672 Lab 8/11 Vital Signs

Pulse Rate

the number of heart beats per minute, the rate at which the ventricular heart contraction pushes a pressure wave of blood throughout the arterial system

Assessing Pulse Rate (in bpm)

often use carotid and radial pulse

never palpate the carotids simultaneously or use the thumb to assess pulses

3 Options for Obtaining Pulse

60 sec

30 sec x 2

15 sec x 4

Normal Range of Pulse for Adults

60-100 bpm

<60 bpm

bradycardia

>100 bpm

tachycadia

Respiratory Rate

the number of breaths a person takes per minute, the rate at which air is drawn into the lungs during inspiration and expelled during expiration when the intercostal muscles and diaphragm relax (allowing the chest wall to recoil)

Obtaining Respiratory Rate in Breaths Per Minute (bpm)

can place arm on shoulder to better feel each breath, easiest to take respiratory rate immediately after pulse, may need to distract patient so they don’t change their breathing pattern

2 Options for Obtaining Respiratory Rate

0 sec

30 sec x 2

Normal Range of Respiratory Rate for Adults

12-20 breaths per min

<12 breaths pm

bradypnea

>20 breaths pm

tachypnea

0 breaths pm

apnea

3 Elements of Pulse Palpation Technique

student palpates carotid pulse bilaterally, one at a time, and reports pulse rate in bpm

student palpates radial pulse bilaterally and reports pulse rate in bpm

student reports if pulse is high, low, or as expected

2 Elements of Reporting Respiration Technique

student obtains and reports respiratory rate in breaths per min

student reports if respiratory rate is high, low, or as expected

Blood Pressure

the force of the blood against the wall of an artery as the ventricles of the heart contract and relax

systolic pressure/diastolic pressure

Systolic Pressure

the force exerted when the ventricles contract

is largely the result of cardiac output, blood volume, and compliance of the arteries

Diastolic Pressure

the force exerted by peripheral vascular resistance when the heart is in the filling or relaxed state, lowest arterial pressure during ventricular filling

Anatomy of a Stethoscope

Anatomy of a Sphygmomanometer

How to Place the BP Cuff Correctly

placed approx 1 inch above the antecubital fossa, must be on bare skin, place artery marker over the brachial artery, make sure the artery marker is within the range indicated on the cuff

BP Cuff too Big

underestimated blood pressure

BP Cuff too Small

overestimated blood pressure

Why should the patient’s arm be kept at heart height while BP is being taken?

placing the arm below heart level leads to an overestimation of systolic and diastolic pressures (bp measured is higher than actual bp)

placing the arm above the heart leads to an underestimation (bp measured is lower than actual bp)

How do you ensure the patient’s arm stays at heart height?

either pin it to your side under your arm or rest it on a table/pillow

Taking Systolic BP with Palpation

palpate radial or brachial artery

inflate cuff until you no longer feel a pulse +20-30 mmHg

then deflate the cuff slowly and note when you feel the pulse again (systolic)

document as (SBP)/Palpatory

Obaining BP By Ausculation

place and inflate the cuff same as method used for palpatory

place stethoscope over brachial artery

deflate until you hear the first and last beats (korotkoff sounds)

Normal Adult BP

120/80

can be between <90/<60 and >130/>80

Hypotension

<90/60

Hypertension

>130/80

Korotkoff Sounds

sound made by the turbulent flow of blood in artery

pressure at which the first tapping sound is heard is the systolic bp

pressure at which the last sound is heard is diastolic bp

Orthostatic Hypotension

within 2-5 mins of standing or following a seated or supine position, the systolic bp drops by 20 mmHg+ or the diastolic drops by 10 mmHg+, leading to a “faint” or “lightheaded” feeling upon standing

5 Elements of Blood Pressure Technique

student places cuff appropriately on the patient’s arm

student keeps the arm at or near the level of the patient’s heart

student supports patient’s arm (or rests on table)

student obtains a systolic blood pressure reading by palpation

student obtains BP by auscultation and reports the value

What portion of SOAP do vital signs and comments go in?

objective

3 Components of Physical Exam Used for Vital Signs

inspection

ausculation

palpation

Inspection

note general appearance, symmetry, presence of edema, deformities, color, and presence of any skin lesions always comparing bilaterally

Auscultation

listen to body sounds with and without the stethoscope, use the diaphragm for high-frequency sounds and the bell for low-frequency sounds

Palpation

identify landmarks that are related to the region being examined

note presence of heat, deformities, edema, effusion, tenderness, crepitus, and pulses

4 Vital Signs

temp

heart rate/pulses

respiratory rate

blood pressure

How is body temp maintained and regulated?

controlled by the hypothalamus, set point can be raised or lowered in response to external and internal stimuli

Vasoconstriction (for temp)

increases body temp by reducing heat loss through the skin

Vasodilation (for temp)

decreases body temp by promoting heat loss through the skin

3 Ways Body Temp is Taken

oral or rectal thermometry

infrared thermometry

smart phones

Oral or Rectal Thermometry

preferred for body temp, central thermometry (bladder, rectal) or peripheral thermometry (oral, ear, axilla, forehead)

Infrared Thermometry

measure the amount of heat produced, accuracy may be affected by sweating or vascular changes, can be higher or lower than rectal

Smart Phones Temp

apps that track fever and require an external sensor with accuracy commensurate, not recommended

Normal Body Temp

97.2-99.9 F or 36.2-37.5 C

average 98.6 F or 37 C

How does body temp vary?

varies with age, time of day, level of activity, phase of menstrual cycle (temp rises 0.9 F during ovulation)

highest in evening and lowest in morning

certain non-infectious disease can cause high or low temp

Serial Temperature Measurements

can be used in hospitalized patients to provide a clue to the severity of the disease

>100.4 F or>38.0 C

fever

Persistent Fever

does not fluctuate by >1.8 F in a 24 hour period

Remittent Fever

oscillates by 3.6 F during the day

Intermittent/Spiking Fever

present for several hours at a time before returning to normal

Geriatric Patient Temp

a normal temp is commonly observed in patients with severe infections due to blunted response from the hypothalamus

Arterial Pulse

rhythmic wave produced by the ejection of blood from the left ventricle into the aorta, the pressure causes a smooth and rapid upstroke that can be palpated in arteries, venous pulse is not palpated because it is a low-pressure system

3 Ways Pulse is Evaluated

rate and rhythm of heart

contour of the pulse

amplitude of the pulse

Contour of the Pulse

the shape of the pulse wave

described by the speed of the upward slope, downward slope, and duration of wave

Amplitue of the Pulse

the maximal force of the pressure wave

described as normal, increased, diminished, or double-peaked

5 Types of Irregular Pulse

anacrotic

waterhammer

bisferiens

alternans

paradoxical

Anacrotic

type of irregular pulse, caused by aortic stenosis

small, slow rising, delayed pulse with a notch or shoulder on the scending limb

Waterhammer

type of irregular pulse, caused by aortic regurgitation

rapid and sudden systolic expansion

Bisferiens

type of irregular pulse, caused by aortic regurgitation

double-peaked pulse with a midsystolic dip

Alternans

type of irregular pulse, caused by congestive heart failure

alternating amplitude of pulse pressure

Paradoxical

type of irregular pulse, caused by tamponade, constrictive pericarditis, and chronic obstructive heart disease

detected by blood pressure assessment, and exaggerated drop in systolic pressure during inspiration

6 Arteries to Palpate

carotid

radial

femoral

popliteal

dorsalis pedis

posterior tibial

Adult Athlete Heart Rate

50-60 resting

Children Heart Rates

newborn = 120-170 bpm

toddler = 80-120 bpm

school age 70-110 bpm

Pulse Oximetry

measures the percentage of oxygen-saturated hemoglobin in SpO2, normal is >97%

oxygen saturation is a percentage of the maximum amount of the oxygen the blood can carry

Respiratory Rate

number of breaths per minute, one respiration is start of inspiration to end of expiration

Child Respiratory Rate

newborn = 40-60 bpm

toddler = 20-30 bpm

school age = 16-20 bpm

White Coat Syndrome

isolated elevation of blood pressure measurements in the healthcare setting

Direct vs Indirect Blood Pressure

direct → intra-arterial catheter connected to a pressure sensor

indirect → blood pressure cuff

Width and Length of BP Cuff Bladder Should Be

width → 1/3 to ½ circumference of limp

length → 2x width or 80% of limb circumference

5 Phases of Korotkoff Sounds

phase 1 - sharp thuds, two sounds for systolic

phase 2 - thuds become more blowing or swishing

phase 3 - softer thuds, still crisp less blowing sound

phase 4 - soft thuds become soft blowing that disappears

phase 5 - silence, last sound is diastolic

15 Full Steps of Measuring Blood Pressure

Patient is at rest; sitting or lying down

Palpate the brachial artery

Wrap the cuff around the patients arm with the “artery” indicator towards the brachial artery

Support the patients arm atop your arm at heart level

Hold the inflator bulb in your opposite hand

While palpating the radial artery, inflate the bladder until the pulse is no longer felt

Slowly deflate the cuff by 2 – 3 mmHg per second until you feel two beats of the pulse

Deflate the cuff completely

Record the reading as “Systolic pressure by Palpation” e.g. “120/P”

Wait 30 seconds before inflating cuff again

Inflate the cuff to 20 – 30 mmHg above the systolic pressure determined by palpation

Place the diaphragm of the stethoscope over the brachial artery

Listen for the Korotkoff sounds

Deflate the cuff completely

Document your findings