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PTA 210

PTA Technique

Vital Signs

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Review Last Lecture

Why learn aseptic technique? 3 modes of infection transmission

3 levels of cleanliness

Standard precautions (hand hygiene, PPE,respiratory hygiene,equipment/environment care)

Sterile Field (creating, maintaining,gowning & gloving)

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Why Learn Vital Signs?

1. It is an objective measurement of

physiological function

2. Used to monitor a patients status prior

to or during patient care

3. Vital Signs may indicate physiological

responses to treatment

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Vital Signs

Heart rate

Blood pressure

Respiration rate

Temperature

Pain

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Heart Rate

There are 2 reasons that we measure heartrate

1. to assess a patients cardiovascular

(CV) health and response to PT

treatment

2. to determine patency (the openness of

the peripheral portion of the CV

system)

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Heart Rate

Pulse: a measurement of heart rate

Determining when to measure pulse rateduring a PT session is dependent upon the

patients condition Resting heart rate: measured during rest,

one indication of cardiovascular function

During PT session: measuring CV systemscapacity to provide blood flow during physical

stress After PT session: measuring the CV systems

ability to recover

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Heart Rate & Patency

Patency: the openness of the peripheral portionof the CV system

We measure the presence or absence of a pulseat a chosen site

Chosen sites: Brachial, popliteal, posterior tibial, dorsal pedal, femoral,carotid, radial, apically

Why would a pulse not be there? May indicate arterial occlusion secondary to disease

states (ie diabetes). Edema may be a barrier to finding a peripheral pulse If there is no pulse and you dont have a medical

explanation, it is a red flag. The PT must be notified sothat an appropriate referral can be made.

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Methods for Measuring Pulse

Manual palpation

Use of a stethoscope

Oximeter (not responsible for)

Doppler (not responsible for)

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Manual Palpation

of Pulses

Do not use the pad of the thumb (due topresence of an artery in your thumb)

Use the pads of the index and middlefingers of one hand over the site where

the pulse is to be measured Do not press too hard

Measured in beats per minute (bpm)

must be included in documentation

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Heart Rate Measurement

Use a watch or clock with a second hand

Once a pulse is palpated, count beats within aspecific interval of time

60 seconds (no calculation needed) * most accurate

15 seconds (multiply by 4)

10 seconds (multiply by 6)

Less than 10 seconds = less precise

Using short cuts increases errors Actual = 72 bpm

Miss 1 in 60 second count = 71bpm (1.4% error)

Miss 1 in 10 second count = 66bpm (8.3% error)

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Heart Rate Measurement continued

Start the time period of counting at aspecific time on the watch, and the firstheartbeat felt after the time period has

begun is considered beat 1 Resting Heart Rate

Adult norm 60-100 bpm

Infant/child norm 80-100 bpm

Bradycardia less than 60 bpm

Tachycardia greater than 100 bpm

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Maximal Heart Rate

The highest heart rate a person shouldachieve upon exertion with respect to age.

The following guidelines are based for

patients without cardiovascular pathology

220 patients age = maximal heart rate

Ex. 47 year old: 220-47 = 173 bpm

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Target Heart Rate

The heart rate that an individual shouldachieve during cardiovascular conditioningwith respect to age and medical condition.

For patients without contraindications,target HR must fall between 60% & 80& ofmaximal heart rate

177(0.60) and 177(0.80)

Between 106 bpm & 142 bpm

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Measurement Tools

Stethoscope

An instrument used to transmit soundsproduced by the body to the examiners ears.

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Stethoscope

Components

Ear pieces

For an individuals use,potential for spread of

disease with sharing ofearpieces.

Use alcohol to cleanthe ear pieces

Y Tubing

Should be flexible and

free of cracks

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Stethoscope

Bell/diaphragm

An enlarged metal orplastic attachment onthe distal portion of the

stethoscope to beapplied to the skin ofthe patient

Amplifies the soundsbeing made by thebody underneath it

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Stethoscope

Diaphragm/Bell

active position

Test for sound with a lighttap to make sure that theside down is active

Bell Smaller diameter

For hearing low frequencysounds (heart murmur)

For smaller areas ofcontact

Diaphragm

Larger diameter

Lung sounds, heart sounds

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Blood Pressure

Why do we measure blood pressure? To determine vascular resistance to blood flow

Two values make up blood pressure

Systolic pressure: how much pressure theblood is exerting against the arterial wallswhen the heart is contracting (top #); the firstsound heard during reading

Diastolic pressure: how much pressure the

arterial walls are exerting on blood when theheart is not contracting (bottom #); the lastsound heard during reading

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Method for taking BP

Auscultation of an artery using astethoscope while a sphygmamonometeris applied over the same artery

Reported in mmHg (millimeters ofmercury) b/c it was originally based onthe pressure required to raise a column ofmercury in a glass tube

Sounds you are listening for are calledKorotkoff sounds

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Monitoring Blood Pressure

Location

Most commonly

The brachial artery inthe cubital fossa

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Documentation of BP

A systolic reading of 120 mmHg and adiastolic pressure of 80 mmHg isdocumented as 120/80 mmHg

Verbally reported as 120 over 80 Documentation should include

The body part

The side (left or right)

Patient position

reading

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Contraindications to BP

Do not measure BP

On arm with lymphedema

On arm of ipsilateral side of recent

mastectomy Over open wound

Dialysis shunt

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What can affect BP readings?

Arm side (left is higher)

Patient position

Medications

Disease states

Stress

Physical activity

age

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BP Norms & Red Flags

Norms

Systolic less than 120 mmHg

Diastolic less than 80 mmHg

Red Flags (an indication to stop PT and examinecardiac status) Systolic does not rise with activity

Diastolic increase greater than 20 mmHg during activity

Diastolic decrease greater than 10 mmHg with activity

Resting Systolic greater than 200 mmHg Resting Diastolic greater than 110 mmHg

Norm = 120/80 mmHg

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Sphygmomanometer

PRONUNCIATION

Sphyg sfig

Mo mo

Man man Ometer ah meter

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Measurement Tools

Sphygmomanometer(blood pressure cuff)

An instrument used fordetermining arterial

blood pressureindirectly.

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Sphygmomanometer

Components

Sleeve that contains an air bladder

Pressure gauge

Bulb and valve for adjustment of pressure

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Sphygmomanometer

The Bladder

Located in the sleeve, itshould be positionedover the area to be

occluded Over the brachial

artery in the cubitalfossa

Over the poplitealartery if the UE is

contraindicatedbilaterally

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Sphygmomanometer

The valve

Tightened and loosenedwith the thumb andindex finger

There is a definite openand closed position

Check the operationBEFORE applying thecuff to a patient

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Sphygmomanometer

The Gauge

Either Mercury oraneroid reading mmHgof pressure

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Monitoring Blood Pressure

Procedure

Inspect the cuff forbreaks and the locationof the bladder

Inspect the valve Practice opening and

closing the valve

With one hand

Wrap the cuff around

the UE with the bladderover the brachial artery

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Monitoring Blood Pressure

Palpate the brachialpulse

Check the bell of thestethoscope for the

active position

Place thestethoscopes bell overthe brachial pulse

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Monitoring Blood Pressure

Close the valve & inflatethe cuff until the pulse isnot longer audible

Slightly open the valve,allowing the cuff to slowlydeflate

Watch the gauge

Systolic BP occurs whenthe pulse first becomesaudible

Diastolic BP occurs whenthe last audible pulse isheard

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Monitoring Blood Pressure

Continue to deflatethe cuff

Record the readingsindicating mm HG for

systolic/diastolicpressures

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Blood Pressure

Normal is considered 120/80 mmHg

Abnormal

Hypertension

Systolic consistently greater than 140 mmHg

Diastolic consistently greater than 90 mmHg

Hypotension

Systolic consistently less than 100 mmHg

Diastolic consistently less than 60 mmHg

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Blood Pressure

Systolic Abnormality

Flat response

Decreased systolic pressure

Normal response followed by systolic BP dropat increased workload

Excessive increase

Patients with severe ischemia

Poor ventricular function Inability of the ventricles to increase stroke volume

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Blood Pressure

Diastolic Abnormality

Persistent rise indiastolic pressure

Greater than 15-20

mm Hg May indicate severe

cardiac arterial disease

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Blood Pressure

Orthostatic hypotension

Definition: A fall in blood pressure associated withdizziness, syncope, and blurred vision that appears withsitting or standing up.

Results from: prolonged bed rest

Poor ventricular function

medications

Treatment:

Lie back down if severe Slowly raise the head of the bed

Have patient stay in seated position before standing

Ankle pumps

Wh i id d h i

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What is considered orthostatic

hypotention?

Drop in systolic greater than 20 mmHg

Systolic less than 100 mmHG whilestanding

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Respiration

the act ofbreathing

Inhaling and

exhaling The lungs are provided

with air throughinhaling

Carbon dioxide isremoved through

exhaling

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Respiratory Rate (RR)

Measures the rate of breathing

Each cycle includes one inspiration andthe subsequent exhalation

Methods: Auscultation: listening with stethoscope

Observation: visual, auditory, or palpation

Visual and auditory measurements areunobtrusive and can be made without thepatient knowing, just prior to or after taking apulse

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RR continued

When the patient is breathing too shallowor quietly to easily measure using auditoryor visual observations, then you can either

use a stethoscope to listen, or place yourhand on the patients thorax or use thedorsum of your hand close to but nottouching the mouth/nose to feel the air

flow.

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RR continued

Measured as the number of breathingcycles per minute

Same process as testing heart rate

Count only full cycles (inhalation &exhalation)

Reported without the use of units

Documented as 12 RR (not 12 cycles perminute)

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RR continued

Exhalation is usually longer thaninhalation

Can also document:

Depth of inspiration (shallow, normal) Use of accessory muscles of respiration

Normal resting resp rates:

Adults = 12 RR

Children = 20 RR

Abnormal = less than 10 or greater than 20 RR

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Respiratory Rate

A patient will often alter their rate if theyare aware that they are being monitored.

Be discreet!!!

Observe the following for expansion: Rib cage

Nostrils

Chest

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Respiratory Rate

Influencing Factors

Pulmonary Pathology

Cardiac Pathology

De-conditioning

Pain/anxiety medications

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Measurement Tools

Clock (with a secondhand)

60 seconds is a fairlylong period of time to

count the number ofsomething, yet it is themost accurate amountof time whenirregularities arepresent.

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Temperature

Gives us info regarding (1) potentialpresence of infection and (2) metabolicresponse to exercise

You may not routinely measure temp, butyou need to know the methods and norms

Method = thermometer

Norms = 98.6 F or 36.6 C

Temps fluctuate a few degrees during the day

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Temperature continued

PTs and PTAs frequently measure skintemperature

Skin temperature provides information

concerning: Circulatory status (cold extremity?)

Potential peripheral nerve injury (CRPS)

Local inflammatory responses

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Skin Temperature Method

Use the dorsum of your hand lightly onthe skin, moving it slowly distal toproximal, noting any temp changes

Helpful to do this on both left and right tocompare

Not objective

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Pain

A subjective perception described bypatients

These perceptions are unique to each

individual and may depend on: Previous experience

Type of injury or disease

Body part affected

Age

Time since onset

Ethnic background

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Pain continued

Why document pain levels?

To help the PT determine diagnosis &prognosis

To help determine appropriate interventions To measure the patients response to

interventions

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Pain

Method of Measurement

Visual Analog Scale (VAS) marking their painlevel on a visual line from 0 to 10

We use a common adaptation called the NPS(numeric pain scale), which is to ask patientsto provide a number between 0 and 10 thatrepresents where they rank their currentperception of pain

Children = faces

Body Diagrams

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Effects of Exercise on Vital Signs

During Exercise Long Term

HR Increases & thenplateaus

Decreases by 5-25bpm

BP systolic Increases & thenplateaus

Decreases

BP diastolic Stays the same orslight decrease

Decreases

RR Increases and then

plateaus

Decreases

Temp increases No affect

Pain Dependent onmany factorsgoal?

depends

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Measuring Vitals DuringExercise

How?

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Safety during Emergency Episodes

First make sure patient is in a safeposition and environment

Contact the PT, or nurse, and then PT

depending on setting Continue to assess vital signs, signs and

symptoms

Possibly need to call 911

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Cyanosis

Definition: a dark bluish or purplishcoloration of the skin, nail beds, lips, ormucous membranes due to deficient

oxygenation of the blood

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Responding to edema, pain, dyspnea

Edema Pain Dyspnea

AggravatingActivities

-dependentpositions

-exercise

-Unique toeachpatient

-Intensephysicalexertion

Relieving

Activities

-RICE -Modalities

-Rest-Movement(gentle)

-Rest

-Meds ifasthma

-breathingtechniques

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Documenting Vital Signs

Heart Rate

Ex. Resting HR 78 bpm

Ex. HR after 10 min walk 100 bpm

Blood Pressure Ex. BP a rx 120/80mmHg left upper arm

seated

Ex. BP p rx 130/75mmHg left upper arm

supine

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Documenting Vital Signs

Respiratory Rate

Ex. RR 12 at rest

Temperature

Ex. Left knee displays warmth to the touch in 5inch radius surrounding incision site

Pain

Ex. Left shoulder pain reported at 3/10 prior to

rx.

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Wrap up Todays Lecture

Measuring HR during exercise tell uswhat?

What finger do you not want to use to

take pulse and why? Tell me something about systolic &

diastolic BP.

Contraindications for taking BP.

Normal RR for an adult?

Pain scale?

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THE MUDDIEST POINT

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Looking Forward

Next Weeks Lecture:

Positioning/Draping/Wound Care

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Questions???

Minor, M.A., Minor, S., (2006), PatientCare Skills, 6th ed. Pearson Prentice Hall:Upper Saddle River, NJ.