Vital Signs Review

What is Blood Pressure?

• Blood pressure measures the force of blood pulsing outwards on your arterial walls.

• NORMAL ADULT BP is systolic <120 and diastolic <80

Systolic - the top number is the pressure against the arterial walls when the heart beats (ventricles contract).Diastolic- the bottom number is the pressure against the arterial walls when the heart rests between beats (ventricles relax).

How is BP Calculated?

BP is measured as a fraction in mm of MercurySYSTOLIC/DIASTOLIC

EXAMPLE: 125/78 mm Hg

What is HIGH Blood Pressure?

• High blood pressure means the pressure in your arteries is elevated.

• High blood pressure is diagnosed when the systolic is above 140 and/or the diastolic is above 90

Respirations

A respiration is one complete inhalation and exhalation.The normal respiratory rate for an adult is 12-20 breaths per minute.*Count respirations after counting pulse*You may hold wrist while pretending to assess pulse next to clients chest. DON’T TELL CLIENT YOUR ASSESSING RESPIRATIONS.Count for 30 seconds and multiply by two OR count for 1 minute if abnormal pattern is present.

Respirations

• What do the respirations look like? Assess for rate, depth, and pattern (regular or irregular)

*Are the respirations fast, slow, shallow, deep, speed up slow down, any difficulty breathing??*-Kussmaul (rate >20) -Cheyne-Stokes-dyspnea (difficulty breathing)-apnea (no breath)-bradypnea (<12), tachypnea(>20)

How do you measure HR?

*Radial Pulse- radial artery*Brachial pulse- brachial arteryPALPATE WITH INDEX AND MIDDLE FINGER. NEVER THUMB!!!Count for FULL minute. Why?? You're assessing for irregularities (such as Afib) and characteristics of the pulse such as intensity.Normal HR in adult is 60-100 beats per minute

Pulse Rate

• Measured in Beats Per Minute (BPM)• Normal Pulse for Adult is 60-100 BPM*Pulse < 60 is bradycardia and > 100 is tachycardia*• Assess for rhythm (regular or Irregular) and

Quality (are they equal bilaterally). What is the strength? Is it strong, bounding (excessively strong), or thready ( difficult to palpate, weak)?

Pulse Oximeter

• Normal Oxygen saturation (SPO2) is 95% or greater on room air. Less than 93% could be cause for concern and require further assessment.

The percentage reading (pulse ox) is measuring the amount of hemoglobin saturated with O2 as the blood pulses through the finger, ear, or forehead.

Pulse Oximeter

• Hemoglobin is a substance in the red blood cells (RBC’S) that carry O2 and gives blood its red color. RBC’s pick up O2 in the lungs then the hemoglobin carries O2 to the cells.

Pulse ox uses an infrared light and Red light to determine the percentage of hemoglobin that has combined with oxygen. (SaO2= oxygen saturation)

SaO2 (cont.)

Pt must have adequate peripheral blood flow for the oximeter to detect a pulse.**Cigarette smoking, client motion, finger nail polish, temperature can affect sensor accuracy.WATCH FOR PULSE SENSING BAR ON FACE OF OXIMETER TO FLUCUTATE WITH EACH PULSATION AND REFLECT PULSE STRENGTH

How do you take a BP?

• Apply cuff with bladder directly over brachial artery.

• Make sure the bladder width of the cuff is 40% of the arm circumference. Cuff too big=false low; Cuff too small = false high

• Have stethoscope around neck ready to use.• Make sure pt has rested for at least 5 minutes.

Arm should be at heart level with palm up. Arm free of clothing.

BP (CONTINUED)

• Close valve on cuff (to right).Palpate radial or brachial pulse while inflating cuff until you can no longer feel pulse.

• When you no longer feel pulse, increase cuff pressure by 30mm of Hg. Do you still feel pulse? If not continue to next step. If you do, keep pumping up by 30mm Hg until pulse not felt.

THIS GIVES YOU THE APPROXIMATE SYSTOLIC BP TO PREVENT UNDERESTIMATING THE READING.

BP (cont.)

• Place stethoscope in ears and diaphragm on brachial artery.

• Slowly turn dial to left about 2 mm Hg per second.

• First sound is systolic. When pulse disappears, that is the diastolic.