Babitha's Note on vital signs

VITAL SIGNS
Mrs. Babitha K Devu
Assistant Professor
SMVDCoN

Learning Objectives
After completing this chapter, you should be able to:
Define & Identify factors that affect body temperature.
Enumerate the physiology of body temperature
Demonstrate temperature conversions between
Fahrenheit (F) and Celsius (C).
Describe how to select the proper method to measure
body temperature.
Compare different types of thermometers.

Learning Objectives
After completing this chapter, you should be able to:
Describe characteristics of pulse rate.
List average pulse rates according to age.
Identify the pulse site locations on the human body.
Describe characteristics of respirations.
List average respiratory rates according to age.
List average blood pressure readings according to
age.

Introduction
A healthy human body is able to self-regulate
through homeostasis, which is the body’s
natural ability to maintain a stable internal
environment by correcting abnormal conditions
and balancing bodily processes. Vital signs
are indicators of the body’s ability to maintain
homeostasis.

Introduction
Temperature (T), pulse (P), respiration (R), and blood
pressure (BP) measurements are considered vital
signs because they measure some of the body’s vital
functions and provide necessary information about
the patient’s physical well - being. Thus, vital signs
must be obtained and calculated with the utmost care
and accuracy.
Recently, many agencies have designated pain as a
fifth vital sign.

What are Vital Signs?
Temperature
Pulse
Respirations
Blood Pressure
Oxygen Saturation
Pain (considered the 6th vital sign)

When to measure vital signs?
On admission to health care facility
In a hospital on regular hosp schedule or as
ordered (q8hours, q4 hours, etc)
Before and after procedures (surgery, invasive
diagnostic procedures, medications)
Before, during, and after blood transfusions
When patient’s general condition changes
(nursing judgment)

Guidelines For Taking Vital Signs
Taken by nurse giving care
Equipment should be in good condition
Know baseline VS and normal range for pt and
age group
Know pt’s medical history
Minimize environmental factors
Be organized in approach
Increase frequency of VS as condition worsens
Compare VS readings with the whole picture
Record accurately
Describe any abnormal VS

Body Temperature
Difference between heat produced by body
processes and the heat lost to the external
environment.
Heat produced – Heat lost = Body temperature
The warmth of the human body.
Shell Temperature ~ warmth at skin surface (Ex.
Temperature of armpit or axilla)
Core Temperature ~ warmth in deep tissues within
the body (Ex. Pulmonary artery, more reliable
indicator of body temperature)

Physiology of Body Temperature
Body temperature is regulated by balancing the
amount of heat the body produces with the
amount of heat the body loses. Body heat is
produced as a by-product of metabolism, which
is the sum of all biochemical and physiological
processes that take place in the body. The
hypothalamus, a gland located in the brain, acts
as a thermoregulator. It is able to adjust body
temperature that results in either increasing or
decreasing heat production throughout the day.

The anterior Hypothalamus promotes heat
loss through vasodilatation and sweating
The posterior Hypothalamus promotes:
– Heat conservation by vasoconstriction
– Heat production
And maintains the core temperature

Consider this jogger:
While jogging on a hot day, the jogger’s body temperature will
increase due to the sun and increased physical activity. Sensing the
rise in body temperature, the hypothalamus will send signals to
sweat glands to produce sweat. As the sweat evaporates, it cools
the jogger by removing some of the excessive heat
being produced.

Heat can be lost from the body by the following
processes:
Radiation — Transfer of heat between two
objects without physical contact; 65 percent
of the body’s heat is released this way
Convection — Dispersion/ transfer of heat
away from the body by air currents; 10–15
percent of heat is released through this method

Heat can be lost from the body by the following
processes:
Conduction —Transfer of heat from one
object to another with direct contact (e.g.,
when a patient with high fever is given sponge
with cool water)
Evaporation — Transfer of heat energy when
a liquid is changed to gas (breathing) and
sweating.

Heat Conservation
– Adjusting where blood circulates by vasoconstriction
– Causing piloerection (goose bumps or flesh)
– Promoting a muscle shivering response
Heat Production (thermogenesis)
– Increasing metabolism ~ thyroid hormone
– Releasing epinephrine and norepineprine

Factors Affecting Body
Temperature
Time
of
Day/C
ircadi
an
Rhyth
m
Body temperature is lower in the morning upon waking,
when metabolism is still slow. The body’s temperature is
lowest between 2:00 a.m. and 6:00 a.m., and the body’s
highest temperature usually occurs in the evening
between 5:00 p.m. and 8:00 p.m. Daily variation in
normal temperature can range from 97.6°F to 99.6°F
(36.4°C to 37.3°C).
Age
Infants and children normally have a higher body
temperature than adults because of immature heat
regulation. Children often tend to spike a fever late in the
day. Older adults usually have lower-than-normal body
temperature.

Temperature
Gender
Women may experience a slight increase in body
temperature at the time of ovulation.
Physical
Exercise
Body temperature will rise during exercise as a
result of increased muscle contraction and increased
blood flow caused by heightened cardiovascular
activity.
Emotions
Emotions such as crying and anger can cause an
increase in body temperature.
Pregnancy
An increase in metabolism during pregnancy may
cause the body temperature to rise.

Temperature
Environm
ental
Changes
Hot weather can cause serious consequences for
older adults whose bodies are less able to regulate
body temperature because of decreased metabolic
functioning. Exposure to excessively cold
temperatures will lower body temperature. Cool
environments that may feel fine to a younger adult
can cause hypothermia in an older person.
Infections
An elevated temperature may be one of the first
signs of an infection. A fever is the body’s way of
fighting or killing off infectious organisms.

Temperature
Drugs
Drugs may increase muscular activity or metabolism,
which in turn increases temperature. Antipyretic
(fever-reducing) drugs such as aspirin lower the
above-normal temperature.
Food
The process of eating and digestion may cause a
rise in the body temperature. Fasting decreases
metabolism, which will lower body temperature.

Assessment of Body Temperature
Temperature: Normal Values and Terms
Body temperature is recorded in either degrees
Fahrenheit (F) or degrees Celsius (C). The average
body temperature of a healthy person is 98.6°F (37°C).
However, there may be a 1- to 2-degree Fahrenheit
fluctuation (increase or decrease) throughout the day.
Slight variance in body temperature is normal, but it is
important to keep in mind that greater changes from
normal body temperature may be the first signs of
illness.

Temperature: Normal Values and Terms

Fahrenheit and Celsius Conversions
The Fahrenheit (F) scale of temperature measurement
is widely used throughout the United States.
However, some physicians, hospitals, and medical
facilities use the Celsius (or centigrade) (C) scale
especially in countries where metric system is
followed like India.

Fahrenheit and Celsius Conversions

Sites:
Body temperature can be measured in a variety of
ways: oral (mouth); aural (ear) or tympanic
membrane (eardrum); axillary (under the arm);
rectal (rectum); and temporal artery (forehead).
Oral and rectal temperatures measure the body’s
core temperature and are considered the most
accurate. Tympanic membrane, axillary, and
temporal artery temperatures are more variable but
are acceptable for tracking significant changes.

Method Advisable Inadvisable
Oral
(“O”)
Most adults and
children who are
able to
follow instructions
for properly holding
the thermometer.
Patients who have had oral
surgery, mouth sores,
dyspnea; uncooperative
patients; patients on
oxygen; infants and small
children; patients with
facial paralysis or nasal
obstruction; anyone unable
to form an airtight seal around
the thermometer.

Rectal
(“R”)
Infants and small
children; patients
who
have had oral
surgery; mouth-
breathing
patients;
unconscious
patients.
Active children; fragile
newborns; patients with
heart conditions (it can
stimulate the vagus nerve
leading to arrhythmias); those
with recent rectal
surgery or complaints of
diarrhea.

Axillary
(“AX”)
Small children Patients who have underarm
rash, excessive
perspiration, or cannot form
an airtight seal around
the thermometer.
Tympanic
(Aural)
(“T”)
Small children Patient with in-the-ear hearing
aids, impacted
cerumen, earaches, or ear
infections.

Temporal
Artery
(“TA ”)
Most adults, infants,
and small children;
patients who have had
oral surgery;
mouth-breathing
patients; unconscious
patients.
No restrictions—possibly
difficult with combative
children or newborns.

Sites: Normal Values
SITE NORMAL RANGE
ORAL 98.6 ° 97.6 ° TO 99.6 °
RECTAL 99.6 ° 98.6 ° TO 100.6 °
AXILLARY 97.6 ° 96.6 ° TO 98.6 °
TYMPANIC 98.6 ° 98.6 °
TEMPORAL 98.6° 98.6°

Sites:
– Oral:
The oral method of temperature measurement is most
commonly used. Some facilities do not require the
designation “O” when documenting this
measurement, whereas others do. When taking
oral temperature, insert the thermometer under the
tongue on either side of the frenulum linguae,
which is the longitudinal fold of mucous membrane
connecting the tongue to the bottom of the mouth.

Sites:
– Oral:
The potential for error with this method is that the
patient may not form a tight enough closure around
the thermometer, which allows air to enter the
mouth and produce a false temperature reading.
Ask if the patient either smoked or drank fluids
before the appointment. If so, you must wait 15
minutes before obtaining an oral temperature.

Sites:
– Aural (Ear)/Tympanic Membrane :
This method uses the tympanic membrane (the
eardrum) for temperature measurement. The aural
method is sometimes preferred over the oral method
because the space in the external auditory canal is a
more tightly closed cavity than the mouth. Another
benefit of this method of measurement is that it does
not come in contact with saliva or mucus, which helps
prevent the spread of infection.

Sites:
– Axillary :
The axillary (under the arm) method has proven to be
the least accurate of the temperature measurement
sites. However, it is the recommended site for small
children or for patients unable to properly hold an
oral thermometer in their mouths.

Sites:
– Rectal:
A rectal body temperature reading is considered to be
the most accurate and reliable method. This is
because the mucous membrane lining the rectum
does not come into contact with air, as it does with
the oral and axillary methods, which could interfere
with accuracy.

Sites:
– Temporal:
Temporal artery measurement is a newer, noninvasive
method of obtaining body temperature. The temporal
artery is located close to the skin surface on the
forehead and temple area. The temporal thermometer
uses an infrared scanning device that detects the
temperature of the blood. Similar to the tympanic
membrane thermometer, it is a fast and fairly accurate
method of obtaining body temperature.

TYPES OF THERMOMETERS:
There are many types of thermometers available
for measuring body temperature. However, in
2002, the American Hospital Association (AHA)
agreed to eliminate mercury from the health care
environment because of the frequency of
breakage and the potential danger of mercury.
Mercury is toxic and can be harmful to both
humans and animals.

ELECTRONIC THERMOMETERS
The electronic thermometer can be used for oral, rectal,
and axillary body temperature readings. The metal
probes are color coded: blue for both oral and axillary,
and red for rectal. The probe is attached to the battery
unit by a flexible cord. A nonflexible, plastic disposable
probe cover fits over the metal probe to provide each
patient with a new and sanitary thermometer.
Electronic thermometers are time saving but expensive.
They are either battery operated or plugged in and
charged.

DIGITAL THERMOMETERS
They are the most commonly used and are accurate,
easy to read, sanitary, and fast. They require very
minimal cleaning and disinfection. They are battery
operated. It contain a probe connected to a
microprocessor chip, which translates signals into
degrees and sends a temperature measurement to a
digital display.
Can be used for oral, rectal, and axillary
measurements.

INFRARED THERMOMETERS
Tympanic Membrane
Thermometer
Temporal Artery
Thermometer

In these type of thermometers an infra red handle
scanner is used to scan the area. After scanning is
complete, a reading appears on the display unit.
Tympanic thermometers are usually small hand-held
devices with a probe that is inserted into the patient’s
ear canal, i.e. tympanic membrane. The sensor at the
end of the probe records the infrared radiation (IRR)
that is emitted by the membrane converts this into a
temperature. The probe is protected by a disposable
cover, which is changed between patients.

The temporal artery thermometer measures blood
flow through the superficial temporal artery. For this
you can sweep an infrared scanner across the
forehead or just behind the ear. After scanning the
reading appears on the screen.
Tympanic and temporal artery temperatures are
considered reliable non-invasive measures of core
temperature.

CHEMICAL DOT THERMOMETERS
A chemical disposable thermometer uses liquid dots,
that change color to indicate body temperature.
When using these unique thermometer devices, hold
the thermometer in place for about 15 seconds and
read the strip by noting the highest reading among
the selection of dots that have changed color.

Heat – Sensitive Skin Tape Thermometer

SKIN TAPE THERMOMETERS
A heat-sensitive bars, or patches applied to the
forehead that change color to indicate body
temperature. After 15 seconds, read the correct
temperature by reading the color changes.
Both the chemical disposable thermometer and the
heat-sensitive wearable thermometer are excellent
methods when dealing with small children or with
large numbers of patients who need to be evaluated
in rapid succession.

MERCURY THERMOMETERS
This is a glass tube with mercury inside of the tube.
The tube goes underneath the tongue/axilla or
rectum and the body temperature will cause the
mercury to rise inside the tube. The point where the
mercury stops will be what your temperature is

Parts of Clinical Thermometer
Constriction
Mercury Column
Scale

Temperature Alterations
Fever or Pyrexia:
Febrile:
Afebrile:
Hyperthermia:
Hypothermia:
Heatstroke:

Fever or Pyrexia: Fever or pyrexia is a body
temperature above 100.4°F (38°C). When the body is
in a feverish state, it is producing more heat than it is
losing.
Febrile vs Afebrile: A condition caused by fever is
termed febrile; a condition not caused by fever is
termed afebrile.
For example, a febrile seizure is a seizure caused by
fever, whereas an afebrile seizure is caused by
something other than a fever, such as a head trauma.

Clinical signs and symptoms of fever
Increased heart rate,
Increased respiratory rate,
Shivering & chills,
Decreased appetite,
Headache,
Facial flushing (redness to the skin), and
Sweating.

Common types of fevers are:
Intermittent fever—Body temperature that alternates
between febrile and afebrile states
Remittent fever—Elevated body temperature that
remains high throughout the day, fluctuating more than 2
degrees Fahrenheit
Relapsing fever—Febrile periods that last for a
couple of days, go away, and then return
Constant (continuous) fever—Elevated body
temperatures throughout the day with minimal
temperature fluctuation (usually not more than 1 degree
Fahrenheit) over a 24-hour period

Hyperthermia:
When the body temperature exceeds 106.7°F (41.5°C), a
serious condition known as hyperpyrexia or hyperthermia
develops. Hyperpyrexia is a very high fever resulting from
a regulated rise in core body temperature, usually a
response to a physiological threat, such as an infection.
Hyperpyrexia may lead to serious complications, such as
seizures in small children. Hyperthermia, by contrast, is an
unregulated rise in core body temperature and is the result
of the body’s inability to thermoregulate. Hyperthermia may
be caused by exposure to high external temperatures,
such as being outdoors on a very hot day.

Hyperthermia:
As body temperature increases, signs and symptoms
of hyperthermia advance in severity. They include
Muscle cramps,
Fatigue,
Loss of coordination,
Drowsiness,
Confusion, convulsions,
The inability to sweat, and possibly death.

Nursing Management of
Hyperthermia:
Assessment:
• Monitor vital signs
• Assess skin colour and temperature
• Monitor basic laboratory parameters for
indication of infection and dehydration.

Hyperthermia:
Intervention:
Provide adequate nutrition and fluids to meet the increased
metabolic demands and prevent dehydration.
Reduce physical activity to limit heat production.
Provide a tepid sponge bath to increase heat loss
Provide dry clothing and bed linens.
Remove excess blankets when the client feels warm, but
provide extra warmth when the client feels chilled.
Monitor intake and output.
Provide oral hygiene to keep the mucous membranes moist.

Hyperthermia:
Intervention:
Administer antibiotics as ordered.
CURRENT TRENDS: Internal cooling techniques -such as ice
water gastric or rectal lavage etc. External cooling techniques
are usually easier to implement, well tolerated and effective.
Conductive cooling techniques include direct application of
hypothermic blanket, ice bath, or ice. Convective techniques
include removal of clothing and use of fans and air
conditioning. Evaporative cooling by removing clothing and
using a fan in conjunction with misting the skin with tepid water
or applying a single layer wet sheet to bare skin.

Hypothermia: Hypothermia is defined as a body
temperature below 95°F (35°C) and is the result
of the body losing more heat than it is producing.
Hypothermia commonly occurs in cases of
environmental exposure to cool or cold
temperatures and/or submersion in cold water. In
general, a body temperature below 92°F (33.3°C)
is considered severe hypothermia and may be life-
threatening.

Hypothermia:
Clinical signs of hypothermia are
lack of muscle coordination;
slurred speech; violent
shivering; decreased pulse
and respirations; pale, waxy,
cool skin; and drowsiness and
dazed consciousness
progressing to coma and
death.

Heatstroke: also known as sun stroke, is a type of
severe heat illness that results in a body
temperature greater than 40.0 °C (104.0 °F) and
confusion. It is caused by failure of the body's
temperature-regulating mechanism when exposed to
excessively high temperatures.

Hot and Cold Applications
Heat and cold are applied to a part or all of the
patient’s body to bring about a local or systematic
change in body’s temperature for various therapeutic
purposes.
Heat/cold application in the nursing interventions
classification, a nursing intervention defined as
stimulation of the skin and underlying tissues
with heat or cold for the purpose of decreasing pain,
muscle spasms, or inflammation.

Hot Applications
Physiological
Responses
• Promotes vasodilatation
• Decreases blood
viscosity
• Increases tissue
metabolism
• Increases capillary
permeability
• Reduces muscle tension
Therapeutic Benefits
• Promotes circulation to an injured
area; promotes healing
• Aids in removing debris from
infected wound
• Relieves muscle spasm and
reduces pain
• Overcomes feelings of chilliness
and raises body temperature
• Decrease venous congestion and
increase absorption of fluid there
by reduce edema.

Cold Applications
Physiological
Responses
• Promotes
vasoconstriction
• Increases blood viscosity
• Decreases tissue
metabolism
• Has an anaesthetics
effect
• Decreases muscle
tension
Therapeutic Benefits
• Decreases circulation to
an injured area; thereby
decrease inflammation and
edema
• Prevents bleeding at site of
injury
• Reduce tissue O2 consumption
• Overcomes feelings of chilliness
and raises body temperature
• Decreases pain by raising the
threshold of pain receptors

Factors affecting Tolerance to Heat and Cold
BODY PART
SIZE OF THE EXPOSED BODY PART
INDIVIDUAL TOLERANCE
LENGTH OF EXPOSURE
INTACTNESS OF SKIN
AGE

Methods:
I. Dry II. Moist
1. Hot Water Bottles Compresses
2. Aquathermia Pad Packs
3.Hot & Cold Packs Soaks
4. Heat Cradle / heat Lamp Sitz bath
5. Ice Bag/collar Sponge Bath
6. Hypo/hyperthermia blankets

Temperature for hot and cold applications
Description Temperature Application
Very Cold Below 15 C Ice bag
Cold 15 -18 C Cold packs
Cool 18 -27 C Cold Compresses
Tepid 27 -37 C Alcohol sponge bath
Warm 37 -40 C Warm Bath
Hot 40 -46 C Hot soak, hot Compresses
Very Hot Above 46 C Hot water bag for Adult

Precautions in the use of heat and cold applications
1.Neurosensory impairment:
2.Impaired mental status: Clients who are confused or
unconscious need to be monitored and assessed frequently
to ensure safety.
3.Impaired circulation: Clients with cardiovascular and
peripheral vascular problems or diabetes
4.Skin and tissue integrity (open wounds, broken skin, scar
formation, edema): Subcutaneous tissues are more sensitive
to temperature variations than are superficial tissues. (e.g.,
cold can decrease blood flow to an open wound, thereby
inhibiting healing).

PULSE
Definitions:
Pulse rate is the number of times the heart beats per
minute (bpm). During the cardiac cycle, the pulse is
the wave of blood that courses through the body
when the left ventricle contracts. After contraction, the
heart rests as the cardiac muscle relaxes and the
ventricle is filling with blood again. Each pulse beat
represents one complete cardiac cycle or one
heartbeat: contraction and relaxation.

PULSE
Definitions:
A wavelike sensation that can be palpated in a
peripheral artery.
In a healthy adult, a normal per-minute resting heart
rate ranges from 60 to 100 beats a minute.
A resting pulse rate above 100 bpm is considered to
be a rapid pulse rate, or tachycardia, and a rate
below 60 bpm is considered to be a slow pulse
rate, or bradycardia.

PULSE
Average Pulse Rates by Age
Less than 1 year 120–160 bpm
2–6 years 80–120 bpm
7–10 years 80–100 bpm
11–16 years 70–90 bpm
Adult 60–80 bpm
Older adult 50–65 bpm

PULSE
Physiology and regulation:
The pulse is an alternate expansion and recoil of an
artery as the wave of blood is forced through it by the
contraction of the left ventricle.
The blood travels through the four heart chambers. One
of these chambers, the right atrium, contains the sinus
node, which acts as the pacemaker for the heart. The
body's nervous system, neurotransmitters and
hormones regulate the sinus node and play a huge
role in how the body regulates heart rate or pulse.

PULSE
Characteristics of the Pulse:
The following characteristics need to be taken into
consideration when taking pulse rates and are often
noted in the patient’s record:
Rate of pulse:- It is stated as number of pulses per
minute. Count the pulses for not less than half minute.
Volume, or force, refers to the strength of the pulse
when the heart contracts. Volume is influenced by the
forcefulness of the heartbeat, the condition of the
arterial walls, and hydration or dehydration.

PULSE
A variance in intensity of the pulse may indicate heart
disease. The most common volume characteristics
are:
• A full or bounding pulse, indicating an increase in
blood volume.
• A weak or thready pulse, indicating a barely
perceptible force or blood volume.

PULSE
Rhythm refers to the regularity, or equal spacing, of
all the beats of the pulse. Normally, the intervals
between each heartbeat are of the same duration. A
pulse with an irregular rhythm is known as a
dysrhythmia or arrhythmia. An intermittent pulse
occurs when the heart occasionally skips a beat. This
is not considered abnormal if it does not happen
frequently.

PULSE
Factors affecting Pulse Rate:
The pulse rate is influenced by numerous factors
including exercise, age, gender, body size, physical
conditions, disease states, medications, and
emotional states, such as depression, fear, anxiety,
and anger.

PULSE
Exercise
Activity increases pulse rate. Rate may increase 20–
30 bpm, based on the intensity of activity.
Age As age increases, pulse rate decreases. Infants and
children have a faster pulse rate than adults.
Gender Female pulse rate is about 10 bpm higher than a male
of the same age.
Size Pulse rate is proportionate to the size of the body.
Heat loss is greater in a small body, resulting in the
heart pumping faster to compensate. Larger males
have slower pulse rates than smaller males. During
sleep and rest, the pulse rate drops.

PULSE
Physical
Condition
Athletes and people in good physical condition
have lower pulse rates as a result of a more
efficient circulatory system.
Disease
Conditions
Pulse rate is increased in certain disease
conditions such as thyroid disease, fever, and
shock because of increased metabolism.
Medications Many medications can either raise or lower the
pulse rate. Medications such as digoxin are given
to regulate the heartbeat. Caffeine and nicotine can
increase the heart rate in certain people. Drugs
such as cocaine, increase the pulse rate.

PULSE
Depression May lower the pulse rate.
Fear,
Anxiety,
Anger
May raise the pulse rate.
Position
changes.
Pooling results in a graduate decrease in the
venous blood return to the heart and a subsequent
reduction in blood pressure and increase in heart
rate.

PULSE
Assessment of Pulse: Site
There are nine areas in the body that allow for
easy measurement of the pulse. These pulse
sites are at the temporal, carotid, apical,
femoral, brachial, radial, popliteal, posterior
tibial, and dorsalis pedis arteries.

PULSE
Assessment of Pulse: Location
Location of Common Pulse Sites
Site Location
Radial Thumb side of wrist about 1 inch below base of thumb
(most frequently used site)
Brachial Inner (antecubital fossa/space) aspect of the elbow
(pulse heard when taking BP)
Carotid At side of neck between larynx and
sternocleidomastoid muscle (pulse used in CPR)
Temporal At side of head just above the ear

PULSE
Location of Common Pulse Sites
Site Location
Femoral In groin where femoral artery passes to leg
Popliteal Behind the knee; pulse located deeply behind the
knee and felt when knee is slightly bent
Posterior Tibial On medial surface of ankle near ankle bone
Dorsalis Pedis On top of foot slightly lateral to midline; helps
assess adequate blood circulation to the foot
Apical At apex of heart; left of sternum, 4th or 5th
intercostal space below the nipple

PULSE
(A) Brachial pulse; (B) Radial pulse

PULSE
(C) Carotid pulse; (D) Femoral pulse

PULSE
(E) Popliteal pulse; (F) Posterior tibial pulse; (G) Dorsalis
pedis pulse.

PULSE
Assessment of Pulse: Equipments
A pulse is commonly assessed by palpation (feeling) or
auscultation (hearing). The common equipment
needed are:
• Documentation Record
• Pen
• Watch with second hand
• Stethoscope
• Alcohol wipe/cotton balls with 70 percent isopropyl alcohol
• A Doppler ultrasound stethoscope (DUS) is used for pulses
that are difficult to assess.
• Pulse-oximeter

Different types of pulse oximeter

PULSE
Assessment of Pulse: Techniques
Feel over BONY area
DO NOT use thumb
Use 2-3 fingers
DO NOT squeeze
Count 30 seconds if regular x 2
Note Rate, Rhythm, Quality
If irregular, count for 1 full minute or take apical
pulse for 1 minute.

PULSE
Assessment of Pulse: Equipments and Techniques
Measuring Radial Pulse
Equipment and Supplies:
Paper and pen; patient’s medical record; watch with
second hand
Techniques:
1. Perform hand hygiene.
2. Greet and identify the patient. & Explain the procedure.
3. Ask if the patient has recently smoked or performed
physical activity. Both of these factors can cause the
pulse rate to increase.

PULSE
4. Ask the patient to sit down and place the arm in a
comfortable, supported position. The hand should be at
or below chest level with the palm facing up.
5. Place fingertips on the radial artery on the thumb side
of the wrist.
a. Apply enough pressure to feel the pulse. Use
caution in pressing too hard because this may collapse
the artery and interrupt the pulse.

PULSE
6. Check the characteristics of the pulse.
7. Start counting pulse beats when the second hand on
the watch is at 3, 6, 9, or 12.
8. Count the pulse for 1 full minute (60 seconds) or for 30
seconds, which is then multiplied by 2.
10. Record the pulse beats per minute in the patient’s
medical record, describing any characteristics or
abnormalities in pulse rate.

PULSE
Measuring Apical–Radial Pulse (Two Person)
Equipment and Supplies
Stethoscope; alcohol wipe/cotton balls with 70 percent
isopropyl alcohol; paper and pen; patient’s medical
record; watch with second hand
Method
2. Disinfect the stethoscope using an alcohol wipe to
cleanse the earpieces and diaphragm of scope.

PULSE
3. Greet and identify the patient.
4. Explain the procedure. If the patient is a child, explain
the procedure to both the parent and child.
5. Uncover the left side of the patient’s chest. Provide
privacy with a drape, if necessary.
6. The first person will place the earpieces of the
stethoscope in her ears, with openings of the ear tips
pointing forward.

PULSE
7. Locate the apex of the patient’s heart by palpating to
the left fifth intercostal space (between the fifth and
sixth ribs) at the midclavicular line, just below the
nipple.
8. Warm the chest piece by holding it in the palm of the
hand before placing onto patient’s chest.
9. The second person will locate the radial pulse in the
thumb side of the wrist, 1 inch below the base of the
thumb.

The person locates the apical pulse. The second person
locates the radial pulse

PULSE
10. The first person places the chest piece of the
stethoscope at the apex of the heart. When the
heartbeat is heard, a nod is made to indicate to the
second person that counting should begin. The count
should begin when the second hand is at 3, 6, 9, or 12.
11. Count for 1 full minute (60 seconds), and nod to the
second person when time is up and counting should
cease.

PULSE
Note: Both systole and diastole (or “lub/dub”) counts as one beat.
12. Remove the stethoscope and earpieces.
13. Record the rate and quality of the heartbeats. Include
both apical and radial rates using the designation “AP”
and “R,” respectively. Calculate the pulse deficit by
subtracting the radial pulse rate from the apical pulse
rate.

PULSE
Alterations:
Bradycardia is a slower than normal heart rate. The
hearts of adults at rest usually beat between 60 and
100 times a minute. If you have bradycardia, your
heart beats fewer than 60 times a minute.
Bradycardia can be a serious problem if the heart
doesn't pump enough oxygen-rich blood to the body.
For some people, however, bradycardia doesn't
cause symptoms or complications.
An implanted pacemaker can correct bradycardia and
help your heart maintain an appropriate rate.

PULSE
Alterations:
Tachycardia is a common type of heart rhythm
disorder (arrhythmia) in which the heart beats faster
than normal while at rest. Tachycardia occurs when
an abnormality in the heart produces rapid electrical
signals that quicken the heart rate, which is normally
about 60 to 100 beats a minute at rest.
In some cases, tachycardia may cause no symptoms
or complications.

PULSE
Alterations:
Tachycardia But if left untreated, tachycardia can
disrupt normal heart function and lead to serious
complications, including:
– Heart failure
– Stroke
– Sudden cardiac arrest or death
Treatments, such as drugs, medical procedures or
surgery, may help control a rapid heartbeat or
manage other conditions contributing to tachycardia.

PULSEAlterations:
Tachycardia
Types of tachycardia
– Atrial fibrillation. Atrial fibrillation is a rapid heart rate
caused by chaotic, irregular electrical impulses in the
upper chambers of the heart (atria).
– Atrial flutter. In atrial flutter, the heart's atria beat very fast
but at a regular rate. The fast rate results in weak
contractions of the atria.
– Supraventricular tachycardia (SVT). Supraventricular
tachycardia is an abnormally fast heartbeat that originates
somewhere above the ventricles.

PULSE
Alterations:
Tachycardia
Types of tachycardia
– Ventricular tachycardia. Ventricular tachycardia is a
rapid heart rate that originates with abnormal electrical
signals in the lower chambers of the heart (ventricles).
– Ventricular fibrillation. Ventricular fibrillation occurs when
rapid, chaotic electrical impulses cause the ventricles to
quiver ineffectively instead of pumping necessary blood to
the body.

RESPIRATION
Respiration, or the act of breathing, is the process of
inhaling oxygen into the body and exhaling carbon
dioxide. One respiration, also called the respiratory
cycle, consists of one expiration (exhalation) and one
inspiration (inhalation).
Respiratory rate is an indicator of how well oxygen is
being provided to the tissues of the body. Respirations
are counted by watching, listening, or feeling the
movement of inspiration and expiration on the
patient’s back, stomach, or chest. A stethoscope also
may be used to assist with counting respirations.

RESPIRATION
Mechanics of breathing
When we inhale the intercostal muscles (between the
ribs) and diaphragm contract to expand the chest
cavity. The diaphragm flattens and moves downwards
and the intercostal muscles move the rib cage
upwards and out. This increase in size decreases the
internal air pressure and so air from the outside (at a
now higher pressure that inside the thorax) rushes
into the lungs to equalise the pressures.

RESPIRATION
When we exhale the diaphragm and intercostal muscles relax
and return to their resting positions. This reduces the size of
the thoracic cavity, thereby increasing the pressure and forcing
air out of the lungs.

RESPIRATION

RESPIRATION
Mechanism the body uses to exchange gases between
the atmosphere, blood, and the cells. Involves three
processes:
– Ventilation
– Diffusion
– Perfusion

RESPIRATIONPhysiology:
The rate at which we inhale and exhale is controlled by
the respiratory centre, within the Medulla Oblongata in
the brain. Inspiration occurs due to increased firing of
inspiratory nerves and so the increased recruitment
of motor units within the intercostals and diaphragm.
Exhalation occurs due to a sudden stop in impulses
along the inspiratory nerves.
Our lungs are prevented from excess inspiration due
to stretch receptors within the bronchi and bronchioles
which send impulses to the Medulla Oblongata when
stimulated.

RESPIRATION
Physiology:
Breathing rate is all controlled by chemoreceptors within
the main arteries which monitor the levels of O2 and
CO2 within the blood. If oxygen saturation falls,
ventilation accelerates to increase the volume of O2
inspired.
If levels of Carbon Dioxide increase, a substance known
as carbonic acid is released into the blood which
causes (H+) ions to be formed. An increased
concentration of H+ in the blood stimulates increased
ventilation rates.

RESPIRATION
Regulation of breathing
Respiration is controlled by the autonomic nervous
system, which enables us to alter our breathing
without thinking about it. The autonomic nervous
system consists of two branches, the sympathetic
nervous system (the pedals) and the parasympathetic
nervous system (the breaks).
Our respiration is coordinated by the respiratory centre
in the medulla oblongata of the brain.

RESPIRATION
Characteristics of the respiration:
When the respiration rate is taken, several
characteristics should be noted:
• Rate,
• Rhythm,
• Depth, and
• The quality or characteristics of breathing.

RESPIRATION
Respiratory Rate: It is the number of respirations per
minute. The normal respiration rate for healthy adults
at rest is 12 to 20 cycles per minute. Children have a
more rapid rate of breathing than adults.
Respiratory Rate Ranges of Various Age Groups
Newborn 30–50
1–2 years old 20–30
12–Adult 12–20

RESPIRATION
Respiratory Rhythm: It refers to the regular and equal
spacing of breaths. In a regular respiratory rhythm,
the cycles of inspiration and expiration have about the
same rate and depth. With irregular breathing
patterns, the depth and amount of air inhaled and
exhaled and the rate of respirations per minute will
vary.

RESPIRATION
Respiratory Depth: The depth of respiration is the
volume of air that is inhaled and exhaled. It is
described as either “shallow” or “deep.” Rapid but
shallow respirations occur in some disease
conditions, such as high fever, shock, and severe
pain. Hyperventilation refers to deep and rapid
respirations, and hypoventilation refers to shallow and
slow respirations.

RESPIRATION
Respiratory Quality: Respiratory quality or character
refers to breathing patterns — both normal and
abnormal. Labored breathing refers to respirations
that require greater effort from the patient.
Breath Sounds: Normal respirations do not usually
have any noticeable sounds. However, certain
diseases and illnesses can cause irregular respiration
sounds. Terms for describing these abnormal breath
sounds include the following:

RESPIRATION
Breath Sounds:
– Stridor— A shrill, harsh sound, heard more clearly
during inspiration but that can occur during
expiration. This sound may occur when there is
airway blockage, such as in children with croup and
patients with laryngeal obstruction.
– Stertor (stertorous breathing)— Noisy sounds
during inspiration, sounds similar to those heard in
snoring.

RESPIRATION
Breath Sounds:
– Crackles (also called rales) — Crackling sounds
resembling crushing tissue paper, caused by fluid
accumulation in the airways.
– Rhonchi — Rattling, whistling, low-pitched sounds made
in the throat. Rhonchi can be heard in patients with
pneumonia, chronic bronchitis, cystic fibrosis, or COPD.
– Wheezes — Sounds similar to rhonchi but more
highpitched, made when airways become obstructed or
severely narrowed, as in asthma or COPD.

RESPIRATION
Breath Sounds:
– Cheyne-Stokes breathing — Irregular breathing
that may be slow and shallow at first, then faster
and deeper, and that may stop for a few seconds
before beginning the pattern again. This type of
breathing may be seen in certain patients with
traumatic brain injury, strokes, and brain tumours.

RESPIRATION
Factors affecting respiration:
Many factors may affect the respiratory rate: elevated
temperature, age, pain, medications, and some
medical conditions.
Situations Causing Changes in Respiratory Rate
Increased Rate Decreased Rate
Allergic reactions Certain drugs (e.g.,
morphine)
Certain drugs (e.g., epinephrine) Decrease of CO2 in blood
Disease (e.g., asthma, heart disease,
fever, haemorrhage)
Disease (stroke, coma)

RESPIRATION
Factors affecting respiration:
Situations Causing Changes in Respiratory Rate
Increased Rate Decreased Rate
Exercise
Excitement/anger/ Nervousness
High altitudes
Obstruction of air passage
Pain
Shock

RESPIRATION
Assessment of respirations:
Equipment and Supplies
Patient’s medical record; watch with sweeping second
hand; paper and pen.
METHOD
2. Greet and identify the patient.
3. Assist the patient into a comfortable position.
4. Place your hand on the patient’s wrist in position to
take the pulse, or place your hand on the patient’s
chest or back

RESPIRATION
Assessment of respirations:
METHOD
5. Count each breathing cycle by observing or feeling
the rise and fall of the chest, back, or upper abdomen.
6. Count for 1 full minute (60 seconds) using a watch
with a second hand. If the rate is atypical or unusual
in any way, count respirations again for another
minute.
7. Record the respiratory.

RESPIRATION
Alterations in respiration:
Abnormal Breathing Patterns
Apnea: Absence of breathing.
Eupnea: Normal breathing
Orthopnea: Only able to breathe comfortable in upright
position (such as sitting in chair), unable to breath laying
down.
Dyspnea: Subjective sensation related by patient as to
breathing difficulty. Paroxysmal nocturnal dyspnea - attacks of
severe shortness of breath that wakes a person from sleep

RESPIRATION
Hyperpnea: Increased depth of breathing
Hyperventilation: Increased rate or depth, or
combination of both.
Hypoventilation: Decreased rate or depth, or some
combination of both.
Tachypnea: Increased frequency without blood gas
abnormality

RESPIRATION
Kussmaul's Respiration: is a deep and
labored breathing pattern often associated with
severe metabolic acidosis, particularly diabetic
ketoacidosis (DKA) but also kidney failure.
Bradypnea: is a respiratory rate that is lower than
normal for age.

BLOOD PRESSURE
Blood pressure (BP) is one of the most important vital
signs because it aids in diagnosis and treatment,
especially for cardiovascular health. Blood pressure
readings are almost always taken at every medical
visit, even if it is the only vital sign obtained.
Definition:
Blood pressure is the amount of force exerted on the
arterial walls while the heart is pumping blood—
specifically, when the ventricles contract.

BLOOD PRESSURE
TYPES
Blood pressure is measured by gauging the force of this
pressure through two specific readings:
Systolic and Diastolic.
• Systolic blood pressure is the highest pressure that
occurs as the left ventricle of the heart is contracting.
• Diastolic blood pressure is the lowest pressure level
that occurs when the heart is relaxed and the ventricle
is at rest and refilling with blood.

BLOOD PRESSURE
While blood pressure is read in millimeters (mm) of
mercury (Hg), or “mmHg”.
Blood pressure is recorded using just the systolic
(highest pressure) reading over the diastolic (lowest
pressure), similar to writing a fraction.
For example, 120/80 would indicate a systolic pressure
of 120 (mmHg) and a diastolic reading of 80 (mmHg).

BLOOD PRESSURE
Pulse pressure is the difference between the systolic
and diastolic readings and calculated by subtracting
the diastolic reading from the systolic reading.
If the blood pressure is 120/80, the pulse pressure is 40.
In general, a pulse pressure that is greater than 40
mmHg is considered widened, and one that is less
than 30 mmHg is considered to be narrowed.
A widened pulse pressure may be an indicator for
cardiovascular disease and anemia.

BLOOD PRESSURE
Pulse pressure
A narrowed pulse pressure may be an indicator for
congestive heart failure (CHF), stroke, or shock.
Although pulse pressure is useful in predicting
cardiovascular risk in patients, it should not be used
alone and depends on various other factors, such as
the patient’s BP and age.

BLOOD PRESSURE
Physiology and Regulation:
There are two basic mechanisms for regulating blood
pressure:
(1) short-term mechanisms, which regulate blood vessel
diameter, heart rate and contractility
(2) long-term mechanisms, which regulate blood volume

BLOOD PRESSURE
Physiology and Regulation:
(2) long-term mechanisms, which regulate blood volume
Kidneys regulate arterial blood pressure by
• Direct renal mechanism
• Indirect renal (renin-angiotensin-aldosterone)
mechanism

BLOOD PRESSURE
Blood Pressure Guidelines
Blood Pressure
Category
Systolic (mmHg) Diastolic (mmHg)
Normal less than 120 less than 80
Prehypertension 120–139 80–89
Hypertension 140–179 90–109
Hypertensive
Crisis
(Emergency)
Higher than 180 Higher than 110

BLOOD PRESSURE
Blood Pressure Guidelines
Average Normal Blood Pressure Readings
Newborn 75/55
6–9 years of age 90/55
10–15 years of age 100/65
16 years to adulthood 118/76
Adult 119/78

BLOOD PRESSURE
Factors affecting blood pressure.
Many physiological factors may affect blood pressure,
including
Volume or amount of blood in the arteries,
Peripheral resistance of the vessels,
Condition of the heart muscle, and
Elasticity of vessels.

BLOOD PRESSURE
In addition, other factors may affect blood pressure,
especially
Gender and Age. Women generally have a lower
blood pressure than men. Blood pressure is lowest at
birth and tends to increase as people age.
The time of day can also cause blood pressure
variations. For example, blood pressure is usually at
its lowest early in the morning and just before waking.

BLOOD PRESSURE
Activities such as standing, sitting, or lying down can
affect blood pressure.
Additionally, the blood pressure reading in the right
arm is usually 3 to 4 mmHg higher than in the left arm,
so it is often required to document which arm was
used for the blood pressure reading.
Numerous other situations that can affect blood
pressure readings are listed in Table.

BLOOD PRESSURE
Causes of Blood Pressure Variations:
Elevated/Increased BP Lowered/Decreased BP
Anger, Certain drug
therapies, nicotine, caffeine,
Endocrine disorders
(hyperthyroidism), Exercise,
Fear, excitement, Heart and
liver disease, Increased
arterial BP, Late pregnancy
Anemia, Approaching
death, Cancer, Certain drug
therapies
(antihypertensives,
narcotics, analgesics,
diuretics), Decreased
arterial blood volume
(hemorrhage)

BLOOD PRESSURE
Causes of Blood Pressure Variations:
Elevated/Increased BP
Lowered/Decreased
BP
Lying down position with legs
elevated, Obesity, Pain, Renal
disease, Rigidity of blood vessels,
Smoking, Stress, anxiety, Taking
pressure at the right arm,
Vasoconstriction or narrowing of
peripheral blood vessels
Dehydration, Shock,
Starvation, Sudden
postural changes,
Weak heart, Time of
day (during sleep and
early morning)

BLOOD PRESSURE
Assessment of blood pressure: sites
Direct (invasive) blood pressure monitoring is
recommended in sick and compromised patients,
those who are at risk of developing major blood loss
during surgery or for whom abnormal blood gases
are anticipated (patients with respiratory disease or
undergoing thoracotomies).

BLOOD PRESSURE
Direct (invasive) blood pressure monitoring:

BLOOD PRESSURE
Indirect (Non-invasive) blood pressure monitoring
– Auscultatory
– Palpatory

BLOOD PRESSURE

BLOOD PRESSURE
Assessment of blood pressure:
Equipments
Two pieces of equipment are
necessary for measuring blood
pressure: a sphygmomanometer
and a stethoscope.
• The sphygmomanometer, is the
instrument used for measuring the
pressure that the blood exerts
against the walls of the artery.

BLOOD PRESSURE
Assessment of blood
pressure: Equipments
• The stethoscope is a
diagnostic instrument that
amplifies sound. It is used to
detect sounds produced by
blood pressure, as well as the
heart and other internal
organs such as the stomach.

BLOOD PRESSURE
Assessment of blood pressure: Equipments
Stethoscope :

BLOOD PRESSURE
Sphygmomanometer: The components of a
sphygmomanometer are a manometer, inflatable
rubber bladder, cuff, and bulb. The manometer is a
scale that registers the actual pressure reading. The
core of the blood pressure cuff is the rubber bladder,
which is inflated and temporarily constricts blood
circulation in the arm. The pressure bulb has a
thumbscrew attached to a control valve that allows for
inflation and deflation of the cuff.

BLOOD PRESSURE
Sphygmomanometer: Using the correct-size blood
pressure cuff is critical and will ensure a more accurate
blood pressure reading. A cuff that is too large may
result in a lower reading, and a cuff that is too small
may result in a higher reading. Three sizes are
available: a small cuff for a child (blood pressure cuffs
are not generally used on infants) or a frail or small-
limbed adult; a normal adult size; and a large size for
measuring blood pressure on the leg (thigh) or on the
arm of a large or obese adult.

BLOOD PRESSURE
Sphygmomanometer:
Types of sphygmomanometers:
• Mercury,
• Aneroid, and
• Electronic.

BLOOD PRESSURE
Assessment of blood pressure:
Equipments
Sphygmomanometer:
Mercury Sphygmomanometer: The
mercury sphygmomanometer is not
as widely used. They contain a
column of mercury that rises as the
pressure bulb is squeezed and the
rubber bladder inflated.

BLOOD PRESSURE
Sphygmomanometer:
• Aneroid Sphygmomanometer. The aneroid
sphygmomanometer has a round dial that contains a
scale calibrated in millimeters (mm). A needle is
attached to the scale to register the reading. The
needle must be at zero before starting the procedure.
The aneroid sphygmomanometer should be
recalibrated for accuracy every year.

BLOOD PRESSURE
Assessment of blood
pressure: Equipments
Sphygmomanometer:
Electronic
Sphygmomanometer. The
electronic version provides a
digital readout on a lighted
display. It is easy to use and
does not require a stethoscope.

BLOOD PRESSURE
Measuring Blood Pressure:
Equipment and Supplies: Sphygmomanometer;
stethoscope; 70 percent isopropyl alcohol; alcohol
sponges or cotton balls; paper and pen; patient’s
medical record.
Method
2. Assemble the equipment.
3. Try to ensure that the patient is relaxed before
obtaining a blood pressure reading

BLOOD PRESSURE
Method
4. Greet & Explain the procedure.
5. Ask the patient if he has a history of hypertension and
if the patient is aware of his normal blood pressure
reading.

BLOOD PRESSURE
Method
6. Assist the patient into a comfortable position. BP may
be taken with the patient in a sitting or supine (lying-
down) position.
a. The patient’s arm should be at heart level. If the
patient’s arm is below heart level, the BP reading may
be higher than normal.
b. Patients should be reminded not to cross their legs or
talk during the procedure.

BLOOD PRESSURE
Method
7. Uncover the patient’s arm 5 inches above the elbow.
If the sleeve becomes constricting when rolled back,
ask the patient to slip the arm out of the sleeve.
a. Never take a BP reading through clothing.
b. Sleeves that are too tight, when rolled up, will
produce an inaccurate result.

BLOOD PRESSURE
Method
8. Locate the brachial artery within the antecubital space
(bend in the elbow) by palpating with your fingertips. If
the pulse is stronger in one arm than the other, use
the arm with the stronger brachial artery pulse.
9. Have the patient straighten the arm with palm up and
apply the proper-size cuff of the sphygmomanometer
over the brachial artery 1 to 2 inches above the
antecubital space

BLOOD PRESSURE
Measuring Blood
Pressure:
Method
a. Hold the edge of the cuff
in place as you wrap the
remainder of the cuff
tightly around the arm.
b. The manometer should be
at eye level for a more
accurate reading.

BLOOD PRESSURE
Method
10. With the fingertips of your nondominant hand,
palpate the pulse in the radial artery. Then, with your
dominant hand, tighten the thumbscrew on the hand
bulb and pump air into the cuff quickly and evenly.
Pump 20–30 mmHg above the point at which the
radial pulse is no longer palpable. Make note of this
point. Rapidly deflate the cuff and wait 60 seconds
before continuing.

BLOOD PRESSURE
Method
11. Place the earpieces in your ears and the diaphragm
(or bell) of the stethoscope over the area of the
pulsating brachial artery.
12. Close the thumbscrew and Pump the cuff to the
point where the radial artery pulse is no longer
palpable.

BLOOD PRESSURE
Method
13. Slowly turn the thumbscrew, allowing the pressure
reading to slowly and evenly fall 2 to 3 mmHg at a
time.
14. Listen for the point at which the first clear “bump”
sound is heard (Phase I). Take note where this
occurred on the manometer. This is the systolic
pressure.

BLOOD PRESSURE
Method
15. Slowly continue to allow the cuff to deflate. The
sounds will change from loud to murmur and then
fade away (Phases I, II, III, and IV). Take note where
no sound or “bump” is heard on the manometer. This
is the diastolic pressure (Phase IV or V).
16. Quickly open the thumbscrew all the way to release
the air and deflate the cuff completely.

BLOOD PRESSURE
Korotkoff Sounds: These are the rhythmic, tapping
sounds heard while taking blood pressure as the
arterial wall distends under the compression of the
cuff. These sounds appear and disappear as the
blood pressure cuff is inflated and deflated.
With the blood pressure cuff placed and inflated on the
brachial artery, no sound can be heard through the
stethoscope because the brachial artery is fully
compressed and no blood is flowing through it.

BLOOD PRESSURE
Korotkoff Sounds:
As the cuff deflates and air is slowly removed from the
cuff, the Korotkoff sounds become audible.
There are five phases of Korotkoff sounds, sometimes
denoted as Phase I–V or KI–V.

BLOOD PRESSURE
Phases of Korotkoff Sounds:

BLOOD PRESSURE
Phases Characteristics
I
This is the first faint sound heard as the cuff is
deflated. The number that appears on the blood
pressure gauge at that moment is recorded as
the systolic pressure reading.
II
The second phase occurs as the cuff continues
to be deflated and more blood flows through the
artery. This sound has a swishing quality.

BLOOD PRESSURE
III
During this phase, the sound will become less
muffled and develop a crisp tapping sound as
the blood flow moves easily through the artery.
If the BP cuff was not inflated enough to hear
the Phase I sound, then the Phase III sound
may be heard and incorrectly stated as the
systolic reading.

BLOOD PRESSURE
IV
This phase is characterized by the sound
beginning to fade and become muffled.
V Sound will disappear during this phase.

BLOOD PRESSURE
Method
17. Remove the cuff from the patient’s arm.
18. Clean the earpieces and diaphragm or bell of the
stethoscope with an alcohol wipe.
20. Document the patient’s BP as a fraction into the
patient’s medical record, making note of which arm
was used and the patient’s position.

BLOOD PRESSURE
Alterations in blood pressure
Benign: Slow-onset elevated blood pressure without
symptoms.
Essential: Primary hypertension of unknown cause. It
may be genetically determined.
Hypertension: A condition in which the patient’s
blood pressure is consistently above the norm for that
patient’s age group.
Hypotension: Condition of abnormally low blood
pressure

BLOOD PRESSURE
Alterations in blood pressure
Malignant: Rapidly developing elevated blood
pressure that may become fatal if not treated
immediately.
Orthostatic (Postural): A temporary fall in blood
pressure caused by a sudden change in body position,
such as a patient moving rapidly from a lying to a
standing position.
Secondary: Elevated blood pressure associated with
other conditions such as renal disease, pregnancy,
arteriosclerosis, and obesity.

SUMMARY
Vital signs are an important objective indication of the
patient’s overall physical condition. The accuracy of
obtaining and recording vital sign measurements is
critical for the diagnosis and treatment of the patient.
Changes in height and weight can be indicators of a
metabolic condition or other diseases that could affect
the body.
Body temperature is regulated by the hypothalamus,
and slight fluctuations in temperature are normal
throughout the day.

SUMMARY
Pulse rate varies based on various factors. Hence one
must be able to accurately measure the rate and
quality of a patient’s pulse.
Respiratory rate is the number of times that a patient
breathes (one complete inhalation and exhalation) in a
minute. Respiration must also be assessed in regard
to quality, specifically the rhythm and depth.
Blood pressure measures the amount of force that is
placed on the arterial walls during ventricular
contraction.

SUMMARY
High blood pressure (or hypertension) is considered
the “silent killer” because it often presents as
asymptomatic in the patient.
Communication skills are essential when obtaining
vital measurements. A positive and empathetic
approach when interacting with patients will put the
patient at ease and may result in obtaining more valid
vital sign measurements.

Babitha's Note on vital signs

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Babitha's Note on vital signs