Vital signs observation and pain assessment PDF

Vital signs observation and pain assessment PDN24 Foundations of Nursing Therapeutics I 1 Intended Learning outcomes At the end of this lecture, students should be able to: 3. Differentiate the...

Vital signs observation and pain assessment PDN24 Foundations of Nursing Therapeutics I 1 Intended Learning outcomes At the end of this lecture, students should be able to: 3. Differentiate the normal and abnormal findings of vital signs 2. Describe the 4. Describe the nursing factors that influence interventions of handling the vital signs the abnormal findings 5. Analyze the advantages 1. Identify the time for and disadvantages of using assessing vital signs different temperature 2 measuring methods Intended Learning outcomes At the end of this lecture, students should be able to: 7. Describe the 8. Assess the mechanics and pain levels of regulation of verbal and breathing nonverbal clients 6. Identify the location 9. Calculate the Modified of different pulse sites and Early Waring Score (MEWS) and their rationale of selection correlate3 response actions for assessment according to the risk levels Content What is Blood 01 vital signs Pressure 05 Body Oxygen 02 Temperature saturation 06 03 Pulse Pain 07 Modified Early 04 Respirations Warning Score 4 08  Body Blood Oxygen Vital signs Temperature Pulse Respirations Pressure Saturation Pain MEWS Vital signs (生命表徵) Reflecting the body’s physiological status in response to physical, environmental, and psychological stressors Normal = person’s physiological wellbeing Abnormal may = early warning of deterioration Timely and accurate assessment, documentation and interpretation is critical to clinical reasoning, accuracy of nursing diagnosis and5 implementation of appropriate interventions  Body Blood Oxygen Vital signs Temperature Pulse Respirations Pressure Saturation Pain MEWS Vital signs 1. Body temperature (T) 2. Pulses (P) Vital 6. Pain 3. Respiration signs rate (RR) 5. Oxygen 4. Blood saturation (SpO2) pressure (BP) 6  Body Blood Oxygen Vital signs Temperature Pulse Respirations Pressure Saturation Pain MEWS Vital signs Time to assess ▪ On admission to obtain baseline data. ▪ On a routine schedule according to a physician’s order to monitor a client’s clinical improvement or deterioration. ▪ Client has a change in general physical condition, e.g. loss of consciousness and increased intensity of pain. ▪ Client reports specific symptoms of physical distress, e.g. chest pain, feeling hot and difficulty breathing. ▪ Before, during and after surgery or an invasive procedure. ▪ Before, during and after the administration of medications or application of therapies that affect cardiovascular, respiratory, or temperature-control functions. ▪ Before, during and after nursing interventions that could affect the vital signs, e.g. ambulating a client who has been on bed rest and transfusing any type of blood 7 product to a client.  Body Blood Oxygen Vital signs Temperature Pulse Respirations Pressure Saturation Pain MEWS Vital signs Time to assess Abbreviation Meaning Q__H Every ______ hour Daily Once daily B.D. / B.I.D Twice a day T.D.S. / T.I.D Three times daily Q.I.D. / Q.D.S. Four times daily Stat At once 8  Body Blood Oxygen Vital signs Temperature Pulse Respirations Pressure Saturation Pain MEWS Body Temperature A measurement that reflects the balance between the heat produced and the heat lost from the body. Degree Fahrenheit (℉) Degree Celsius (℃) Average normal temperatures for healthy adults Measuring method ℃ Conversion: ℃ = (℉- 32) x 5/9 ℉ Oral 37.5 ℉ = (℃ x 9/5) + 32 99.5 Rectal 38.0 100.4 Tympanic 38.0 100.4 Axillary 37.3 99.1 Temporal 36.0 96.8 Read the instructions of the instrument carefully for the reference range of the9 readings when using different methods of taking body temperatures  Body Blood Oxygen Vital signs Temperature Pulse Respirations Pressure Saturation Pain MEWS Body Temperature A E D Assessment S/S of fever/ I P hypothermia? 10  Body Blood Oxygen Vital signs Temperature Pulse Respirations Pressure Saturation Pain MEWS Body Temperature A E D Possible Nursing Diagnosis I P Hypothermia Risk for hyperthermia 11  Body Blood Oxygen Vital signs Temperature Pulse Respirations Pressure Saturation Pain MEWS Body Temperature A E D Planning I P Patient Equipment Environment 12  Body Blood Oxygen Vital signs Temperature Pulse Respirations Pressure Saturation Pain MEWS Body Temperature A E D Implementation Measuring Explanation I P method Oral Gently place thermometer probe under tongue in posterior sublingual pocket lateral to center of lower jaw. Ask client to hold thermometer probe with lips closed. Rectal Lubricate the thermometer with liberal amount of lubricant. With non-dominant hand separate client’s buttocks to expose anus. Ask client to breaths slowly and relax. Gently insert thermometer into anus in direction of umbilicus 3.5 cm for adult, 2.5 cm for children and 1.5 cm for infant. Withdraw immediately if presence of resistance. 13  Body Blood Oxygen Vital signs Temperature Pulse Respirations Pressure Saturation Pain MEWS Body Temperature A E D Implementation Measuring Explanation I P method Axillary Raise client’s arm away from torso and dry axilla if needed. Insert thermometer probe into center of axilla, lower arm over probe and place arm across client’s chest. Tympanic Pull ear pinna backward, up and out for an adult. Pull ear pinna up and back for children older than 3 years old. Pull ear pinna down and back for children less than 3 years old. Insert the probe slowly using a circular motion until snug. Fit sensor tip snug in canal, pointing toward 14 nose. Once positioned, press scan button.  Body Blood Oxygen Vital signs Temperature Pulse Respirations Pressure Saturation Pain MEWS Body Temperature A E D Implementation Measuring Explanation I P method Temporal Ensure that forehead is dry. Place sensor firmly on client’s forehead. Press scan button and slowly slide thermometer straight across forehead while keeping sensor flat and firmly on skin. Keeping scan button depressed, lift sensor after sweeping forehead and touch sensor on neck just behind earlobe. 15  Body Blood Oxygen Vital signs Temperature Pulse Respirations Pressure Saturation Pain MEWS Body Temperature A E D Evaluation I P 16  Body Blood Oxygen Vital signs Temperature Pulse Respirations Pressure Saturation Pain MEWS Body Temperature Advantages and Disadvantages Measuring Types of Advantages Disadvantages method temperature Oral Surface ▪ Accessible and convenient ▪ Thermometers can break if bitten ▪ Comfortable for patient ▪ Long measurement time ▪ Inaccurate if client has just ingested hot or cold food or fluid or smoked ▪ Could injury the mouth following oral surgery ▪ Risk for body fluid exposure Rectal Core ▪ Reliable measurement ▪ Inconvenient for clients ▪ Source of client embarrassment and anxiety ▪ Difficult for client who cannot turn to the side ▪ Could injure the rectum ▪ Presence of stool may interfere with 17 thermometer placement ▪ Risk for body fluid exposure  Body Blood Oxygen Vital signs Temperature Pulse Respirations Pressure Saturation Pain MEWS Body Temperature Advantages and Disadvantages Measuring Types of Advantages Disadvantages method temperature Tympanic Core ▪ Readily accessible ▪ More variability of measurement ▪ Very fast measurement than other core temperature devices ▪ Obtained without disturbing, waking, ▪ Right and left measurements can or repositioning client differ if there are anatomic or ▪ Used for client with tachypnea pathologic differences, e.g. infection without affecting breathing ▪ Requires removal of hearing aids before measurement ▪ Requires disposable sensor cover ▪ Can be uncomfortable and involves risk of injuring the membrane if the probe is inserted too far ▪ Presence of cerumen can affect the reading ▪ Anatomy of ear canal makes it difficult to 18 correctly position in neonates, infants, and younger children  Body Blood Oxygen Vital signs Temperature Pulse Respirations Pressure Saturation Pain MEWS Body Temperature Advantages and Disadvantages Measuring Types of Advantages Disadvantages method temperature Axillary Surface ▪ Safe and non-invasive ▪ Long measurement time ▪ Reliable in stable and preterm ▪ Requires continuous positioning infants ▪ Affected by exposure to the environment, including time it takes to place thermometer ▪ Underestimates core temperature Temporal Surface ▪ Safe and non-invasive ▪ Inaccurate with head covering or hair ▪ Very fast measurement on forehead ▪ Easy to access without position ▪ Affected by skin moisture such as change sweating ▪ Comfortable ▪ Sensor cover not required 19  Body Blood Oxygen Vital signs Temperature Pulse Respirations Pressure Saturation Pain MEWS Body Temperature Contraindications Oral Rectal Axillary Tympanic Temporal 1. Infants and 1. Diarrhea 1. Uncooperative 1. Ear or 1. No contra- young children 2. Rectal surgery 2. Seizure tympanic indication 2. Unconscious 3. Rectal membrane 3. Confused disorders surgery 4. Uncooperative 4. Hemorrhoids 5. Facial trauma 5. Bleeding or oral surgery tendencies 6. History of 6. Immuno- seizure suppressed 20  Body Blood Oxygen Vital signs Temperature Pulse Respirations Pressure Saturation Pain MEWS Body Temperature 21  Body Blood Oxygen Vital signs Temperature Pulse Respirations Pressure Saturation Pain MEWS Pulse A wave of blood created by contraction of the left ventricle of the heart Pulse wave represents the amount of blood that enters the arteries with each ventricular contraction, i.e. stroke volume Stroke Volume (SV) Heart rate (HR) Cardiac output (CO) The amount of blood The number of The amount of blood ejected from each × contractions of the = pumped by each ventricle with each ventricles each ventricle in 1 minute contraction minute E.g. 65 mL x 70 /min = 4.55 L/ min That means when an adult is resting, the heart pumps about 5 liters of blood each minute. 22  Body Blood Oxygen Vital signs Temperature Pulse Respirations Pressure Saturation Pain MEWS Pulse 23  Body Blood Oxygen Vital signs Temperature Pulse Respirations Pressure Saturation Pain MEWS Pulse Rate 60 – 100 beats/min Pulse Rhythm Adult volume Felt with moderate Regular pressure Obliterated with greater pressure 24  Body Blood Oxygen Vital signs Temperature Pulse Respirations Pressure Saturation Pain MEWS Pulse – Affecting Factors 01 Age Medications 05 09 Pathology 02 Sex Hypovolemia 06 03 Exercise Stress 07 Position 04 Fever Change 08 25  Body Blood Oxygen Vital signs Temperature Pulse Respirations Pressure Saturation Pain MEWS Pulse – Types Apical pulse The point of maximal impulse Used to assess the pulse for newborns, infants and children up to 3 years old Used to determine discrepancies with radial pulse Apical pulse 26  Body Blood Oxygen Vital signs Temperature Pulse Respirations Pressure Saturation Pain MEWS Pulse – Types Apical pulse Indications: 1. Newborn, infant and children age 2 to 3 2. Before administering medications that affects heart rate 3. Peripheral pulse is irregular or unavailable 4. Cardiovascular, pulmonary and renal diseases Apical pulse 27  Body Blood Oxygen Vital signs Temperature Pulse Respirations Pressure Saturation Pain MEWS Apical pulse A E D Assessment I P 28  Body Blood Oxygen Vital signs Temperature Pulse Respirations Pressure Saturation Pain MEWS Apical pulse A E D Possible Nursing Diagnosis Decreased I P cardiac output 29  Body Blood Oxygen Vital signs Temperature Pulse Respirations Pressure Saturation Pain MEWS Apical pulse A E D Planning I P Patient Equipment Environment 30  Body Blood Oxygen Vital signs Temperature Pulse Respirations Pressure Saturation Pain MEWS Apical pulse A E D Implementation I P “lub-dub” sound 31  Body Blood Oxygen Vital signs Temperature Pulse Respirations Pressure Saturation Pain MEWS Apical pulse A E D Implementation I P Regular Count for 30 seconds and multiply by 2 Irregular Count for a full 60 seconds 32  Body Blood Oxygen Vital signs Temperature Pulse Respirations Pressure Saturation Pain MEWS Apical pulse A E D Evaluation I P 33  Body Blood Oxygen Vital signs Temperature Pulse Respirations Pressure Saturation Pain MEWS Pulse – Types Peripheral pulse A pulse located Temporal pulse Carotid pulse away from the heart Femoral pulse Brachial pulse Popliteal pulse Radial pulse Posterior pedis pulse Dorsalis pedis pulse 34  Body Blood Oxygen Vital signs Temperature Pulse Respirations Pressure Saturation Pain MEWS Pulse – Types Peripheral pulse Site Location Rationale of selection Temporal ▪ Over temporal bone of head, ▪ Easily accessible site to assess pulse in children above and lateral to eyebrow Carotid ▪ Along medial edge of ▪ Easily accessible site to assess character of sternocleidomastoid muscle peripheral pulse; used during physiological shock in neck or cardiac arrest when other sites are not palpable Apical ▪ Fourth to fifth intercostal ▪ Site used to auscultate apical pulse space at left midclavicular line Brachial ▪ Groove between biceps and ▪ Site used to auscultate upper-extremity blood triceps muscles at pressure; assesses status of circulation to lower antecubital fossa arm 35 Radial ▪ Radial or thumb side of ▪ Common site to assess character of peripheral forearm at wrist pulse; assess status of circulation to hand  Body Blood Oxygen Vital signs Temperature Pulse Respirations Pressure Saturation Pain MEWS Pulse – Types Peripheral pulse Site Location Rationale of selection Femoral ▪ Below inguinal ligament, ▪ Site used to assess character of pulse during midway between symphysis physiological shock or cardiac arrest when other pubis and anterior superior pulses are not palpable; assesses status of iliac spine circulation to leg Popliteal ▪ Behind knee in popliteal ▪ Site used to auscultate lower-extremity blood fossa pressure; assesses status of circulation to lower leg Posterior ▪ Inner side of each ankle, ▪ Site used to assess status of circulation to foot below medial malleolus tibial Dorsalis ▪ Along top of foot between ▪ Site used to assess status of circulation to foot extension tendons of great pedis and first toe 36  Body Blood Oxygen Vital signs Temperature Pulse Respirations Pressure Saturation Pain MEWS Peripheral pulse A E D Assessment I P S/S of peripheral vascular disease? 37  Body Blood Oxygen Vital signs Temperature Pulse Respirations Pressure Saturation Pain MEWS Peripheral pulse A E D Possible Nursing Diagnosis I P 38  Body Blood Oxygen Vital signs Temperature Pulse Respirations Pressure Saturation Pain MEWS Peripheral pulse A E D Planning I P Patient Equipment Environment 39  Body Blood Oxygen Vital signs Temperature Pulse Respirations Pressure Saturation Pain MEWS Peripheral pulse A E D Implementation I P 40  Body Blood Oxygen Vital signs Temperature Pulse Respirations Pressure Saturation Pain MEWS Peripheral pulse Regular Count for 30 seconds A and multiply by 2 E D Evaluation Irregular Count for a full 60 seconds I P 41  Body Blood Oxygen Vital signs Temperature Pulse Respirations Pressure Saturation Pain MEWS Pulse – Abnormal findings Bradycardia: < 60 beats/min OR Rate Tachycardia: > 100 beats/min 1 Auscultate apical pulse 2 Identify related data Observe for signs and symptoms associated 3 with abnormal cardiac function Confer with health care provider 4 Obtain an electrocardiogram if necessary 42  Body Blood Oxygen Vital signs Temperature Pulse Respirations Pressure Saturation Pain MEWS Pulse – Abnormal findings Irregular rhythm Rhythm Dysrhythmia or Arrhythmia 1. Auscultate ▪ Regular irregular ▪ Irregular irregular apical pulse 2. Assess for S/S of decreased cardiac output 43  Body Blood Oxygen Vital signs Temperature Pulse Respirations Pressure Saturation Pain MEWS Pulse – Abnormal findings Weak, thready or difficult to palpate Pulse peripheral pulse volume Assess the other peripheral pulse bilaterally 1 and compare the findings Observe for symptoms associated with 2 ineffective tissue perfusion Assess for swelling in surrounding tissues / any 3 encumbrance that may impede blood flow Obtain Doppler ultrasound to detect low- 4 velocity blood flow 44  Body Blood Oxygen Vital signs Temperature Pulse Respirations Pressure Saturation Pain MEWS Respirations Inhalation/ Inspiration:intake of air into lungs Exhalation/ Expiration: breathe out gases from lungs Ventilation: movement of air in & out of the lungs Type 1. Costal (thoracic) breathing External intercostal muscles and other accessory muscles 2. Diaphragmatic (abdominal) breathing Contraction and relaxation of the diaphragm 45  Body Blood Oxygen Vital signs Temperature Pulse Respirations Pressure Saturation Pain MEWS Respirations Costal Diaphragmatic breathing breathing 46  Body Blood Oxygen Vital signs Temperature Pulse Respirations Pressure Saturation Pain MEWS Respirations Costal breathing Diaphragmatic breathing ▪ Involves external intercostal ▪ Involves the contraction and muscles and other accessory relaxation of the diaphragm muscles, e.g. sternocleidomastoid ▪ Can be observed by the movement of muscles the abdomen ▪ Can be observed by the movement of the chest upward and outward 47  Body Blood Oxygen Vital signs Temperature Pulse Respirations Pressure Saturation Pain MEWS Respirations - Mechanics and regulation of breathing Respiration is controlled by: Respiratory centres in the medulla oblongata and the pons of the brain; Chemoreceptors located centrally in medulla and peripherally in carotid and aortic bodies. They respond to changes in the concentration of oxygen (O2), carbon dioxide (CO2) and hydrogen (H+) in arterial blood. 48  Body Blood Oxygen Vital signs Temperature Pulse Respirations Pressure Saturation Pain MEWS Respirations - Affecting Factors Exercise Stress Medical condition Pain Affecting Factors Environment Medications temperature Position Altitudes 49  Body Blood Oxygen Vital signs Temperature Pulse Respirations Pressure Saturation Pain MEWS Respirations Rate 12 – 20 breaths/min Rhythm Volume Regular Tidal volume Adult Evenly spaced ~ 500ml Breathing sound Effort 50 Silent Effortless  Body Blood Oxygen Vital signs Temperature Pulse Respirations Pressure Saturation Pain MEWS Respirations A E D Assessment Altering I P factors? 51  Body Blood Oxygen Vital signs Temperature Pulse Respirations Pressure Saturation Pain MEWS Respirations A E D Possible Nursing Diagnosis Impaired gas I P exchange 52  Body Blood Oxygen Vital signs Temperature Pulse Respirations Pressure Saturation Pain MEWS Respirations A E D Planning I P Patient Equipment Environment 53  Body Blood Oxygen Vital signs Temperature Pulse Respirations Pressure Saturation Pain MEWS Respirations A E D Implementation I P Regular Count for 30 seconds and multiply by 2 Irregular Count for a full 60 seconds 54  Body Blood Oxygen Vital signs Temperature Pulse Respirations Pressure Saturation Pain MEWS Respirations A E D Evaluation I P Rechecking? 55  Body Blood Oxygen Vital signs Temperature Pulse Respirations Pressure Saturation Pain MEWS Respirations – Abnormal findings Bradypnea: < 12 breaths/min Tachypnea: > 20 breaths/min Rate Apnea: cessation of breathing for several seconds Hyperventilation: overexpansion of the lungs (deep and rapid breaths) Hypoventilation: under-expansion of the lungs Volume (shallow respirations) 56  Body Blood Oxygen Vital signs Temperature Pulse Respirations Pressure Saturation Pain MEWS Respirations – Abnormal findings Abnormal: irregular rhythm Cheyne-Stokes breathing Rhythm 57  Body Blood Oxygen Vital signs Temperature Pulse Respirations Pressure Saturation Pain MEWS Respirations – Abnormal findings Dyspnea: difficult and laboured breathing Orthopnea: ability to breathe only in Effort upright sitting or standing positions Stridor: a shrill, harsh sound Breathing snoring or sonorous Stertor: sound Wheeze: continuous, high-pitched musical squeak or whistling sound gurgling sound 58 Bubbling:  Body Blood Oxygen Vital signs Temperature Pulse Respirations Pressure Saturation Pain MEWS Respirations – Abnormal findings 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-pitched musical squeak or whistling sound occurring on expiration and sometimes on inspiration when air moves through a narrowed or partially obstructed airway Bubbling/crackle: gurgling sounds heard as air passes through moist secretions in the respiratory tract 59  Body Blood Oxygen Vital signs Temperature Pulse Respirations Pressure Saturation Pain MEWS Respirations – Abnormal findings Related interventions 1 Assess for related factors 2 Assess for environmental factors Assist client to supported sitting 3 position unless contraindicated Provide oxygen therapy as 4 prescribed 5 Notify physician 60  Body Blood Oxygen Vital signs Temperature Pulse Respirations Pressure Saturation Pain MEWS Blood Pressure ▪ The pressure exerted by the blood as it flows through the arteries. ▪ Unit: millimeters of mercury (mmHg) Systolic pressure (SBP) ▪ The pressure of the blood as a result of contraction of ventricles. ▪ The highest point of pressure on arterial walls. Diastolic pressure (DBP) ▪ The pressure when the ventricles are at rest. ▪ The lowest pressure present within the arteries. 61  Body Blood Oxygen Vital signs Temperature Pulse Respirations Pressure Saturation Pain MEWS Blood Pressure 62  Body Blood Oxygen Vital signs Temperature Pulse Respirations Pressure Saturation Pain MEWS Blood Pressure Pulse Pressure SBP-DBP Normal pulse pressure is 40 mmHg elevated pulse pressure occurs in arteriosclerosis Consistently Low pulse pressure occurs in severe heart failure Mean arterial pressure (MAP) (SBP + 2 x DBP)/3 Average pressure actually delivered to the body’s organ perfusion to vital organs Better indicator of Normal MAP: 70 – 110 mmHg 63  Body Blood Oxygen Vital signs Temperature Pulse Respirations Pressure Saturation Pain MEWS Blood Pressure 1. Peripheral resistance increases blood pressure. Some factors that create resistance in the arterial system are the Determinants capacity of the arterioles and capillaries, the compliance of arteries 2. Internal diameter of arterioles and capillaries: the smaller the space within a vessel, the greater the resistance. ↑Vasoconstriction (e.g. smoking) → ↑ BP Pumping 3. Weak pumping action → Peripheral 4. Elasticity of arterioles less blood is pumped into vascular action If elastic and muscular tissues of the arteries → ↓BP resistance arteries are replaced with fibrous tissue, the arteries lose ability to constrict and dilate → arteriosclerosis. Blood Blood Highly viscous blood viscosity volume (ratio of red blood cells to the blood plasma is ↓Blood volume →↓BP high) →↑ BP 64  Body Blood Oxygen Vital signs Temperature Pulse Respirations Pressure Saturation Pain MEWS Blood Pressure - Affecting Factors Medical White coat 1 Age 5 Gender 9 conditions 13 syndrome 2 Exercise 6 Medications 10 Temperature Fluid 3 Stress 7 Obesity 11 status Diurnal 4 Ethnicity 8 variation 12 Smoking 65  Body Blood Oxygen Vital signs Temperature Pulse Respirations Pressure Saturation Pain MEWS Blood Pressure A E D Assessment Altering I P factors? 66  Body Blood Oxygen Vital signs Temperature Pulse Respirations Pressure Saturation Pain MEWS Blood pressure is NOT measured on client’s limb in following situations Shoulder, arm or hand is injured A cast or bulky bandage is on any part of the limb Client has had surgical removal of breast or axillary lymph nodes on that side Client has an intravenous infusion or blood transfusion in that limb Client has an arteriovenous fistula for renal dialysis in that limb 67  Body Blood Oxygen Vital signs Temperature Pulse Respirations Pressure Saturation Pain MEWS 68  Body Blood Oxygen Vital signs Temperature Pulse Respirations Pressure Saturation Pain MEWS Blood Pressure A E D Assessment I P Blood pressure cuff of the appropriate size (cuff width should be 80% of the circumference of the extremities) 69  Body Blood Oxygen Vital signs Temperature Pulse Respirations Pressure Saturation Pain MEWS Blood Pressure A E D Possible Nursing Diagnosis I P 70  Body Blood Oxygen Vital signs Temperature Pulse Respirations Pressure Saturation Pain MEWS Blood Pressure A E D Planning I P Patient Equipment Environment 71  Body Blood Oxygen Vital signs Temperature Pulse Respirations Pressure Saturation Pain MEWS Blood Pressure A E D Implementation Stethoscope I P Cuff Position Preliminary Position Inflate cuff rapidly to pressure 30 mmHg above Brachial pulse site point at which pulse disappears. Slowly deflate 72 cuff and note point when pulse reappears.  Body Blood Oxygen Vital signs Temperature Pulse Respirations Pressure Saturation Pain MEWS Blood Pressure A E D Implementation Close valve of pressureI P bulb. Tightening valve prevents air leak during inflation. Quickly inflate cuff to 30 mmHg above client’s estimated systolic pressure. Rapid inflation ensure accurate measurement of 73 systolic pressure.  Body Blood Oxygen Vital signs Temperature Pulse Respirations Pressure Saturation Pain MEWS Blood Pressure A E D Implementation I P Slowly release pressure at rate of 2 to 3 mmHg/second. A too-rapid decline decreases systolic blood pressure and increases diastolic blood pressure measurement. First Korotkoff sound = systolic blood pressure Last Korotkoff sound = diastolic blood pressure 74  Body Blood Oxygen Vital signs Temperature Pulse Respirations Pressure Saturation Pain MEWS Blood Pressure A E D Implementation I P Deflate the cuff completely. Allow the remaining air to escape quickly. Repeat any suspicious reading but wait at least 1 minute. Continuous cuff inflation causes arterial occlusion, resulting in numbness and tingling of client’s arm; Reinflating the cuff while obtaining the blood pressure is uncomfortable and can cause an inaccurate reading; It causes congestion of blood in the lower arm which lessens the loudness 75 of the sounds.  Body Blood Oxygen Vital signs Temperature Pulse Respirations Pressure Saturation Pain MEWS Blood Pressure 76  Body Blood Oxygen Vital signs Temperature Pulse Respirations Pressure Saturation Pain MEWS Blood Pressure A E D Evaluation I P 77  Body Blood Oxygen Vital signs Temperature Pulse Respirations Pressure Saturation Pain MEWS Blood Pressure – Abnormal findings A single elevated blood pressure reading indicates the need for reassessment. Hypertension is diagnosed if an elevated blood pressure is found when measured twice at different times Usually asymptomatic Primary: Unknown cause; Secondary: Known cause According to American Heart Association (2017): Blood Pressure Systolic (mmHg) Diastolic (mmHg) Category Elevated 120 – 129 and