secs and expiration 2-3 secs  Respiration controlled by respiratory centers in the medulla oblongata & the pons of the brain & chemoreceptors located centrally in the medulla and peripherally in the carotid and aortics bodies.  These centers and receptors respond to changes in the concentrations of O2, CO2, hydrogen in the arterial blood. State terminology a) Eupnea: normal/regular breathing b) Bradypnea: slow respiration c) Tachypnea: fast respiration d) Apnea: absence breathing e) Hyperventilation: deep and rapid respiration f) Hypoventilation: very shallow respiration g) Orthopnea, pt COAD; chronic obstructive airway disease: sit can breath, lying cannot breath Factors Affecting Respirations Increased respiratory rate:  Exercise ( increase metabolism)  Stress (readies the body for “fight or flight”)  Increased environmental temperature  Lowered oxygen concentration at increased altitudes Decreased respiratory rate:  Decreased environmental temperature  Certain medications (eg; narcotics: morphine; large doses of barbiturates : pentobarbital)  Increased intracranial pressure Altered Breathing Patterns and Sounds 1. BREATHING PATTERNS a) Rate  Tachypnea: quick, shallow breaths  Bradypnea: abnormally slow breathing  Apnea: cessation of breathing b) Volume  Hyperventilation: overexpansion of the lungs characterized by rapid and deep breathing  Hypoventilation: underexpansion of the lungs characterized by shallow respiration c) Rhythm  Cheyne-Stokes breathing: rhythmic waxing and waning of respirations, from very deep to very shallow breathing and temporary apnea d) Ease or Effort  Dyspnea: difficult and labored breathing during which the individual has a persistent, unsatisfied need for air and feel distressed  Orthopnea: ability to breath only in upright sitting or standing positions 2. BREATH SOUNDS i. Audible without Amplification  Stridor – a shrill, harsh sound heard during inspiration with laryngeal obstruction  Stertor – snoring or sonorous respiration, usually due to a partial obstruction of the upper airway  Wheeze – continuous, high-pitch musical squeak or whistling sound occurring on expiration and sometimes on inspiration when air moves through a narrowed or partially obstructed airway  Bubbling – gurgling sounds hear as air passes through moist secretions in the respiratory tract ii. Chest Movements  Intercostal retraction – indrawing between the ribs  Substernal retraction – indrawing beneath the breastbone  Suprasternal retraction – indrawing above the clavicles iii. Secretions and Coughing  Hemoptysis - the presence of blood in the septum  Productive cough – a cough accompanied by expectorated secretions  Nonproductive cough – a dry, harsh cough without secretions Assessing Respirations Purpose  To acquire baseline data against which future measurements can be compared.  To monitor abnormal respirations and respiratory patterns and identify changes.  To monitor respirations before or after the administration of a general anesthetic or any medication that influences respirations.  To monitor pt. at risk for respiratory alterations. ASSESSMENT Assess  Skin and mucous membrane color (eg; cyanosis / pallor)  Position assumed for breathing (eg; use of orthopneic position)  Signs of lack of oxygen to the brain(eg; irritability, restlessness, drowsiness, or loss of consciousness).  Chest movements (eg; retractions between the ribs or above or below the sternum).  Activity tolerance  Chest pain  Dyspnea  Medications affecting respiratory rate. DOCUMENTATION Date:………………,Time:……………. Respirations irregular, from………/min in past hour. Shallower respirations during tachypnea. Inspiratory wheeze noted. Respiratory therapist called to provide treatment. Signature:………………….