Stressors that Affect Circulation

NUR101 LECTURE # 9

FALL 2009

K. BURGER, MSEd, MSN, RN, CNEPPP by Sharon Niggemeier RN BSN MSN

Circulatory Needs

Blood circulation affects all aspects of well being.

Circulation is monitored through assessment of Vital Signs along with other collected data.

The patient’s physiological status is reflected by their vital signs.

Vital Signs Signs of Vitality and

Life Deviations from normal

ranges can indicate chg in health status.

TPR & BP = VS T-temperature P-pulse R-respirations BP- blood pressure VS-vital signs

CNS Regulates VS Hypothalamus:

Controls temperature Anterior Hypothalamus

-Dissipation of heat

Posterior Hypothalamus-conservation of heat

Medulla: Vasomotor center

controls BP through vasoconstriction or vasodilation

Cardiac center controls pulse

Respiratory center controls respirations(rate and depth)

Relationship Between VS

R = 1/4 PR 20 = P 80

P = diastolic BPP 80 = 120/80

T increases = an increase in P R and BP

Factors Influencing VSAgeGenderRaceDietWeightHeredityMedicationsActivity

More Factors Influencing VS

PainHormonesStressEmotionsCircadian

Rhythms

Guidelines for Assessing VSSystematicNormal RangeBaselineRecheckClient NormDxTreatmentsMonitor prn

Temperature Regulation

Thermal BalanceHeat ProductionHeat LossCore vs Surface

Heat Production

By product of metabolismB.M.R.- Basal Metabolic RateMuscle activityExposure to increased

temperatureHormones: Thyroxine, Epinephrine

Heat Loss (Transfer)

Conduction - direct transfer of heat by contact

Heat Loss-ConvectionHeat

dissemination via motion. A fan blows warm air across a warm body.

Heat Loss-RadiationHeat given off by

rays from the body. Heat loss from an uncovered head.

Main form of heat loss.

Heat Loss-Evaporation

Conversion of a liquid to a vapor. Perspiration vaporizes from the skin.

Diaphoresis

????What are some other ways heat is lost from body???

FeverPyrexia

100.4 – 104.0 FHyperpyrexia

Above 104.0 F

Fever PatternsIntermittentRemittentConstantRelapsing

?? Fever Terminology ??Which term can be used to describe a fever that: Is constantly elevated with little fluctuation Fluctuates but does not come down to normal Returns to normal for a day or two, but then

goes up again Alternates between normal and fever

Resolutions of Pyrexia

Crisis- sudden return to normal body temp.

Lysis- gradual return to normal body temp.

S/S of Fever

Loss of appetite Delirium

Headache SeizuresDehydration Thirst

Flushed face ?????Rapid pulse Decreased urinary output

(OLIGURIA)

Temperature ranges

Oral- 96.8 – 100.4 F 98.6 = average norm

Axillary- approximately 1 degree lower

Rectal- approximately 1 degree higher

Fever

Onset- (Chill)Course ( Flush)Abatement (fever subsides)

Assessing TemperatureGlassElectronicTympanicTape/PatchDisposable (ie: Clinidot)

Oral Temperature

Most common site Place against sublingual artery Contraindicated in oral surgery/infection Wait 15 min. if pt. ate/drank

or smoked Electronic- blue probe

Axillary Temperature Preferred for children under 6 yrs. routinely

used on infants. Place in center of axilla against artery off

the subclavian. Blue probe -electronic thermometer Document 102.4 A

Rectal TemperatureLast resort for assessing temperaturePlace against inferior rectal arteryContraindicated rectal surgery/cardiac

pt.Lubricate thermometers REMEMBER PPE

(Continued) Rectal Temperature

Electronic thermometers: Red Probe only Insert : ½ - 1 inch adult

¼ - 1/2 inch child

Left position is bestDocument 102.8 R

Electronic ThermometersCheck for baseline number- specific

number after being turned on.Error indicators- low battery # completeness- digital display clearly

shows entire numbers If probe cover breaks- discard, check

pt.mouth/axilla/rectum for broken pieces.

Do not use bent probes.

??? Nursing Diagnoses ???

Nursing Interventions Temperature

Check VS frequently

Assess skin Note change in

LOC Seizure

precautions ? Monitor I & O REDUCE

COVERINGS

Encourage fluidsTepid bathsAdminister

antipyretics Promote comfort

& RESTHypothermia

blanket

Heat Stroke

Hot, dry skinDizzinessAbdominal painDeliriumEventual LOC

Hypothermia

Mild (93.2 – 96.8 F)Moderate (86.0-93.2 F)Severe ( below 86.0 F)

Evaluations-Temperature

Is patient afebrile?Are interventions working? i.e cool

compresses, tepid bath, antipyretics?

S/S of infection present?

Nurse’s Notes

5/31/02

4:15pm Reports headache, feeling “on fire”, face flushed, skin warm, T-104.6 A P-100 R- 20 BP- 150/80. Dr. Arrid notified. Tylenol 650mg po administered as per telephone order. Fluids encouraged, tepid bath given. S.Niggemeier RN-----------------------------

4:45pm T-102.2 A P- 88 R-18 BP 130/78 taking fluids, feels “better than before”. S.Niggemeier RN-----------------------------

Pulse-Physiology SA node- creates electrical impulses

causing contraction of Left ventricle. A wave of blood is pumped into the

arteries. Throbbing sensation is felt - Pulse Pulse rate should = the heart rate Pulse rate is the number of pulsations felt

in a minute. Pulse usually = diastolic pressure

Pulse RatesNewborn 120-150 Infant 80-140Child 75-110Adult 60-100Pulse rates ????? as age increases

Cardiac Output CO=SV x HR Cardiac output (CO)

is the amount of blood pumped/min by the heart and = approximately 5000ml or 5L/min

Stroke Volume (SV) is the amount of blood ejected from the L ventricle with each contraction.

Heart rate (HR) is the number of times the heart contracts.

Inversely related- when SV goes up the HR goes down.

?? CARDIAC OUTPUT ??CV (5000) = SV(70) X HR

In the above equation, what would the client’s heart rate be?

If a client had a weak heart (ie:CHF) that was only able to eject a SV of 50, what would happen to the client’s HR?

If a client had a well-conditioned heart muscle (ie: athlete) that was able to eject a SV of 100, what would their HR be?

Pulse Sites Temporal Carotid Apical Brachial Radial Femoral Popliteal Dorsalis Pedis Posterior Tibia

Pulse assessment Rate -number of

beats /min Rhythm- pattern

of the rate. Regular or Irregular. Count irregular rhythm for 1 min.

Quality- strength of the pulse 0-4+

Pulse - Quality Scale 4+ bounding very strong, does not disappear

with moderate pressure 3+ normal, easily felt, 2+ weak, light pressure causes it to

disappear 1+ thready, not easily felt, disappears with

slight pressure 0- no pulse

??? NURSING DIAGNOSES

Nursing Interventions-Pulse

Monitor for symmetryNote pulse deficitPromote circulation – i.e. massage,

TEDS, Teaching – i.e don’t cross legs

Evaluations

Is pulse with normal range?All pulses presentEqually Bilateral?Are interventions to promote

circulation working? i.e. massage, TEDS etc.

Terminology Bradycardia- HR below 60/min Tachycardia- HR above 100/min Sinus Arrhythmia- HR increases on

inspiration and decreases on exhalation common in children and young adults

Dysrhythmia- abnormal rhythm Palpitation-aware of your HR without

feeling for it…usually rapid Pulse deficit- difference between apical

and radial pulses Apical-100 Radial-80 then the Pulse deficit is 20

Pulse Documentation

5/23/02 1:20am c/o palpitations. P-96 reg 3+. No pulse deficit.------------------- S.Niggemeier RN

Respirations Physiology

Process whereby CO2 and O2 are exchanged in the tissues.

Oxygenation of the bodyCO2 is the stimulus for breathing Inspiration - breathing in

Diaphragm contracts – pulls downExpiration- breathing out

Diaphragm relaxes – moves upNormal Tidal Volume = 500 ml

Respiration Rates

Newborn 40-60/min Child 20-30 School age 18-26 Adult 16-20 Respirations

decrease as age increases

Assessing Respiratory Status

Oxygenation status

Neurological state

Musculoskeletal status

Oxygenation status

Note S/S of hypoxia (oxygen deprivation

Cyanosis - bluish tinge caused by decrease in O2 in RBC.

Cyanosis is assessed by checking the mucous membranes of the conjunctiva (lower eyelids), under the tongue and inside the mouth..should be pink not pale or bluish

??Other signs of dyspnea??

Neurological state

Hypoxia results in neurological changes alert becomes anxious then irritable progresses to drowsiness eventually a coma

Musculoskeletal StatusAbnormalities that prevent the thorax

from expanding result in hindered respirations

ScoliosisLordosisPectus excavatumKyphosisPectus carinatum

Respiratory Assessment Rate- number of

breaths/min

Rhythm - even, labored

Quality- deep, shallow

Pulse Oximetry

Indirect measurement of arterial oxygen saturation of hemoglobin

95% - 100% normal range Below 90% = hypoxia Factors that interfere with accurate

measurement: dark nail polish, anemia,vasoconstriction (PVD, hypothermia), carbon monoxide poisoning, movement, excessive background light, tight probe

?? NURSING DIAGNOSES??

Nursing Interventions- Respirations

Elevate HOB (head of the bed)Promote calm atmosphereAdminister oxygen as neededRelaxation techniques

Evaluation- Respiratory

Rate within normal range?SOB?Dyspnea?Breathing less labored?Less cyanotic?

TerminologyApneaAdventitious soundsRales/cracklesGurgles /rhonchiStertorWheezeCheyne-Stokes

Terminology

BradypneaDyspneaHyperinflationHypoxiaOrthopneaTachypnea

Documentation

5/30/02 Reports dyspnea. R = 24, labored , shallow. HOB elevated. Dry crackles auscultated bilaterally. Dr. C. Stokes notified. O2 2L via NC applied. S. Niggemeier RN------------------------

Blood Pressure -Physiology

Blood pressure is the force against the arterial walls.

Maximum BP is achieved when the Left ventricle contracts - Systolic pressure

Lowest BP is when the heart rests - Diastolic pressure

Pulse pressure is the difference between the Systolic and Diastolic pressures BP 140/90 PP (pulse pressure) = 50

Maintaining and Regulating Blood Pressure

Peripheral Resistance

Pumping Action of heart (Cardiac Output)

Blood volume

Viscosity of blood

Elasticity of vessel walls

Hormonal factors: renin, aldosterone

Hypertension Elevated BP above

normal for sustained time

Unknown cause - primary or essential hypertension

Known cause- secondary hypertension

3 or more elevated readings to confirm DX

Hypertension Normal Blood

Pressure < 120/80

Prehypertension

Systolic 120-139

Diastolic 80-89

Stage 1

Systolic 140-159

Diastolic 90-99

Stage 2

Systolic >160

Diastolic >100

Hypotension

Low BP - systolic of 90-115 with no ill effects

Can be drug induced or illness related (MI, burns, blood loss)

Orthostatic Hypotension or Postural Hypotension = low BP when rising to an erect position, common after periods of bed rest

Terminology

Auscultatory GapDiastolicKorotkoff soundsPulse PressureSystolic

Direct BP Measurement

Measure BP by means of inserting a catheter (arterial line) into an artery and measure by machine

Used in critical care

Indirect BP Measurement Auscultating with

stethoscope and sphygmomanometer

Palpating- feeling for an estimated systolic

Doppler amplifies Korotkoff sounds

Electronic meters- monitor BP with no need for stethoscope

Sphygmomanometers

Aneroid-measures mmHg on calibrated dial

Mercury - measures mmHg via mercury filled cylinder (no longer used due to mercury hazardous material)

Cuff Sizes Stethoscope Use Vary in size Must use

appropriate size for pt.

Pedi cuff, small, medium, large etc..

Thigh cuffs

Use either bell or diaphragm to auscultate sounds

Make sure ear tips block out noise

Clean after each use with alcohol pads

Augment Korotkoff Sounds

Raise arm over head for 15 sec prior to retaking BP

Have pt. open/close hands - empties veins

Pump bulb up quicklyWait 30-60 sec between readings Don’t reinflate cuff once air is being

released it muffles sounds

Brachial Popliteal

Use either armPreferred siteEasy access

Use either thighLess preferredDifficult to accessSystolic pressure

will be 10-40 mmHg higher than brachial

Palpating BP

Cuff is inflated 30mmHg above the point where pulse is no longer palpated.

Release cuff and as air is releasing feel for return of pulse …that is the systolic

No stethoscope is used.No diastolic pressure can be assessed

Nursing Interventions- Blood Pressure

Monitor BP Administer antihypertensives as orderedTeaching - i.e. diet, exercise, stress,

etc.

Evaluation –Blood pressure

B/P within normal range?C/O headaches or other s/sTeachings regarding diet, weight,

exercise, stress etc being followed?

Terminology

A/R- apical radialFUO - fever unknown originPP -pulse pressureSOB - short of breathVS- vital signs

?? Documentation of VS ??

On what type of chart form are vital signs usually documented?