Vital Signs

V/S are : BP, T , P , R

Many agencies have designated Pain as a fifth vital sign
Checked to monitor functions of body
Reflect changes in function that otherwise might not be observed
Monitoring pt v/s should not be an automatic or routine procedure ; it
should be a thoughtful, scientific assessment

Times to Assess
On admission to a health care agency to obtain baseline data
When a client has a change in health status or report symptoms
Before and after surgery
Before and/or after the administration of a medication that could affect
respiratory or cardiovascular system
Before and after any nursing intervention that could affect vital signs (e.g
ambulating a client who has been on bed rest)

When and How often

Chiefly nursing judgments
Depends on clients health status
Nurse should measure v/s more often if the clients health status requires it
Body Temperature

Reflects the balance bet. the heat produced and the heat lost from the body
Measured in heat units called degrees
Heat is by-product of metabolism
Heat balance is When the amount of heat produced by the body equals the
amount of heat loss

Radiation

Transfer of heat from the surface of one object to the surface of

another w/o contact bet. the two objects , mostly in the form of
infrared rays
Conduction

Transfer of heat from one molecule to a molecule of lower temperature

Convection

Dispersion of heat by air currents

Vaporization

Evaporation of moisture from the respiratory tract and from the

mucosa of the mouth and from the skin
Insensible water loss

Unnoticed water loss

Insensible heat loss

Accompanying heat loss

Regulation of Body temperature

System that regulates body temp has 3 main parts :

o
Sensors in the shell and in the core
o
An integrator in the hypothalamus
o
An effector system that adjusts production and loss of heat
Most sensors or sensory receptors are in the skin
Skin has more receptors for cold than warmth , therefore skin sensors

detect cold more efficiently than warmth

When skin becomes chilled over the entire body, 3 physiologic

processes to increase body temp take place :

o
Shivering increases heat production
o
Sweating is inhibited to decrease heat loss
o
Vasoconstriction decreases heat loss

Kinds
Core temperature

Temperature of deep tissues of the body such as abdominal cavity and

pelvic cavity

Remains relatively constant

Surface temperature

Temperature of the skin , subcutaneous tissue, and fat

Rises and falls in response to the environment

Factors that affect bodys heat production

Basal Metabolic Rate (BMR)

Rate of energy utilization in the body required to maintain essential

activities such as breathing

Decrease w/ age
Muscle activity

Shivering increases the metabolic rate

Thyroxine output

Increased thyroxine output increases rate of cellular metabolism

throughout the body (chemical thermogenesis)

Chemical thermogenesis is the stimulation of heat production in the

body through increased cellular metabolism
Epinephrine, norepinephrine, and sympathetic stimulation / stress
response

These hormones immediately increase the rate of cellular metabolism in

many body tissues

Directly affect the liver and muscle cells, thereby increasing cellular
metabolism
Fever

Increases the cellular metabolic rate

Factors that affect bodys heat loss

Hypothalamic integrator

Center that controls the core temperature

Located in the preoptic area of the hypothalamus

Signals from cold-sensitive receptors of hypothalamus initiate

effectors (e.g vasoconstriction , shivering , release of epinephrine) w/c

increases cellular metabolism and hence heat production

When warmth-sensitive receptors in hypothalamus are stimulated ,
effector system sends out signals that initiate sweating and peripheral
vasodilation

Factors Affecting Body temperature

1. Age
Infant
Greatly influenced by the temp. of the environment
Must be protected from extreme changes
Children
Temp. continue to be more variable than those of adults until puberty
Elderly
At risk of hypothermia because of a variety of reasons :
o
Inadequate diet
o
Loss of subcutaneous fat
o
Lack of activity
o
Reduced thermoregulatory efficiency
Sensitive to extremes in the environmental temp. due to decreased
thermoregulatory controls

2. Diurnal variations (Circadian rhythms)

Body temp. normally change throughout the day
Point of highest body temp. is usually reached bet. 4pm and 6pm
Lowest point is reached during sleep bet. 4 am and 6am


3. Exercise
Hard work or strenuous exercise can increase body temp. to as high as 38.3
degree C to 40 degree C measured rectally
4. Hormones
Women usually experience more hormone fluctuations than men
In women, progesterone secretion at the time of ovulation raises body temp.
by about 0.3 degree C to 0.6 degree C above basal temp.
5. Stress
Stimulation of sympathetic NS can increase production of epinephrine and
norepinephrine thereby increasing metabolic activity and heat production
6. Environment

Extremes in environmental temp. can affect a persons temp. regulatory

systems

Alterations in Body temp

Pyrexia / Hyperthermia
A body temp. above the usual range
Fever in lay terms
Hyperpyrexia
A very high fever
Febrile
Pt who has a fever
Afebrile
One who does not have fever
Common types of fever :
Intermittent fever
Body temp. alternates at regular intervals bet. periods of fever and periods
of normal or subnormal temp
Ex : Malaria
Remittent fever
A wide range of temp. fluctuations (more than 2 degree C) occurs over the
24-hour period , all of w/c are above normal
Ex : Cold, Influenza
Relapsing fever
Short febrile periods of a few days are interspersed w/ periods of 1 or 2
days of normal temp.
Constant fever
Body temp. fluctuates minimally but always remains above normal
Ex : Typhoid fever
Fever spike
A temp. that rises to fever level rapidly following a normal temp. and then
returns to normal within a few hours
Bacterial blood infections often cause this
In some conditions , an elevated temp. is not a true fever :
Heat exhaustion

Result of excessive heat and dehydration

Signs :
o
Paleness
o
Fainting
o
Dizziness
o
Moderately increased temp.
o
N/V
Heat stroke

Persons experiencing this generally have been exercising in hot weather

, have warm ,flushed skin and often do not sweat

Temp. of 106 degree F or higher

Person may be delirious , unconscious or having seizures

Clinical manifestations of fever :

Occur as a result of changes in the set point of the temp. control

mechanism regulated by the hypothalamus

In fever , set point of the hypothalamic thermostat changes suddenly
from the normal level to a higher than normal value as a result of the
effects of :
o
Tissue destruction
o
Pyrogenic substances
o
Dehydration on the hypothalamus

I. Onset (Cold or Chill phase)

Although set point changes rapidly , the core body temp. that is the blood
temperature reaches this new set point only after several hours
At this time, bodys physiologic processes are attempting to raise the core
temp to the new set point temp.
During the interval , the usual heat production responses that cause
elevation of the body temp occur :
o
Increased heart rate
o
Complaints of feeling cold
o
Increased respiratory rate and depth
o
Cyanotic nail beds
o
Shivering
o
Gooseflesh appearance of the skin
o
Pallid, cold skin
o
Cessation of sweating
Nursing measures :
o
Help client decrease heat loss
II. Course (Plateau phase)
When the core temp. reaches the new set point
Person feels neither cold nor hot and no longer experiences chills
o
Absence of chills
o
Increased pulse and rr
o
Herpetic lesions of the mouth
o
Skin that feels warm
o
Increased thirst
o
Loss of appetite (if fever is prolonged)
o
Photosensitivity
o
Mild to severe dehydration
o
Malaise, weakness, and aching muscles
o
Glassy-eyed appearance
o
Drowsiness, restlessness, delirium, or convulsions
Very high temp. such as 41 degree C to 42 degree C can lead to :
o
Damage the parenchyma cells of cells throughout the body ,
particularly in brain where destruction of neuronal cells is
irreversible
o
Damage to the liver, kidneys and other body organs
o
Death
III. Defervescence (fever abatement/ flush phase)
When the cause of high temp. is suddenly removed , the set point of
hypothalamic thermostat is suddenly reduced to a lower value
Hypothalamus now attempts to lower the temp.
The usual heat loss responses occur :
o
Sudden vasodilation
o
Skin that appears flushed and feels warm
o
Sweating
o
Decreased shivering
o
Possible dehydration
Nursing measures :
o
Increase heat loss
o
Decrease heat production
Nursing interventions for clients with fever :
Monitor v/s
Ask skin color and temp.
Monitor WBC count, hematocrit value , etc. for indications of infection or
dehydration

 Remove excess blankets when client feels warm but provide extra warmth
when the client feels chilled
Provide adequate nutrition and fluids to meet the increased metabolic
demands and prevent dehydration
Measure I and O
Reduce physical activity to limit heat production , esp. during the flush stage
Administer antipyretics as ordered
Provide oral hygiene to keep the mucous membranes moist
Provide TSB to increase heat loss through conduction
Provide dry clothing and bed linens

Hypothermia

A core body temp. below the lower limit of normal

3 Physiologic mechanisms of hypothermia :

o
Excessive heat loss
o
Inadequate heat production to counteract heat loss
o
Impaired hypothalamic thermoregulation

Induced hypothermia
o
Lowering of the body temp. to decrease the need of oxygen
by the body tissues such as during certain surgeries

Accidental hypothermia
o
Exposure to cold environment
o
Immersion in cold water
o
Lack of adequate clothing , shelter or heat

In elders hypothermia can be compounded by a decreased BMR and

use of sedatives
Frostbite
o
If skin and underlying tissues are damaged by freezing cold
o
Most commonly occurs in hands, feet, nose and ears

Clinical manifestations of hypothermia :

Decreased body temp, pulse, and respirations

Frostbite (nose, fingers, toes)

Disorientation

Severe shivering (initially)

Hypotension

Drowsiness progressing to coma

Feelings of cold and chills

Decrease urinary output

Pale, cool, waxy skin

Lack of muscle coordination

Nursing interventions for clients with hypothermia :

Provide a warm environment

Keep limbs close to body

Apply warming pads

Provide dry clothing

Cover the clients scalp w/ a cap

Apply warm blankets

Supply warm oral or intravenous fluids

I. Oral
Nurse should wait 30 min. if client has been taking cold or hot food or fluids
or smoking to ensure that temp. of mouth is not affected by the temp.
of the food or warm smoke.
Advantages :
Accessible and convenient
Disadvantages :
Can break if bitten
Inaccurate if pt has just ingested hot or cold flood, etc.
Could injure the mouth following oral surgery
II. Rectal
Considered to be very accurate
Contraindicated for clients who are undergoing :
o
Rectal surgery
o
Immunosuppression
o
Diarrhea
o
Clotting disorder
o
Disease of the rectum
o
Hemorrhoids
Advantages :
Reliable measurement
Disadvantages :
Inconvenient
Could injure the rectum ff rectal surgery
More unpleasant for pt
Presence of stool may interfere w/ thermometer placement
Difficult for pt who cannot turn to the side
III. Axilla
Preferred site for measuring temp. in newborns because it is accessible and
safe
Advantages :
Safe and noninvasive
Disadvantages :
Thermometer must be left in place a long time to obtain an accurate
measurement
IV. Tympanic membrane
Nearby tissue in the ear canal
Frequent site for estimating core body temp.
Has an abundant arterial blood supply , primarily from the branches of
external carotid artery
Advantages :
Readily accessible
Reflects the core temp.
Very fast
Disadvantages :
Can be uncomfortable
Involves risk of injuring the membrane if the probe is inserted too far
Repeated measurements may vary
R and L measurements can differ
Presence of cerumen can affect the reading

Assessing Body temperature

From Fahrenheit to Celsius :
C = ( F 32 ) x 5/9
From Celsius to Fahrenheit :
F = ( C x 9/5 ) + 32

V. Temporal artery
Using a chemical thermometer or a temporal artery thermometer
Most useful for infants and children
Advantages :
Safe and noninvasive
Very fast
Disadvantages :
Requires electronic equipment that may be expensive or unavailable
Variation in technique needed if the pt has perspiration on the forehead

Lifespan considerations
Infants

The body temp. of newborns is extremely labile, and newborns

must be kept warm and dry to prevent hypothermia
Using the Axillary site, you need to hold the infants arm against
the chest
The Axillary route may not be as accurate as other routes for
detecting fevers in children
Tympanic route is fast and convenient . Place the infant supine
and stabilize the head . Pull the pinna straight back and slightly
downward . Direct the probe tip anteriorly and insert far enough
to seal the canal . The tip will not touch the tympanic membrane
Avoid tympanic route in a child w/ active ear infections or
tympanic drainage tubes
Tympanic membrane route may be more accurate in determining
temp. in febrile infants
When using a temporal artery thermometer , touching only the
forehead or behind the ear is needed
The rectal route is least desirable in infants

Children

Tympanic or temporal artery sites are preferred

For the tympanic route, have the child held on an adults lap w/
the childs head held gently against the adult for support . Pull
the pinna straight back and upward for children over age 3

Avoid the tympanic route in a child w/ active ear infections or

tympanic membrane drainage tubes

The oral route may be used in children over age 3 , but

nonbreakable , electronic thermometers are recommended

For a rectal temperature , place the child prone across your lap
or in a side lying position w/ the knees flexed. Insert
thermometer 1 inch from the rectum
Pinna back and up children over 3 years of age
Pinna back and down children under 3 years of age
Elders

Temp. tend to be lower than those of middle-aged adults

Temp. are strongly influenced by both environmental and internal
temperature changes
Their thermoregulation control processes are not as efficient as
when they are younger , and they are at higher risk for both
hypothermia and hyperthermia
Can develop significant build up of ear cerumen that may
interfere w/ tympanic thermometer readings
More likely to have hemorrhoids . Inspect the anus before taking
a rectal temp.
Temp. may not be a valid indication of the seriousness of the
pathology of disease

Pulse

Wave of blood created by contraction of the left ventricle of the

heart
Represents the Stroke volume output , the amount of blood that

enters the arteries w/ each ventricular contraction

Reflects the heart beat that is, it is the same as the rate of
ventricular contractions of the heart

Compliance

Ability of the arteries to contract and expand

When a persons arteries lose their distensibility , greater pressure is

required to pump the blood into the arteries

Apical

Cardiac Output

Volume of blood pumped into the arteries by the heart

Equals the result of SV x HR per min.

About 5L of blood each min. heart pumps when an adult is resting

At the apex of the heart

Heartbeat is normally loudest over the apex of the heart

S1 (lub)
Occurs when AV valves close after the ventricles have been
sufficiently filled
S2 (dub)
When the SV valves close after the ventricles empty

Peripheral pulse

Located away from the heart

Apical pulse

Central pulse

Located at the apex of the heart

Also referred to as the point of maximal impulse (PMI)

Factors affecting pulse

Age

As age increases, the pulse rate gradually decreases overall

Gender

After puberty, average males pulse rate is slightly lower than the females

Exercise

Pulse rate normally increases w/ activity

Fever

Pulse rate increases :

Brachial
o
In response to the lowered BP that results from peripheral vasodilation
associated w/ elevated body temp.
o
Because of the increased BMR

At the inner aspect of the biceps muscle of the arm or medi

in the antecubital space

Radial
Cardiotonics (e.g digitalis preparations) decrease the heart rate
Epinephrine increases heart rate

Where the radial artery runs along the radial bone on the
thumb side of the inner aspect of the wrist

Femoral
Loss of blood from the vascular system normally increases pulse rate

Where the femoral artery passes along the inguinal ligament

Where the popliteal artery passes behind the knee

On the medial surface of the ankle

Where the posterior tibial artery passes behind the medial
malleolus

Medications

Hypovolemia

Stress

Position changes

Pathology

Sympathetic nervous stimulation increases the overall activity of the heart

Fear , Anxiety , and as well as Perception of severe pain stimulate
the sympathetic
Popliteal
system

When a person is sitting or standing , blood usually pools in dependent

vessels
Posterior
tibialof the
venous system
Pooling results in transient decrease in the venous blood return to the heart and
subsequent reduction in BP and increase in HR

Pedal (dorsalis pedis)

Certain diseases such as heart condition or those that impair oxygenation can alter the
resting pulse rate

Where the dorsalis pedis artery passes over the bones of th

foot , on an imaginary line drawn from the middle of the a
to the space bet. the big and second toes

Pulse Sites
Variations in Pulse and Resp by Age
Temporal

Carotid

Where the temporal artery passes over the temporal bone

of the head
Age
Superior and lateral to the eye
Newborn
At the side of the neck where the carotid artery runs bet. the
1 year
trachea and sternocleidomastoid muscle
Never press both carotids at the same time because this can
5-8 years
cause a reflex drop in BP or PR

Pulse Average
(and ranges)
130 (80-180)

Respirations
average (and
ranges)
35 (30-80)

120 (80-140)

30 (20-40)

100 (75-120)

20 (15-25)

10 years

70 (50-90)

19 (15-25)

Teen

75 (50-90)

18 (15-20)

Adult

80 (60-100)

16 (12-20)

Older Adult

70 (60-100)

16 (15-20)

Assessing pulse

Pulse is commonly assessed by palpation and auscultation

The middle three fingertips are used for palpating all pulse sites

except the apex of the heart

A stethoscope is used for assessing apical pulses
A Doppler Ultrasound stethoscope (DUS) is used for pulses that are

Arterial wall elasticity

Reflects expansibility or its deformities

Healthy normal artery
Feels straight, smooth , soft and pliable

Presence or absence of Nurse should also assess the corresponding pulse on the oth
the bilateral equality

difficult to assess , it detects movement of RBC through a blood

vessel
Pulse is normally palpated by applying moderate pressure w/ the 3
middle fingers of the hand
o
W/ Excessive pressure one can obliterate a pulse
o
W/ Too little pressure one may not be able to detect it

Before assessing , nurse should be aware of the ff :

Any medication that could affect the heart rate

Whether the client has been physically active . If so, wait 10 to 15

min. until the client has rested and pulse slowed to its usual rate

Any baseline data about the normal heart rate for the pt

4. Whether the client should assume a particular position . In some pt,

the rate changes w/ the position because of the changes in blood flow
volume and autonomic NS activity

Lifespan considerations
Infants

When assessing , nurse collects the ff data :

Rate

Tachycardia
Excessively fast heart rate
Over 100 BPM
Bradycardia
Less than 60 BPM

Children

Apical pulse should be assessed if client has either of these two

Rhythm

Pattern of the beats and intervals bet. the beats

Normal pulse
Has equal time periods bet. beats

Volume

Use the apical pulse for the heart rate of newborns , infants, and
children 2 to 3 years old
Place a baby in supine position , and offer pacifier if the baby is
crying or restless . Crying and physical activity will increase the
pulse rate
Locate the apical pulse in the 4th ICS , lateral to the MCL during
infancy
Brachial, popliteal, and femoral pulses may be palpated . Due to
normally low BP and rapid heart rate , infants other distal pulses
may hard to feel
May have heart murmurs that are not pathological but reflect
functional incomplete closure of fetal heart structures

To take peripheral pulse , position the child comfortably . This

may decrease anxiety
To assess apical pulse, assist a young child to a comfortable
supine or sitting position
Demonstrate the procedure to the child using a stuffed animal or
doll and allow the child to handle the stethoscope before
beginning the procedure . This will decrease anxiety and promote
cooperation
Apex of the heart is normally located in 4th ICS in young
children , 5th ICS in children 7 years and over
Locate the apical impulse along the 4th ICS , between the MCL and
anterior Axillary line
Count the pulse prior to other uncomfortable procedures so that
rate is not artificially elevated by discomfort

Dysrhythmia/ Arrhythmia
Pulse w/ an irregular rhythm
Elders
May consist of random , irregular beats or a predictable pattern of irregular
beats
If the pt
has severe hand or arm tremors , the radial pulse may
(regularly irregular)
be difficult to count
When detected , apical pulse should be assessed

Cardiac changes in elders, such as decrease in CO, sclerotic

ECG is necessary to define this further
changes to heart valves , and dysrhythmias often indicate that
obtaining an apical pulse will be more accurate

Often have decreased peripheral circulation , so pedal pulses

Also called the pulse strength or amplitude
should also be checked for regularity , volume and symmetry
Force of blood w/ each beat

Pulse returns to baseline after exercise more slowly than w/

Usually same w/ each beat
other age groups
Can range from absent to bounding

Normal pulse
Can be felt w/ moderate pressure of the fingers
Can be obliterated w/ greater pressure
Pressure is equal w/ each beat
Full /bounding pulse
A forceful or full blood volume that is obliterated only w/ difficulty
Weak, feeble, or thready
A pulse that is readily obliterated w/ the pressure from the fingers

Respirations
Respiration

Act of breathing
Inhalation / Inspiration

Intake of air into the lungs

Exhalation / Expiration

Breathing out or the movement of gases from the lungs to the

atmosphere
Ventilation

Movement of air in and out of the lungs

Types
Costal (thoracic) breathing
Involves external intercostal muscles and other accessory muscles such as
the sternocleidomastoid muscles
Can be observed by the movement of the chest upward and outward
Diaphragmatic breathing
Involves contraction and relaxation of the diaphragm
Can be observed by the movement of abdomen

Mechanics and Regulation of Breathing

During inhalation

Diaphragm contracts , ribs move upward and outward , sternum moves

outward thus enlarging the thorax , permitting lungs to expand
During exhalation

Diaphragm relaxes , ribs move downward and inward , sternum moves

inward thus decreasing the size of the thorax as the lungs are
compressed
Respiration is controlled by :

Respiratory centers in medulla oblongata and pons of brain

Chemoreceptors located centrally in medulla and peripherally in

carotid and aortic bodies

These centers respond to changes in concentrations of : (in the
arterial blood)
o
Oxygen
o
CO2
o
Hydrogen

Factors affecting Respirations

Increase :

Exercise Increase metabolism

Stress Readies the body for fight or flight
Increased environmental temperature

 Lowered O2 concentration at increased altitudes

Breathing sounds
Decrease :
Decreased environmental temp.
Certain medications (e.g narcotics [morphine] and
barbiturates [secobarbital sodium] )
Increased ICP

Audible w/o
Amplification

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

Respiratory depth
Gen. described as normal, deep, or shallow

Deep respiration

A large volume of air is inhaled and exhaled, inflating

most of the lungs

Shallow
respiration

Involve exchange of a small volume of air and often

the minimal use of lung tissue

Tidal volume

During normal inspiration and expiration , an adult

takes in about 500 mL of air

Supine position

Experience 2 physiologic processes that suppress

respiration :
o
Increase in the volume of blood inside the
thoracic cavity
o
Compression of the chest
Person have poorer lung aeration w/c predisposes
them to the stasis of fluid and subsequent
infection

Hyperventilation

Very deep , rapid respirations

Stridor A shrill, harsh sound heard during

inspiration w/ laryngeal obstruction

Bubbling Gurgling sounds heard as air passes

through moist secretions in the respiratory tract
Chest
Movements

Intercostal retraction Indrawing bet. the ribs

Substernal retraction Indrawing beneath the
breastbone
Suprasternal retraction Indrawing above the
clavicles

Secretions and
Coughing

Hemoptysis Presence of blood in the sputum

Productive cough Accompanied by expectorated
secretions
Nonproductive cough Dry, harsh cough w/o
secretions

Breathing Patterns

Rate

Eupnea Normal in rate

Tachypnea/ Polypnea Quick, shallow breaths

Hypoventilation

Very shallow respirations

Resp. rhythm

Regularity of expirations and inspirations

Can be described as regular or irregular
Normally, respirations are evenly spaced
An infants respiratory rhythm may be less regular

Bradypnea Abnormally slow breathing

Apnea Cessation of breathing

Volume

Hyperventilation Overexpansion of the lungs characteri

than an adults

Hypoventilation Underexpansion of the lungs , characte

Resp. quality or
character

Aspects of breathing that are different from normal,

effortless breathing
2 of these aspects : amount of effort a client must
exert to breathe and sound of breathing
Usually breathing does not require noticeable effort
Sometimes clients can breathe only with substantial

Rhythm
( Regularity of the
expirations and
inspirations )

effort (labored breathing)

Assessing Respirations
Exercise and Anxiety

Affect respiration, increasing their rate and depth

Respirations may also need to be assessed after exercise to identify

the pts tolerance to activity
Before assessing, nurse should be aware of the ff :

Clients normal breathing pattern

The influence of the clients health problems on respirations
Any medications or therapies that might affect respirations
The relationship of the clients respirations to cardiovascular function

Normal Evenly spaced

Regular
Irregular
Cheyne-Stokes breathing Rhythmic waxing and waning
to very shallow breathing and temporary apnea

Ease or effort

Dsypnea - Difficult and labored breathing during w/ the p

unsatisfied need for air and feels distressed

Orthopnea Ability to breathe only in upright sitting or s

Blood Pressure

Lifespan considerations
Infants

Children

Elders

Arterial blood pressure

Measure of the pressure exerted by the blood as it flows through the

Infant or child who is crying will have an abnormal respiratory

rate and rhythm and needs to be quieted before respirations can
be accurately assessed
They use their diaphragms for inhalation and exhalation . If
necessary , place your hand gently on the infants abdomen to feel
the rapid rise and fall during respirations
Most are complete nose breathers and nasal obstruction can be
life-threatening
Some display periodic breathing in w/c they pause for a few sec.
bet. respirations . This condition can be normal , but parents
should be alert to prolonged (apnea) or frequent pauses that
require medical attention
Have fewer alveoli and their airways have a smaller diameter . As
a result, their RR and effort of breathing will increase w/
respiratory infections
Because they are diaphragmatic breathers , observe the rise and
fall of the abdomen
Count respirations prior to the other uncomfortable procedures
so that RR is not artificially elevated by the discomfort

Ask the client remain quite , or count respirations after taking

the pulse
Experience anatomic and physiologic changes that cause the
respiratory system to be less efficient
Any changes in rate or type of breathing should be reported
immediately

arteries
Measured in millimeters of mercury (mm Hg)
Can vary considerably among individuals
It is important for nurse to know a specific pts baseline BP

Blood Pressure measures :

Systolic pressure

Result of contraction of the ventricles , that is the pressure of the

height of the blood wave
Diastolic pressure

Pressure when the ventricles are at rest

Lower pressure , present at all times within the arteries

Pulse pressure :
Difference bet. the diastolic and systolic pressure
Normal is about 40 mm Hg
A consistently elevated pulse pressure occurs in arteriosclerosis
Low pulse pressure occurs in conditions such as severe heart failure

Determinants

Pumping Action
of the heart

When the pumping action of the heart is weak, less

blood is pumped into arteries (lower CO) and the BP
decreases

Peripheral
Vascular
Resistance

The resistance supplied by blood vessels through w/c the

blood flows
Can increase the BP
Diastolic pressure esp. is affected
Some factors that create resistance in the arterial
system :
o
Capacity of the arterioles and capillaries
o
Compliance of arteries
o
Viscosity of blood
The smaller the space within a vessel , the greater the
resistance
Increased vasoconstriction such as occurs w/ smoking
raises the BP
If elastic and muscular tissues of the arteries are
replaced w/ fibrous tissue , arteries lose much of their
ability to constrict and dilate , this is most common in
middle-aged and elders (arteriosclerosis)

Blood Volume

Blood Viscosity

When the blood volume decreases , BP decreases because

of decreased fluid in the arteries
BP is higher when the blood is highly viscous (thick) that
is when the proportion of RBC to the blood plasma is
high (hematocrit)
Viscosity increases markedly when the hematocrit is
more than 60 % to 65 %

Factors affecting BP

Lack of physical exercise

Obesity
High blood cholesterol levels
Heavy alcohol consumption
Continued exposure to stress

Primary hypertension
Elevated BP of unknown cause
Age

Newborns have a mean systolic pressure of about 75 mm Hg

Secondary hypertension
Pressure rises w/ age

Exercise

Stress

Race

Gender

Elevated BP of known cause

Physical activity increases CO

Hypotension
20 to 30 min. of rest following exercise is indicated before the resting
BP can be
reliably assessed
BP that is below normal
It is important to monitor pt carefully to prevent falls
Factors associated :
Stimulation of the sympathetic NS increases CO and vasoconstriction
o andAnalgesics (meperidine HCL [Demerol] )
Severe pain can decrease BP greatly by inhibiting the vasomotor center
o
Bleeding
producing vasodilation
o
Severe burns
o
Dehydration
Orthostatic hypotension
African American males over 35 years have higher BP
BP that falls when the client sits or stands
Usually the result of peripheral vasodilatation in w/c blood leaves the
After puberty , females usually have lower BP than males of the same age
central
due body
to organs esp. the brain and moves to the periphery often
hormonal variations
causing the person to feel faint
After menopause , women generally have higher BP than before

Assessing BP
Medications

May meds including caffeine may increase or decrease BP

BP is measured with :
Blood pressure cuff consists of a rubber bag that can be inflated w/ air
called bladder
Obesity
Both childhood and adult obesity predispose to hypertension
One tube connects to a rubber bulb that inflates the bladder
A small valve on the side of the bulb traps and releases the air in the
bladder
Diurnal variations Pressure is lowest early in the morning , when the metabolic rate is lowest
Other tube is attached to a sphygmomanometer w/c indicates pressure of
Pressure rises throughout the day and peaks in the late afternoon or early in the
the air within the bladder
evening
Doppler Ultrasound stethoscopes are also used when BP sounds are difficult
to hear such as in infants, obese clients, and clients in shock
Disease process

Any condition affecting CO, blood volume, blood viscosity and/or compliance
of sphygmomanometer :
2 Types of
arteries has a direct effect on BP
Aneroid sphygmomanometer
A calibrated dial w/ a needle that points to the calibrations

Classification of BP

Category

Systolic BP mm Hg

Digital (electronic) sphygmomanometer

Eliminate the need to listen for the sounds of the pts systolic and diastolic
BP through a stethoscope
Diastolic BP
mm Hg
BP sites

Normal

<120

< 80

Prehypertension

120-139

80-89

Hypertension , stage 1

140-159

90-99

Hypertension , stage 2

> 160

>100

Hypertension
BP that is persistently above normal
Diagnosed as an elevated BP w/c is measured twice at diff times
Factors associated :
o
Thickening of the arterial walls w/c reduces the size of the
arterial lumen
o
Inelasticity of the arteries
o
Lifestyle factors :
Cigarette smoking

Assessing the BP on pts thigh is indicated in these situations :

o
o

BP cannot be measured on either arm (e.g because of burns or other trauma

BP on one thigh is to be compared w/ the BP in the other thigh

BP is not measured on a pts limb in the ff situations :

o
o
o
o
o

Shoulder, arm or hand is injured or diseased

A cast or bulky bandage is on any part of the limb
Pt has had surgical removal of the axilla or hip lymph nodes on that side
Pt has an IV in that limb
Pt has an arteriovenous fistula (e.g for renal dialysis) in that limb

Methods

Direct (invasive Involves insertion of a catheter into the brachial, radial, or femoral artery
monitoring)
Arterial pressure is represented as wavelike forms displayed on a monitor
With correct placement, this pressure reading is highly accurate

Common Errors in Assessing BP

Indirect
methods :

1 . Auscultatory method
Most commonly used in hospitals, clinics, and homes
Error
Required equipment is a sphygmomanometer , a cuff and a stethoscope

Bladder cuff too narrow

2. Palpatory method
Sometimes used when :
o
Korotkoffs sounds cannot be heard
Bladder cuff too wide
o
Electronic equipment to amplify the sounds is not available
o
To prevent misdirection from the presence of an auscultatory gap
Instead of listening for the blood flow sounds , nurse uses light to moderate
Arm unsupported
pressure to palpate pulsations of the artery as the pressure in the cuff is
released
The pressure is read from the sphygmomanometer when the first pulsation is felt
Insufficient rest before the
assessment
Auscultatory gap
Occurs particularly in hypertensive clients
Temporary disappearance of sounds normally heard over the brachial artery when
Repeating assessment too quickly
the cuff pressure is high followed by the reappearance of the sounds at a lower
level
Occurs in the latter part of phase 1 and phase 2
May cover a range of 40 mm Hg
Cuff wrapped too loosely or
unevenly

Korotkoffs sound
Deflating cuff too quickly

When taking a BP using a stethoscope , nurse identifies phases in the series of sounds

First the nurse pumps the cuff up to about 30 mm Hg above the point where the pulse is

no longer felt that is point when the blood flow in the artery is stopped
Then the pressure is released slowly (2 to 3 mm Hg per sec. )
Deflating cuff too slowly
Nurse observes the readings on the manometer and relates them to the sounds heard

through stethoscope
Five phases occur but may not always audible

Phase 1

Failure to use the same arm

consistently

The pressure level at w/c the first faint , clear tapping or thumping sounds are
heard
Arm above level of the heart
These sounds gradually become more intense
To ensure that they are not extraneous sounds, the nurse should identify at least 2
consecutive tapping sounds
Assessing immediately after a meal
The first tapping sound heard during deflation of cuff is the systolic BP
or while pt smokes or has pain

Phase 2

Period during deflation when the sounds have a muffled, whooshing, or swishing quality
Failure to identify auscultatory gap

Phase 3

Period during w/c the blood flows freely through an increasingly open artery
Sounds become crisper and more intense
Assume a thumping quality but softer than in phase 1

Phase 4

Sounds become muffled and have a soft, blowing quality

Phase 5

Pressure level when the last sound is heard

Followed by period of silence
Pressure at w/c the last sound is the diastolic BP in adults

Effect
Erroneously high

Erroneously low

Erroneously high

Erroneously high

Erroneously high systolic or low diastolic

readings

Erroneously high

Erroneously low systolic and high diastolic

readings

Erroneously high diastolic readings

Inconsistent measurements

Erroneously low

Erroneously high

Erroneously low systolic pressure and

Erroneously low diastolic pressure