Measuring Radial Pulse & Respiration - Fundamental p 3 PDF

Define key terminology ❖ Describe the circulatory system as it relates to pulse, and identify the pulse sites ❖ Define and describe respiration and factors that affect respiratory rate ❖ Describe observations to be made when measuring respirations Describe abnormal breathing pattern...

Define key terminology ❖ Describe the circulatory system as it relates to pulse, and identify the pulse sites ❖ Define and describe respiration and factors that affect respiratory rate ❖ Describe observations to be made when measuring respirations Describe abnormal breathing patterns Heart Anatomy - The Chambers 1- the arteries :- are the blood vessels which transport blood away from the heart 2- the veins :- the blood vessels which transport blood to the heart ❑ Right atrium tricuspid valve right ventricle ❑ Right ventricle pulmonary semi lunar valve pulmonary arteries lungs ❑ Lungs pulmonary veins left atrium ❑ Left atrium bicuspid valve left ventricle ❑ Left ventricle aortic semi lunar valve aorta ❑ Aorta systemic circulation Pulse is : An alternative expansion and recoil of an artery as the wave of blood is forced through it by the contraction of the left ventricle It is felt by palpating superficial artery that had bone behind it apical Caroid Temporal  Radial Femoral Brachial POSTERIOR Dorsalis Pedis Popliteal TIBIAL (Pedal) Normal pulse rate is from 60 – 90 b/m a-Tachycardia , the pulse rate is abnormally rapid (100b/m or more) B- bradycardia , pulse rate is abnormally slow and below 60b/m Abnormal Normal Pulse Tachycardia b/m 60-90 Rate bradycardia irregular regular Rhythm weak strong Force empty full Volume Figure 21.1 Oxygen intake and elimination of carbon dioxide is achieved through respiration The gas exchange between the individual and the environmental air in which the individual take in oxygen and eliminate carbon dioxide and water vapor Qualities of normal respirations ◦12- 20 respirations per minute ◦ Quiet ◦ Effortless ◦ Regular Healthy adult breathe approximately 14-20 c/m A rapid breathing , the respiratory rate is above normal level above 25 rpm Bradybnea : a slow breathing , the respiratory rate below normal level usually below 10 rpm The depth is described as deep or shallow breathing , depending whether the volume of air taken in is above or below normal level. Normal respiration is rhythmic or regular. The time interval for each breath (inspiration , expiration and short period of rest ) is equal approximately 4 seconds. Hyperventilation: refers to very deep, rapid respiration. Hypoventilation: refers to very shallow respiraion. Eupnea: breathing that is normal in rate and depth. 1. To obtain base line data. 2. To determine rate and quality of patient pulse and respiration. 3. To detect presence of arrhythmia or inadequate circulation or other changes in patient condition. 4. To detect the presence of respiration abnormalities (e.g depression or respiratory distress). 5. To assess heart's ability to deliver blood to distant areas of the (fingers and lower extremities). 6. To assess vascular status of limbs. 7. To assess response of heart to cardiac medications, blood volume and gas exchange. 8. To estimate dose of some medications. 1-Watch with a second hand or digital readout 2- graphic chart or patient record  1-Wash hands ❑ to prevent cross infection 2- explain procedure to the patient ❑ to gain patient’s cooperation 3-Examine the patient previous pulse and respiratory rate recording 4-Ascertain the patient medical diagnosis and any prior history of arrhythmia or respiratory difficulty 5- determine if the patient is taking any medications that may affect his or her pulse rate or respiratory rate or depth ❑ To provide comfort 6- assist the patient to a ❑ Also in standing position position of comfort ( sitting pulse may differ or lying position ) , resting ❑ The pulse wouldn’t be felt the hand in comfortable , if the patient is holding relaxed position anything tightly in his hand  7- locate the patient radial pulse and palpate with your midlle three fingers Place (2 ,3 and 4 ) finger tips along the radial artery which passes over ❑ If thumb is used for the radial bone and press palpating the pulse , the nurses own pulse may be gently against the radius, felt and confuse the rest the thumb in a position measurement of patient to fingers on the back of pulse the client wrist and from ❑ To detect accurate counting one spot to another (forward and backward ) untill you feel pulsation To detect abnormalities in 8-Count pulse for one rhythm , for accurate minute measurement 9- note the rhythm and volume of patient pulse To avoid patient voluntary 10- with fingers still on the control of his respiration wrist count respiration for one minute by looking at the chest as the chest rises and falls  11- observe patient color, depth of respiration, presence of nasal flaring, retraction , and rhythm of respiration.also observe the body position he or she assume For medical records and 12 – hand washing written communication 13- record the results Rec. provide accurate Pulse (rate, rhythm , force, docum. For future volume) comparison Respiration ( rate ,depth, abnormalities) ❖ To asses heart rate when the peripheral pulse is weak or irregular ❖ To assess heart rate before administering medication such as digitalis ❖ To identify pulse deficit A difference between a peripheral pulse rate and apical pulse rate If ventricular contraction are not stronger or regular , some of them may be so weak that the wave caused by contraction doesn’t reach the peripheral pulse site In these instance the peripheral count is inaccurate Stethoscope Tray Two iodine bowels Alcohol sponges  1-Wash hands ❑ to prevent cross infection 2- explain procedure to the patient ❑ to gain patient’s cooperation 3-Examine the patient previous pulse and respiratory rate recording 4-Ascertain the patient medical diagnosis and any prior history of arrhythmia or respiratory difficulty 5- determine if the patient is taking any medications that may affect his or her pulse rate or respiratory rate or  6- assist the patient to position of comfort 7- locate the patient apical pulse , for adult , between fifth and six rib , fifth intercostal space 8 cm from mediastinal , left midclavicular line to prevent cross infection Clean the stethoscope chest piece and ear piece with an alcohol sponge before and after the procedure Warm the end pieces of the stethoscope first by rubbing it in palm of your hands.insert the ear pieces in your ears with the tips bent forward toward your nose. Place the stethoscope over the apex of the heart and count for one minute Note the rhythm Wash your hands Record the results