Nikocevic Let's Check You Out-Obtaining Vital Signs in a ... nikocevic lets check you out...• Palpate brachial artery • Place the center of cuff bladder over brachial artery and

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Let’s Check You Out: Obtaining Vital Signs in a Pharmacy

Bedrija Nikocevic, PharmD

Roosevelt University College of Pharmacy

Disclosures and Conflict of Interest

• Dr. Nikocevic declares no conflicts of interest, real or apparent, and no financial interests in any company, product, or service mentioned in this program, including grants, employment, gifts, stock holdings and honoraria.

Pharmacist Objectives

At the conclusion of this program, the pharmacist will be able to:

1. List normal values for vital signs discussed in this course

2. Describe the proper steps to measure respiratory rate, heart rate, blood pressure, and temperature

3. Describe various blood pressure and temperature measurement methods

4. Discuss factors that may cause fluctuations in vital signs measurements

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Pre-Test Questions

1. When measuring pulse, it is important to assess rate, rhythm, and amplitude.

a. True

b. False

Pre-Test Questions

2. Which phase of Korotkoff sounds correlate to systolic blood pressure?

a. Phase I

b. Phase II

c. Phase III

d. Phase IV

e. Phase V

Pre-Test Questions

3. AJ’s estimated SBP is 140 mmHg. What is the estimated maximum inflation level for this patient?

a. 150 mmHg

b. 160 mmHg

c. 170 mmHg

d. 180 mmHg

Pre-Test Questions

4. Which of the following could cause fluctuations in oral temperature measurement?

a. Eating or drinking 15 minutes before taking a

measurement

b. Improper positioning of the oral thermometer

c. Brushing teeth 30 minutes prior to taking a measurement

d. Walking around while taking a measurement

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Vital Signs

• Respiratory rate

• Heart rate

• Blood pressure

• Temperature

Respiratory Rate

Respiratory Rate

• Observe rate, rhythm, depth and effort of breathing

• Count number of respirations in 1 minute by visual inspection

• Units: breaths per minute

– Normal: 12-20 breaths/minute

1Beginning the physical examination: general survey, vital signs, and pain. In: Bickley LS, Szilagyi PG, editors. Bates’ guide to physical examination and history taking. 11th ed. Philadelphia: Wolters Kluwer Health/Lippincot Williams and Wilkins; 2013. p. 118-127.

Pulse/Heart Rate

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Pulse

Heart rhythmically pumps blood into arteries

Blood collides with arterial walls

Arterial walls expand and contract

Pulse is generated

• Units: cardiac (ventricular) contractions per time

– Beats per minute

1Beginning the physical examination: general survey, vital signs, and pain. In: Bickley LS, Szilagyi PG, editors. Bates’ guide to physical examination and history taking. 11th ed. Philadelphia: Wolters Kluwer Health/Lippincot Williams and Wilkins; 2013. p. 118-127.

Arterial Pulses

• May be felt on the following arteries:

– Carotid

– Brachial

– Radial

– Ulnar

– Femoral

– Popliteal

– Dorsalis pedis

– Posterior tibial arteries

– Abdominal aorta

2Longe RL, Calvert JC. Blood vessels. In: Young LY, editor. Physical assessment: a guide for evaluating drug therapy. Vancouver: Applied Therapeutics, Inc.; 1994. p. 10-1-10-31.

http://img.tfd.com/mk/P/X2604-P-57.png

Measuring Radial Pulse

• Rate

• Amplitude

– Bounding

– Normal

– Diminished

– Absent

• Rhythm

2Longe RL, Calvert JC. Blood vessels. In: Young LY, editor. Physical assessment: a guide for evaluating drug therapy. Vancouver: Applied Therapeutics, Inc.; 1994. p. 10-1-10-31.

Measuring Radial Pulse

• Place index and middle finger on the base of the thumb, then slide about an inch towards the elbow

• Press lightly on the radial artery, and count pulses for 30 seconds, then multiply by 2

http://health.liputan6.com/read/462612/cek-denyut-nadi-sebelum-olahraga-biar-tak-kena-serangan-jantung

1Beginning the physical examination: general survey, vital signs, and pain. In: BickleyLS, Szilagyi PG, editors. Bates’ guide to physical examination and history taking. 11th

ed. Philadelphia: Wolters Kluwer Health/Lippincot Williams and Wilkins; 2013. p. 118-127.

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Normal Heart Rate

Newborns 0-1 months old 70-190 bpm

Infants 1-11 months old 80-160 bpm

Children 1-2 years old 80-130 bpm




Children 10 years and older AND adults 60-100 bpm

Well trained athletes 40-60 bpm

3Pulse. MedLine Plus. https://medlineplus.gov/ency/article/003399.htm. Accessed 6/20/2017.

Blood Pressure

Blood Pressure

• Measure of force exerted on arterial walls as blood is pumped out of the heart

• Systolic blood pressure (SBP)

• Diastolic blood pressure (DBP)

• Reported as SBP/DBP

• Units: mmHg

4Pickering TG, Hall JE, Appel LJ, et al. Recommendations for blood pressure measurement in humans and experimental animals. Hypertension. 2005;45:142-161.

Factors Affecting Blood Pressure Measurement

• Room temperature

• Exercise

• Alcohol or nicotine consumption

• Positioning (patient, arm)

• Muscle tension

• Bladder distension

• Talking

• Background noise

• Location of measurement4Pickering TG, Hall JE, Appel LJ, et al. Recommendations for blood pressure measurement in humans and experimental animals. Hypertension. 2005;45:142-161.

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Blood Pressure Measurement Methods

• Intra-arterial blood pressure

• Auscultatory (Korotkoff) method

• Oscillometric technique

• Finger cuff method of Penaz

• Ultrasound techniques

• Tonometry


Auscultatory (Korotkoff) Method

• Utilizes sphygmomanometers

– Mercury

– Aneroid

– Hybrid

• Underestimates SBP and overestimates

DBP


Blood Pressure Measurement Procedure

• Patient positioning– Seated for at least 5 minutes

– Legs uncrossed

– Back and arm supported

– Arm at heart level

– Avoid clothing under the cuff if possible

– Quiet environment

– Empty bladder

• Assess caffeine and smoking within 30 minutes

• Instruct patient not to talk/move


Blood Pressure Measurement-Cuff Selection

http://medical-dictionary.thefreedictionary.com/Blood+pressure+cuff

Adult Arm Circumference

Cuff Size

22 – 26 cm Small

27 – 34 cm Regular

35 – 44 cm Large

≥ 45 cm Thigh cuff

5Clark Briggs G, Duhon H.Chapter 48. Home testing and monitoring devices. In: Krinsky DL, Ferreri SP, Hemstreet B et al., editors. Handbook of non-prescription drugs: an interactive approach to self-care, 18th ed. Washington: American Pharmacists Association; 2015. http://pharmacylibrary.com/doi/full/10.21019/9781582122250.fm (accessed

6/20/2017).

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• Palpate brachial artery

• Place the center of cuff

bladder over brachial

artery and 1” above the

antecubital fossa

• Attach the cuff to a

manometer

5Clark Briggs G, Duhon H.Chapter 48. Home testing and monitoring devices. In: Krinsky DL, Ferreri SP, Hemstreet B et al., editors. Handbook of non-prescription drugs: an interactive approach to self-care, 18th ed. Washington: American PharmacistsAssociation; 2015. http://pharmacylibrary.com/doi/full/10.21019/9781582122250.fm(accessed 2017 Jun 20)6Saseen JJ, MacLaughlin EJ. Chapter 13. Hypertension. In: DiPiro JT, Talbert RL, Yee GC et al. editors. Pharmacotherapy: a pathophysiologic approach, 1oth ed. New York: McGraw-Hill; 2017. http://accesspharmacy.mhmedical.com/content.aspx?bookid=1861&sectionid=146028752(accessed 2017 Jun 20).

https://www.google.com/search?q=brachial+artery&source=lnms&tbm=isch&sa=X&ved=0ahUKEwjw38uTks3UAhXJ64MKHXI6CLcQ_AUICigB&biw=1280&bih=640#imgrc=qgUGsvbtKP9zpM:


• Estimate maximum inflation level (MIL) by estimating systolic blood pressure (SBP)– MIL=estimated SBP + 30 mmHg

– Palpate radial pulse

– Rapidly inflate the cuff to 70 mmHg

– Inflate further in increments of 10 mmHg until the radial pulse is no longer palpated

– Note the pressure at which the radial pulse is no longer palpated, deflate cuff until pulse reappears

• This is the estimated SBP

– Rapidly deflate the cuff

6Saseen JJ, MacLaughlin EJ. Chapter 13. Hypertension. In: DiPiro JT, Talbert RL, Yee GC et al. editors. Pharmacotherapy: a pathophysiologic approach, 1oth ed. New York: McGraw-Hill; 2017. http://accesspharmacy.mhmedical.com/content.aspx?bookid=1861&sectionid=146028752 (accessed 2017 Jun 20).


• Bell over brachial artery

• Eartips pointed towards nose

http://www.buzzle.com/articles/tips-to-use-a-stethoscope-in-a-proper-way.html



• Pump the cuff rapidly up to MIL

• Deflate the cuff at a rate of 2-3 mmHg/s

• Listen for Korotkoff sounds


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Korotkoff Sounds

• Faint, clear, tapping sounds appear=SBPPhase I

• Sounds become softer and longer

• SwooshingPhase

II

• Sounds become crisper and louder

• KnockingPhase III

• Sounds become muffled and softerPhase IV

• Sounds disappear completely=DBPPhase V

7Jones RM. General assessment and vital signs. In: Jones RM, Rospond RM, editors. Patient assessment in pharmacy practice. 2nd ed. Baltimore: Lippincott Williams & Wilkins; 2009. p. 51-74.


• Rapidly deflate the cuff after reaching 30 mmHg under DBP (loss of sound)

• Round measurements to the nearest 2 mmHg

• Minimum 2 readings at least 1 minute apart; report average

• If difference between first and second reading is > 5 mmHg:– Obtain 1-2 additional readings

– Use average of all readings as patient’s BP


Variation in BP Measurements

• White coat hypertension

– More common in elderly patients

• Masked hypertension

• Pseudohypertension

– Test with Osler’s maneuver

• Orthostatic hypotension


Auscultatory Gap

• As cuff pressure � from true SBP value, the Korotkoff sounds may disappear (false DBP), reappear (false SBP), and then disappear again at the true DBP value

• Eliminate by elevating the arm overhead for 30 seconds before inflating the cuff,

then bringing the arm to the usual position to continue the measurement


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Absence of Korotkoff Phase V Sounds

• May occur in:

– Pregnant women

– Patients with AV fistulas

– Patients with aortic insufficiency

• Sounds are audible even after complete

deflation of the cuff

• Utilize a non-auscultatory method to measure BP


Blood Pressure Goals

•≤150/90 mmHg≥60 years old≥60 years old

•≤ 140/90 mmHg< 60 years old< 60 years old

•≤ 140/90 mmHg≥ 18 years old with CKD or

DM

≥ 18 years old with CKD or

DM

8James PA, Oparil S, Carter BL, et al; for JNC 8. 2014 evidence based guidelines for the management of high blood pressure in adults. JAMA. 2014;311(5):507-520.

Blood Pressure Measurement

https://vimeo.com/8068713

Temperature

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Temperature

• Measurement sites

– Rectal

– Oral

– Axillary

– Tympanic

– Temporal

9Feret BM. Chapter 6. Fever. In: Krinsky DL, Ferreri SP, Hemstreet B et al., editors. Handbook of non-prescription drugs: an interactive approach to self-care, 18th ed. Washington: American Pharmacists Association; 2015. http://pharmacylibrary.com/doi/full/10.21019/9781582122250.ch6 (accessed 2017 Jun 21).

Rectal Electronic Thermometers

• Cover the tip with a probe cover

• Turn on and wait until ready to use

• Apply a water soluble lubricant to tip


Rectal-Infants or Young Children

• Place child over lap

• Separate buttocks

• Insert the thermometer gently in the direction of the umbilicus

• For infants, insert thermometer to the

length of the tip

• For young children, insert thermometer about 1 inch into the rectum


Rectal-Adults

• Adults

– Have the patient lie on one side with legs flexed to ~ 45° angle from the abdomen

– Insert the tip of the thermometer 0.5-2 inches into the rectum

– Instruct the patient to take a deep breath

• Helps position the thermometer


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Rectal Electronic Thermometer

• Wait until thermometer beeps and a reading appears

• Remove the thermometer

• Dispose of probe cover, sanitize thermometer, and rinse with cool water

• Wipe away any remaining lubricant from the anus

• Wash hands


Oral Electronic Thermometers-Digital Probe

• Do not eat or drink for 20-30 minutes before

• Affix a probe cover

• Turn on

• Place tip of thermometer under tongue

• Close mouth and breathe through nose

• Read and record temperature when thermometer beeps (~5-30 seconds)

• Remove and dispose of probe cover9Feret BM. Chapter 6. Fever. In: Krinsky DL, Ferreri SP, Hemstreet B et al., editors. Handbook of non-prescription drugs: an interactive approach to self-care, 18th ed. Washington: American Pharmacists Association; 2015. http://pharmacylibrary.com/doi/full/10.21019/9781582122250.ch6 (accessed 2017 Jun 21).

Oral Electronic Thermometers-Digital Pacifier

• Wait 30 minutes after drinking or eating

• Inspect the pacifier for any tears or cracks

• Turn the thermometer on and place the pacifier in child’s mouth

• Have the child hold pacifier in mouth

without moving for ~2-6 minutes

• Record temperature when thermometer beeps


Axillary Electronic Thermometer

• Affix a probe cover

• Turn on the thermometer

• Place tip of thermometer under a clean, dry armpit, directly on skin

• Hold children close

• Read and record the temperature when

thermometer beeps


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Tympanic Thermometer

• Affix a disposable lens cover over ear probe

• Turn on thermometer • Children <1 year old

– Pull ear backward to straighten ear canal

• Patients >1 year old– Pull ear backward and up to straighten ear canal

• Place the ear probe into canal– Aim the tip toward patient’s eye

• Press the button and wait ~1-5 seconds• Read and record temperature

• Discard lens cover


Temporal Thermometer

• Acclimatize the thermometer to the environment

• Probe on one side of the head near the temple

• Depress button and hold while scanning • Sweep thermometer across forehead to the

hairline on the opposite side of the head

• Sweat on forehead– Nest on neck directly behind the ear lobe

• Lift thermometer, release button, record temperature


Normal Temperature

Measurement Site Normal Range Fever

Rectal 97.9°F – 100.4°F ≥100.4°F

Oral 95.9°F-99.5°F ≥99.5°F

Axillary 94.5°F-99.3°F ≥99.3°F

Tympanic 96.3°F-100°F ≥100°F

Temporal 97.9°F-100.1°F ≥100.7°F for 0-2 months old

≥100.3°F for 3-47 months old≥100.1°F for ≥4 years old


Post-Test Questions

2. When measuring pulse, it is important to assess rate, rhythm, and amplitude

a. True

b. False

All of the above characteristics are important to assess when measuring pulse.

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Post-Test Questions

3. Which phase of Korotkoff sounds correspond to systolic blood pressure?

a. Phase I

b. Phase II

c. Phase III

d. Phase IV

e. Phase V

Phase I Korotkoff sounds correspond to SBP

Post-Test Questions

4. Which of the following could cause fluctuations in oral temperature measurement?

a. Eating or drinking 15 minutes before taking a measurement

b. Improper positioning of the oral thermometer

c. Brushing teeth 30 minutes prior to taking a measurement

d. Walking around while taking a measurement

Patients should avoid eating or drinking for 20-30 minutes before taking a measurement. Thermometer should be properly position to ensure accurate measurement.

Post-Test Questions

4. AJ’s estimated SBP is 140 mmHg. What is the estimated MIL for this patient?

a. 150 mmHg

b. 160 mmHg

c. 170 mmHg

d. 180 mmHg

MIL=estimated SBP + 30 mmHg

Take Home Points• Normal values of vital signs are different for different

age/activity/disease state groups• Utilizing proper technique is of utmost importance when

measuring vital signs

• Having the basic understanding of different blood pressure and temperature measurement methods will assist the

pharmacist in selecting the most appropriate method for

their patients• Understanding the factors that may cause fluctuations in

vital signs measurements will result in more accurate

measurements

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Speaker Contact Information

Bedrija Nikocevic, PharmD

Roosevelt University College of Pharmacy

1400 N Roosevelt Blvd Office 255

Schaumburg, IL, 60173

[email protected]

Documents

Nikocevic Let's Check You Out-Obtaining Vital Signs in a ... nikocevic lets check you out...• Palpate brachial artery • Place the center of cuff bladder over brachial artery and