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Key PointI. Definition of Blood PressureA. The measurement of the force of blood against artery walls.1. Force comes from the pumping of the heart2. If arteries are hardened or narrowed, this force might be increased to pump the blood throughout the bodyB. Measurement is done by listening for two sounds with a stethoscope - the first sound and the change in sound/or in some instances the last sound1. The first sound is called the systolic blood pressure – it measures the pressure in an artery when the heart is contracting2. The change in sound/or last sound heard is the diastolic blood pressure - it measure the pressure in an artery when the heart relaxes between contractionsC. The units of measurement are millimeters of mercury1. the top number/systolic is charted first, then the diastolic as in systolic/diastolic2. 120/80 is an example of a blood pressure and this would be in millimeters of mercury or mm HgII. Blood pressure valuesA. Normal range of B/P = 90-100/60 - 140/90B. Someone whose B/P is < 90-100/60 is said to be hypotensive 1. Someone with hypotension may have symptoms of dizziness, light-headedness, might faint2. No presence of signs and symptoms3. Contributing factors includea. medicationsb. level of physical fitness - ex. Someone who is extremely fit might be hypotensive, but this isnormal for themc. illnessd. injuryD. Someone with a B/P greater than 140/90 is said to be hypertensive1. Hypertension is called the silent killer because there are often no symptoms. Some people might experience headache, pressure in the head, ringing in ears, general feeling of malaise2. Continued elevation over time may result in a Cerebral Vascular Accident (stroke)3. Contributing factors may includea. overweightb. emotional upsetc. family historyd. high salt diete. painf. illnessg. medicationsAHA RecommendationHigh blood pressure, or hypertension, is defined in an adult as a systolic pressure of 140 mm Hg or higher and/or a diastolic pressure of 90 mm Hg or higher. Blood pressure is measured in millimeters of mercury (mm Hg).Blood pressure (mm Hg) Normal Prehypertension HypertensionSystolic (top number) less than 120120–139 140 or higherDiastolic (bottom number)less than 80 80–89 90 or higher**Mm Hg = millimeters of mercuryHigh blood pressure directly increases the risk of coronary heart disease (which leads to heart attack) and stroke, especially along with other risk factors.High blood pressure can occur in children or adults. It's particularly prevalent in African Americans, middle-aged and elderly people, obese people and heavy drinkers. People with diabetes mellitus, gout or kidney disease havehypertension more often.High blood pressure usually has no symptoms. It's truly a "silent killer." But a simple, quick, painless test can detect it. . Instruments necessary to complete the procedureA. Blood pressure cuff/sphygmomanometer1. This must fit the arm properly. The width of the cuff should approximately equal the width of the upper arm.2. The gauge should be calibrated and the needle should be on 0B. StethoscopeIV. ProcedureA. Person should be comfortably seated or lying downB. Should have rested for 10-15 minutes prior to the readingC. Arms that are paralyzed, injured, have an IV or shunt should not be usedD. Infant blood pressures can be taken on the leg, but adults must use the armE. Electronic blood pressure equipment can be used - the type used most often in the hospital setting is the Dyna mapF. Excess air should be squeezed out of the cuffG. Cuff should be placed snugly on upper arm.H. Gauge should be easily visualizedI. Valve should be closed, but easily able to be openedJ. Two techniques for obtaining the pressure1. Find radial pulse. Pump cuff till pulse no longer palpated. Then pump another 30 mm Hg higher. Placediaphragm of stethoscope on brachial artery about ? - 1inch above the elbow. Release the valve and listen for the two measurements - slowly deflating the cuff.2. Find brachial artery and put diaphragm over the site. Pump cuff to 120 mm Hg and listen for the heart beat. If it is heard, pump another 30 mm Hg and listen again. When the pulse is no longer heard, then pump another 30 mm Hg and slowly deflate, listening for the two measurements.K. If reading is uncertain, wait 30 seconds to 1 minute before remeasuringL. Record the reading and report any abnormalities. If the B/P reading is outside of the normal limits, retake it before reporting the value to a supervisor to be certain of accuracyKey PointsI. Vital signs includeA. TemperatureB. PulseC. RespirationD. Blood PressureII. TemperatureA. Refers to temperature inside the body or core body heat.B. Can be measured by four basic routes1. Oral2. Rectal3. Axillary4. TympanicC. Several types of thermometers1. Electronic/Digital2. Glass3. Thermoscan for Tympanic measurementD. Normal temperature ranges1. Oral 97.6 degrees F. – 99.6 degrees F.2. Axillary 96.6 degrees F. – 98.6 degrees F.3. Rectal 98.6 degrees F. – 100.6 degrees F.4. Tympanic: Manufacturer’s guidelines suggest that the measurement isthe same as rectal temperatures.5. Axillary is one degree Fahrenheit lower than Oral6. Rectal is one degree Fahrenheit higher than OralE. Reading temperatures1. By degree and tenth of a degree2. Place thermometer at eye level and look for silver line of mercury3. Never place fingers on bulb of thermometer as this might change thevalueF. Thermometers and routes1. Probes for electronic and mercury-free ends are color coded for route.2. Red = rectal; Blue = oral/axillary3. If no color present, the route will be written on the thermometerG. Measurement of temperature1. Use protective cover on each thermometer2. Tympanic probe placed in ear3. Rectal thermometer or probe placed in rectum one inch with lubricationapplied before insertion.4. Oral thermometer placed in mouth under the tongue5. Do not take oral temperatures ona. preschool childrenb. patients with oxygenc. delirious, confused, disoriented patientsd. comatose patientse. patients with nasogastric tubes in placef. patients who have had oral surgeryg. patients who are vomiting or are quite nauseated6. Do not take rectal temperatures ona. infants or children unless a core temperature is neededb. patients who have had rectal surgeryc. combative patientsH. Duration of taking temperature1. Tympanic – a couple of seconds – long enough to gently press abutton.2. Oral and rectal (glass thermometer) – three minutes.3. Axillary glass thermometer) – 10 minutes4. Electronic temperatures – when beep sounds, temperature is obtainedI. Abnormal temperatures1. Fever, febrile, hyperthermia all indicate someone who has an elevatedtemperature (greater than 100 degrees Fahrenheit).2. High fever would include anything over 103 degrees Fahrenheit.3. Moderate fever would include anything 100 – 103 degrees Fahrenheit.4. Hypothermia is subnormal temperature. This can be equallyproblematic for a person. Anything under 96 degrees Fahrenheit wouldindicate hypothermia.III. PulseA. Wave of blood produced by beating of heart and traveling along theArtery.B. Can feel at points where the artery is between finger tips and a bonyareaC. These areas are called pulse points and include1. Temporal2. Carotid3. Apical4. Brachial5. Radial6. Femoral7. Popliteal8. Dorsal PedalisD. Measured by index, middle, and ring fingers over pulse point.E. Do not take with the thumb, since it has a pulse of its own.F. Count for 30 seconds and multiply by 2, or count for 60 secondsG. Normal range is 60 – 100 beats per minute. The area of 90-100 is agray area in that a pulse should never constantly remain in this area.H. > than 100 = tachycardiaI. < than 90 = bradycardiaJ. Quality of pulse is determined as well as rate1. Rhythm – regular or irregular2. Strength – Bounding or threadyK. Circumstances affecting pulse rate1. Body temperature2. Emotions3. Activity level4. Health of heartL. Perfusion is the flow of blood throughout the body. Someone withsufficient perfusion has a strong enough heart beat to adequatelyoxygenate the body.IV. RespirationA. Each breath includes inspiration and expiration.B. Measure by observing chest rise and fall.C. Measured in breaths per minute.D. Normal range = 12-24 breaths per minute.E. > than 24 = tachypnea – if breathing in great depth then called hyperpneaF. < than 12 = bradypneaG. Difficulty in breathing is called dyspneaH. Quality of breathing is determined as well as the rate of breathing1. Depth2. Clarity of breath sounds3. Pain with breathing4. Difficulty breathing – use of accessory muscles – sternocleidomastoidand intercostal musclesV. Procedure for taking TPRsA. If using glass thermometer, insert the thermometer. If axillary or rectalhold the thermometer throughout the time. If oral, insert the thermometerand proceed to take the pulse and respiration.B. If using electronic – take the temperature first, then proceed to the pulseand respiration.C. When taking the pulse and respiration, do not drop the wrist until both thepulse and respiration are taken. This way the person does not know whenhis/her respirations are being measured – insuring a more accuratemeasurement.D. When measuring axillary temperature, remove any clothing that couldimpede the accuracy of the temperature. Also clean the axilla if there isexcessive deodorant or perspiration present.E. When measuring the rectal temperatures, always lubricate thethermometer with water-soluble gel before inserting into the rectum.F. Never touch the bulb end of the thermometer with the fingers.V. ChartingA. Chart in order of TPRB. Do not write T =, P =, etc., simply 98.6 – 84 – 22 ................
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