Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 1 General Survey Initial...

Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.

1

General Survey

Initial Observations

Speech Speech patterns and patterns and voice voice intonationsintonations

Signs and Signs and symptoms symptoms of distressof distress

Client’s physical appearance

Mood Mood and and behaviorbehavior

Vital Vital signssigns

Height and Height and weightweight


2

Vital signs are physical signs that indicate an individual is alive, such as heart beat, breathing rate, temperature, and blood pressure. These

signs may be observed, measured, and monitored to assess an

individual's level of physical functioning. Normal vital signs change with age, sex, weight, exercise tolerance, and condition.

Vital signs (temperature, pulse, respiratory rate and blood pressure) are the first measurements obtained as a part of a nurses’ routine

assessment. Vital signs provide baseline data and can indicate changes in physiological function. So, nurses must be skilled in the

process to obtain, interpret and communicate accurate vital signs.

• Vital signs

http://www.healthline.com/adamcontent/vital-signs

http://www.healthline.com/adamcontent/vital-signs


3

• Getting Started: The examination room should be quiet, warm and well lit. After you have finished interviewing the patient, provide them with a gown (a.k.a. "Johnny") and leave the room (or draw a separating curtain) while they change. Instruct them to remove all of their clothing (except for briefs) and put on the gown so that the opening is in the rear. Occasionally, patient's will end up using them as ponchos, capes or in other creative ways. While this may make for a more attractive ensemble it will also, unfortunately, interfere with your ability to perform an examination! Prior to measuring vital signs, the patient should have had the opportunity to sit for approximately five minutes so that the values are not affected by the exertion required to walk to the exam room. All measurements are made while the patient is seated.

• Observation: Before diving in, take a minute or so to look at the patient in their entirety, making your observations. Does the patient seem anxious, in pain, upset? What about their dress and hygiene? Remember, the exam begins as soon as you lay eyes on the patient.


4

Normal ranges for the average healthy adult:

• The sequence for recording vital sign measurements in the nurses’ notes is T-P-R and BP.

• Temperature: (T), 97.8 - 99.1 degrees Fahrenheit / average 98.6 degrees Fahrenheit

• Pulse: (P) 60 - 80 beats per minute (at rest)

• Breathing: (R) 12 - 18 respirations (breaths) per minute

• Blood Pressure: (BP). Systolic: less than 120 mm of mercury (mm Hg) Diastolic: less than 80 mm Hg

Examples of how to record TPR on a worksheet or notepad are:a. Ms. Jones - room 314A - TPR 992 - 72 - 18.b. Mr. Fever - room 206B - TPR 1008 - 84 - 22 shallow

Examples of how to record BP and pulse on a worksheet are:a. Mr. Brown - - BP 132/84, P-76.b. Ms. Skip A. Beat - BP 146/82/70, P-84.


5

Factors Influencing Vital Signs1. Age2. Gender3. Heredity4. Race5. Lifestyle6. Environment7. Medications8. Pain9. Exercise10. Anxiety and Stress11. Postural Changes12. Diurnal (daily) Variations


6

AGING CHANGES

• Normal body temperature does not change significantly with aging. Temperature regulation, however, is more difficult.

• Because of changes in the heart, the resting heart rate may become slightly slower. It takes longer for the pulse to speed up when exercising, and longer to slow back down after exercise. The maximum heart rate reached with exercise is lowered.

• Blood vessels become less elastic. The average blood pressure increases from 120/70 mm Hg to about 150/90 mm Hg and may remain slightly high even if treated. The blood vessels also respond more slowly to a change in body position.

• Although lung function decreases slightly, changes are usually only in the reserve function. The rate of breathing usually does not change.

http://www.healthline.com/adamcontent/high-blood-pressure


7

Variations by age Children and infants have respiratory and heart rates that are faster

than those of adults as shown in the following table:

Age Normal heart rate (beats per minute)

Normal respiratory rate(breaths per minute)

Newborn 120-160 30-50

0-5 months 90-140 25-40

6-12 months 80-140 20-30

1-3 years 80-130 20-30

3-5 years 80-120 20-30

6-10 years 70-110 15-30

11-14 years 60-105 12-20

14+ years 60-100 12-20


8

EFFECT OF CHANGES• Loss of subcutaneous fat makes it harder to maintain body heat. Many older

people find that they need to wear layers of clothing in order to feel warm. Likewise, skin changes include the reduced ability to sweat. Therefore, older people find it more difficult to tell when they are becoming overheated.

• There may be decreased tolerance to exercise. Some elderly people have a reduced response to decreased oxygen or increased carbon dioxide levels (the rate and depth of breathing does not increase as it should).

• Many older people find that they become dizzy if they stand up too suddenly. This is caused by a drop in blood pressure when they stand called orthostatic hypotension.

• Medications that are used to treat common disorders in the elderly may also have a profound effect on the vital signs.

• For example, digitalis (used for heart failure) and certain blood pressure medications called beta blockers may cause the pulse to slow. Pain medications can slow breathing. Diuretics can cause low blood pressure and aggravate orthostatic hypotension ( (postural hypotension)– Sudden drop in systolic pressure when client moves from a lying to a

sitting to a standing position

http://www.healthline.com/adamcontent/heat-emergencies

http://www.healthline.com/galecontent/beta-blockers

http://www.healthline.com/galecontent/pain-2

http://www.healthline.com/galecontent/diuretics

http://www.healthline.com/adamcontent/blood-pressure-low

http://www.healthline.com/galecontent/orthostatic-hypotension


9

COMMON PROBLEMS• Older people are at greater risk for overheating (hyperthermia or heat

stroke). They are also at risk for dangerous drops in body temperature (hypothermia).

• Fever is an important sign of illness in the elderly. Many times, fever is the only symptom for several days. Any fever that is not explained by a known illness should be investigated by a health care provider.

• Often, older people are unable to create a higher temperature with infection so very low temperatures and checking the other vital signs plays an important role in following these people for signs of infection.

• Heart rate and rhythm problems are fairly common in the elderly. Excessively slow pulse (bradycardia) and arrhythmias such as atrial fibrillation are common.

• High blood pressure (hypertension) and a drop in blood pressure when changing body position (orthostatic hypotension) are common blood pressure problems. High blood pressure should always be discussed with your health care provider.

• Breathing problems are seldom normal. Although exercise tolerance may decrease slightly, even a very elderly person should be able to breathe without effort under usual circumstances.

http://www.healthline.com/adamcontent/fever

http://www.healthline.com/adamcontent/hypothermia

http://www.healthline.com/adamcontent/malaise

http://www.healthline.com/adamcontent/atrial-fibrillation-flutter


10

Thermoregulation

• Thermoregulation– The heat of the body is measured in units called degrees.– The core internal temperature of 98.6 degrees Fahrenheit (F)

does not vary more than 1.4 degrees F.– Core internal temperature is higher than the skin and external

temperature.

– What is the formula to change Celsius to Fahrenheit and back?

– A calculator helps here. To convert Fahrenheit to Celsius, subtract 32 degrees and divide by 1.8. To convert Celsius to Fahrenheit, multiply by 1.8 and add 32 degrees.

– NOW YOU KNOW!


11

Temperature: This is generally obtained using an oral thermometer that provides a digital reading when the

sensor is placed under the patient's tongue. As most exam rooms do not have thermometers, it is not necessary to

repeat this measurement unless, of course, the recorded value seems discordant with the patient's clinical condition

(e.g. they feel hot but reportedly have no fever or vice versa). Depending on the bias of a particular institution, temperature is measured in either Celcius or Farenheit,

with a fever defined as greater than 38-38.5 C or 101-101.5 F. Rectal temperatures, which most closely reflect internal or core values, are approximately 1 degree F higher than

those obtained orally.


12

orallyTemperature can be taken by mouth using either the classic glass thermometer, or the more modern digital thermometers that use an

electronic probe to measure body temperature. rectally

Temperatures taken rectally (using a glass or digital thermometer) tend to be 0.5 to 0.7° F higher than when taken by mouth.

axillaryTemperatures can be taken under the arm using a glass or digital

thermometer. Temperatures taken by this route tend to be 0.3 to 0.4° F lower than those temperatures taken by mouth.

by earA special thermometer can quickly measure the temperature of the ear drum, which reflects the body's core temperature (the temperature of

the internal organs).


13

Oral temperatures are contraindicated for clients who have

mouth injuries/surgery, who are confused, infants and young children, comatose, have a history of seizures, are

intubated, or are short of breath and must breath through the mouth or who are receiving 02 via mask. If they just

drank or ate something, wait 20-30 minutes before you take an oral temperature.

Rectal temperatures are contraindicated in restless clients, those who have rectal pathology or recent rectal surgery

and in some agencies those who have a history of seizures or with myocardial infarctions (MI's). Rectal stimulation may

stimulate the vagus nerve and interfere with heart rate or rhythm.


14

Assessing Body Temperature

• Thermometers (temperature measurement)

• Purpose: To assess the functional status of the body’s tissues and

• Glass or electronic thermometers are used.

• Temperature Sites– Oral (blue or white

colored probe)– Axillary– Rectal(red)

• The electronic thermometer consists of a battery-powered display unit, thin wire cord, and a temperature sensitive probe. The probe must be covered with a disposable sheath before use. The probes are color-coded for proper use


15

Hypothermia is total body cooling, a bodily response which occurs when the

right conditions are present such as wind exposure, wet conditions, where the body becomes very cold, coupled with total exhaustion. Individuals usually

shiver for a period of time, then lose consciousness. Core body temperature can

then drop to life-threatening levels. Patients may appear clinically dead, but area able to be resuscitated if handled very carefully and properly warmed. The

knowledge that these individuals can be treated if they receive quick attention is of critical concern to those spending time in the out of doors, where these

potential conditions could develop. Cold, blue, stiff patients with no palpable pulse are always to be treated as if they can be resuscitated, especially if

hypothermia appears to be the major cause. Although it may seem surprising, it

is not uncommon for individuals in Florida to become hypothermic when swimming in the ocean, as hypothermia can occur any time a situation is

involved where core body temperature decreases. Hypothermia can occur outside of a cold environment. The very young and very old are more

susceptible to hypothermic conditions. A person in their 6th to 7th decade of life down in Florida, for example, could while swimming in the ocean drop their core

body temperature to a level that could potentially induce hypothermia.


16

Common signs and symptoms of depressed body temperature including the following:

94° Fahrenheit or less Stumbling or wide gait

Slurred speech Shivering

Faraway gaze Hypothermia is suspected when you see an exhausted individual who is

cold, wet, with a depressed body temperature.

• IF A PERSON IS UNCONSCIOUS, GREAT CARE MUST BE TAKEN NOT

TO JOSTLE THE INDIVIDUAL. EVEN IF YOU ARE TAKING OFF WET CLOTHES AND REPLACING THEM WITH DRY ONES, IT IS IMPERATIVE THAT YOU ARE VERY GENTLE. IT HAS BEEN DOCUMENTED OVER AND OVER THAT AN INDIVIDUAL WITH SEVERE HYPOTHERMIA CAN EASILY DEVELOP LIFE-THREATENING HEART ARRHYTHMIAS AND DIE IF PROPER PRECAUTIONS ARE NOT TAKEN AND JOSTLING AND

QUICK MOVEMENTS OCCUR.


17

•In a severely hypothermic individual, DO NOT MOVE THE PATIENT. BE VERY GENTLE. The following are priorities:

Stop the individual's temperature from dropping and slowly increase. It is important to maximize a safe warming rate. There are many ways to do this. There are external and internal ways to heat. In an outdoor

situation, externally warming is obviously the most practical. Some other creative ways would be building a fire, use sleeping bags, tarps

and tents to redirect the warm air towards the victim's body. This should be done slowly. Heating pads, if available, or simply laying next

to the victim, using another's body warmth to warm the victim is beneficial in terms of re-warming and increasing temperature

Remove wet clothing as gently as possible, without jostling the torso In the initial stages of hypothermia, exercising is not the best way to

increasing temperature since you are burning up sugar and eventually this could be counterproductive.


18

Pre-hospital treatment:

• Replace wet clothes if possible • Increase insulation • Try creative vapor barrier • External heat, if possible • Heated air is good for the patient to breath in • Warm drinks - sugar added or some type of

sweetener added • NO ALCOHOL


19

Severe hypothermia:

• No rough handling • Change wet clothes to dry. Cut the clothes if

necessary. Don't jostle the torso • Maximize your insulation • External heat is a must • No drinks at this point in severe hypothermia • Transport as gentle and as soon as possible to a

treatment facility


20

Respiration- is the act of breathing.

Assessing Respirations A stethoscope is used to auscultate breath sounds throughout the respiratory system. Rate is counted by number of breaths taken per minute. Observation of thoracic and abdominal movements includes:

Depth, rhythm, and symmetry

Costal (thoracic) breathing

Diaphragmatic breathing

Respiratory Rate: Respirations are recorded as breaths per minute. They should be counted for at least 30 seconds as the total number of breaths in a 15 second period is rather small and any miscounting can result in rather large errors when multiplied by 4. Try to do this as surreptitiously as possible so that the patient does not consciously alter their rate of breathing. This can be done by observing the rise and fall of the patient's hospital gown while you appear to be taking their pulse. Normal is between 12 and 20. In general, this measurement offers no relevant information for the routine examination. However, particularly in the setting of cardio-pulmonary illness, it can be a very reliable marker of disease activity.


21

Assessing Respiratory Function


22

Assessing Respirations

• Sites– Observation of chest wall expansion and

bilateral symmetrical movement of the thorax– Placement of back of hand next to client’s

nose and mouth to feel expired air


23

Hemodynamic Regulation Assessing Pulse

• Pulse: This can be measured at any place where there is a large artery, though for the sake of convenience it is generally done by palpating the radial impulse. You may find it helpful to feel both radial arteries simultaneously, doubling the sensory input and helping to insure the accuracy of your measurements. Place the tips of your index and middle fingers just proximal to the patients wrist on the thumb side, orienting them so that they are both over the length of the vessel.

• assessment of pulse rate at the following sites:1. temporal2. carotid3. apical4. brachial5. radial6. femoral7. popliteal8. dorsal pedis9. posterior tibial

• The most accessible peripheral sites are the radial and carotid sites.– The carotid site should always be used to assess the pulse in a cardiac

emergency.• A peripheral pulse is palpated by placing the first two fingers on the pulse

point with moderate pressure.• A Doppler ultrasound stethoscope is used on superficial pulse points.• A stethoscope is used to auscultate the heart’s rate and rhythm.


24

Taking your carotid pulse

• Assessment of arterial pulses include the presence and strength of the pulse and a bilateral comparison. Never palpate both carotid pulses at the same time because occlusion could cause compromised circulation to the brain.

• The carotid arteries take oxygenated blood from the heart to the brain. The pulse from the carotids may be felt on either side of thefront of the neck just below the angle of the jaw. This rhythmic "beat" is caused by varying volumes of blood being pushed out of the heart toward the extremities.


25

Radial pulse • Arteries carry oxygenated

blood away from the heart to the tissues of the body; veins carry blood depleted of oxygen from the same tissues back to the heart. The arteries are the vessels with the "pulse", a rhythmic pushing of the blood in the heart followed by a refilling of the heart chamber. To determine heart rate, one feels the beats at a pulse point like the inside of the wrist for 10 seconds, and multiplies this numbers by six. This is the per-minute total.


26

Technique for Measuring the Radial Pulse

• The pictures below demonstrate the location of the radial artery (surface anatomy on the left, gross anatomy on the right).

•

•


27

An apical pulse is the heartbeat at the apex of the heart. The apex of the heart is located in left fifth intercostal space on the midclavicular line. The stethoscope is placed just below the left nipple between the

fifth and six ribs.• Carotid Pulse• A common location for taking the pulse is the neck. There are two large arteries near

the front of the throat which supply the head with blood. These arteries are called the carotid arteries.

• One artery is located in a groove on the right side of the larynx and the other artery is located in a groove on the left side of the larynx. The artery on the casualty's left side is the left carotid artery and the artery on the casualty's right side is the right carotid artery. Either artery can be used to take the casualty's carotid pulse.

• To locate the artery, place the middle and index fingers on the casualty's larynx, which is usually called the Adam's apple.

• Move the fingers to the side until you feel the groove created by the muscles next to the trachea.

• Press on the groove until you feel the pulse.• Question:Why don't you use your thumb when taking a casualty's pulse?• Response:The thumb has a pulse of its own. You may be taking your pulse instead of

the casualty's pulse. • Radial Pulse• Another common location for taking the pulse is the wrist. When taking the pulse at

the wrist, gently press the radial artery against the bones of the wrist. The radial pulse is taken on the inside of the wrist near the base of the thumb. Do not use the back of the wrist. Either wrist can be used to take the casualty's radial pulse.

• Question:When would you need to take a casualty's radial pulse?• Response:You have applied a splint to a fractured arm and want to check the

casualty's blood circulation below the splint.


28

Posterior Tibial PulseA less common location for taking the pulse is the ankle. When taking the

pulse at the ankle, gently press the posterior tibial artery against the bones of the ankle. The pulse is taken on the inside of the ankle behind

the large ankle bone. The pulse can be found using either ankle. Question:When would you need to take a casualty's posterior tibial

pulse?Response:You have applied a splint to a fractured leg and want to check

the casualty's blood circulation below the splint. Other Pulse Sites

The temporal pulse is felt at the temple near the ear.

The brachial pulse is felt on the inside of the elbow.The femoral pulse is felt in the groin area.

The groin areas are located on each side of the body in the folds where the abdomen joins the legs. The pubic area lies between the two groin

areas.The popliteal pulse is felt behind the knee.

The dorsalis pedis pulse is felt on top of the foot.


29

• Frequently, you can see transmitted pulsations on careful visual inspection of this region, which may help in locating this artery. Upper extremity peripheral vascular disease is relatively uncommon, so the radial artery should be readily palpable in most patients. Push lightly at first, adding pressure if there is a lot of subcutaneous fat or you are unable to detect a pulse. If you push too hard, you might occlude the vessel and mistake your own pulse for that of the patient. During palpation, note the following:

Pulse Characteristics

• Quantity: Measure the rate of the pulse (recorded in beats per minute). Count for 30 seconds and multiply by 2 (or 15 seconds x 4). If the rate is particularly slow or fast, it is probably best to measure for a full 60 seconds in order to minimize the impact of any error in recording over shorter periods of time. Normal is between 60 and 100. Pulse rate (bradycardia, tachycardia)


30

Regularity: Is the time between beats constant? In the normal setting, the heart rate should appear metronomic. Irregular rhythms, however, are quite common. If the pattern is entirely chaotic with no discernable pattern, it is referred to as irregularly irregular and likely represents atrial fibrillation. Extra beats can also

be added into the normal pattern, in which case the rhythm is described as regularly irregular. This may occur, for example, when impulses originating

from the ventricle are interposed at regular junctures on the normal rhythm. If the pulse is irregular, it's a good idea to verify the rate by listening over the

heart (see cardiac exam section). This is because certain rhythm disturbances do not allow adequate ventricular filling with each beat. The resultant systole may generate a rather small stroke volume whose impulse is not palpable in

the periphery.

Pulse rhythm (dysrhythmias)

Volume: Does the pulse volume (i.e. the subjective sense of fullness) feel

normal? This reflects changes in stroke volume. In the setting of hypovolemia, for example, the pulse volume is relatively low (aka weak or thready). There may even be beat to beat variation in the volume, occurring occasionally with

systolic heart failure.


31

A normal pulse rate for an adult when resting is between 60 to 80 beats per minute. The average is 72 beats per minute.

A resting pulse rate of more than 80 beats per minute is a higher than normal pulse rate. This can be caused by shock, bleeding, heat, dehydration, fever, pain, emotions, and vigorous activity (such as

running).

Tachycardia is an abnormal condition that exists when the casualty's

pulse rate is over 100 beats per minute.

A resting pulse rate of less than 60 beats per minute is a lower than

normal pulse rate which can be caused by heart disease and

medications.A pulse rate below 60 may also occur in a soldier who is physically fit.A pulse rate of less than 50 beats per minute is called bradycardia.

pulse deficitThe absence of palpable pulse waves in a peripheral artery for one or more heart beats, as is often seen in atrial fibrillation, the number of such missing pulse waves (usually expressed as heart rate minus

pulse rate per minute). if pulse is irregular, do an apical/radial pulse assessment to detect a pulse deficit. Count apical pulse while colleague counts radial pulse. Begin apical pulse count out loud to simultaneously assess pulses. If

pulse count differs by more than 2, a pulse deficit exists.

For example,An apical rate of 92 with a radial rate of 78 leaves a pulse

deficit of 14 beats. Pulse deficits are freguantly associated with abnormal rhythms.

http://cancerweb.ncl.ac.uk/cgi-bin/omd?absence

http://cancerweb.ncl.ac.uk/cgi-bin/omd?palpable

http://cancerweb.ncl.ac.uk/cgi-bin/omd?pulse+waves

http://cancerweb.ncl.ac.uk/cgi-bin/omd?peripheral

http://cancerweb.ncl.ac.uk/cgi-bin/omd?artery

http://cancerweb.ncl.ac.uk/cgi-bin/omd?heart+beats

http://cancerweb.ncl.ac.uk/cgi-bin/omd?atrial+fibrillation

http://cancerweb.ncl.ac.uk/cgi-bin/omd?atrial+fibrillation

http://cancerweb.ncl.ac.uk/cgi-bin/omd?number

http://cancerweb.ncl.ac.uk/cgi-bin/omd?pulse

http://cancerweb.ncl.ac.uk/cgi-bin/omd?waves

http://cancerweb.ncl.ac.uk/cgi-bin/omd?heart+rate

http://cancerweb.ncl.ac.uk/cgi-bin/omd?minus

http://cancerweb.ncl.ac.uk/cgi-bin/omd?pulse+rate

http://cancerweb.ncl.ac.uk/cgi-bin/omd?minute


32

Classify the Strength of the PulseRegular -- Pulse is easy to feel and has even beats of good force.Bounding -- Pulse is easily detected due to the exceptionally large

amount of blood being pumped with each heartbeat.Weak -- Pulse is difficult to detect due to a decreased amount of blood

flowing through the arteries, usually due to bleeding or shock.

Absent -- Pulse cannot be detected, usually due to a blocked or injured artery or due to a lack of heart action.

Question:At which pulse site will you probably feel the most distinct pulse?

Response:The carotid pulse site. If you remain with the casualty for a significant amount of time, take the casualty's pulse periodically and note any significant changes in rate,

rhythm, or strength of the casualty's pulse. Remember that an irregular or fluctuating pulse may indicate an early stage of hypovolemic shock and a weak and rapid pulse may indicate a more advanced stage of

hypovolemic shock. Taking a casualty's pulse is important in identifying shock and in

evaluating a nerve agent casualty, which we will discuss shortly. In a chemical environment, you will need to count a chemical agent

casualty's carotid pulse rate while wearing your protective gloves.


33

Nursing Considerations

1. An irregular pulse rate, if not previously documented, should be reported immediately.

2. Clients on certain cardiac medications may need to monitor their pulse rate.

3. Routine exercise lowers resting and activity pulses.


34

Assessing Pulse


35

Hemodynamic Regulation

• Blood Pressure Measurement of pressure pulsations exerted against

the blood vessel walls during systole and diastole

Systolic PressureSystolic Pressure Maximum pressure exerted Maximum pressure exerted against arterial walls during against arterial walls during systolesystole

Diastolic PressureDiastolic Pressure Pressure remaining in Pressure remaining in the arterial system the arterial system during diastoleduring diastole


36

Assessing Blood Pressure• purpose:To assess cardiovascular

function by measurement of peripheral blood flow

• The most common site for indirect measurement is the client’s arm over the brachial artery.

• Accurate measurement requires the correct width of the blood pressure cuff as determined by the circumference of the client’s extremity.

• In order to measure the BP, proceed as follows: • Wrap the cuff around the patient's upper arm so

that the line marked "artery" is roughly over the brachial artery, located towards the medial aspect of the antecubital fossa (i.e. the crook on the inside of their elbow). The placement does not have to be exact nor do you actually need to identify this artery by palpation.

• Blood vessels become less elastic with age. The "average" blood pressure increases from 120/70 to 150/90 and may persist slightly high even if treated. The blood vessels respond more slowly to a change in body position.


37

Blood Pressure: Blood pressure (BP) is measured using

mercury based manometers, with readings reported in millimeters of mercury (mm Hg). The size of the BP cuff will

affect the accuracy of these readings. The inflatable bladder, which can be felt through the vinyl covering of the cuff, should reach roughly 80% around the circumference of the arm while its width should cover roughly 40%. If it is

too small, the readings will be artificially elevated. The opposite occurs if the cuff is too large. Clinics should have at least 2 cuff sizes available, normal and large. Try to use the one that is most appropriate, recognizing that there will

rarely be a perfect fit.


38

Assessing Blood Pressure

• Korotkoff sounds are five distinct phases of sound heard with a stethoscope during auscultation.

• The forearm or leg sites can be palpated to obtain a systolic reading when the brachial artery is inaccessible.


39

If you have difficulty hearing the BP, double-check the following:

a. direction of stethoscope ear pieces in your ears.

b. is all air out of the BP cuff before beginning?c. are you keeping the stethoscope check piece against the pt's

brachial artery?d. are the tubes free from twists, bends, occlusions?

e. is the environment too noisy and needs temporary adjusting, i.e. people, radio, TV, etc.?

• If you have difficulty getting the BP, deflate the cuff, allow the arm to rest a minute, reassure the pt. that you need to take it again for accuracy, and try again.


40

Blood pressures would not be taken on arms in which IV's are infusing (or heparin locks), or on the side of women who have had mastectomies (may

cause severe edema/swelling). They are also contraindicated if the arm has a phlebitis, an

arterio-venous shunt (for dialysis clients), or is paralyzed and atrophied from past injury.


41

Assessing Blood Pressure

• Hypotension refers to a systolic blood pressure less than 90 mm Hg or 20 to 30 mm Hg below the client’s normal systolic pressure.

• Hypertension refers to a persistent systolic pressure greater than 135 to 140 mm Hg and a diastolic pressure greater than 90 mm Hg.

Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 1 General Survey Initial...

Documents

Transcript of Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 1 General Survey Initial...