LECTURE ON:

NCM- 100

Prepared by:

Prof. Gloria Yang

FEUIN- Faculty
 Basic Nursing Skills -Introduction to VITAL SIGNS

This session introduces the basic nursing skills student

nurse will need to perform towards their clients in taking
Vital Signs

Learning Objective:
After 6 hours of brief Didactic followed by actual
performance on vital signs measurement which consist of
taking : (TPR-BP)
 Temperature,
 Pulse Rate,
 Respiratory Rate,
 Blood Pressure &
 Pain Assessment (higher level)
• students should be able to perform the following with
confidence:
 A. BODY TEMPERATURE ( T ) :
1. Understand Importance/
purposes of Vital Signs in
assessing client’s clinical
condition.
2. Identify the various sites in
assessing Body Temperature.
3. Distinguish & handle different
types of Thermometer.
4. Accurately compute/convert :
Centigrade & Fahrenheit / vice-
versa
5. Recognize factors on alteration
in body temperature
6. To perform the step-by-step
procedure on how to take body
temperature.
7. That students is able to perform
with confident n taking body
temperature.
B. PULSE RATE (PR) :
1.Understand importance/
purposes of checking
Peripheral and Apical Pulse
Rate in assessing the client’s
clinical condition.
2. Identify factors affecting
Pulse Rate
3. Recognize different Pulse
sites
4. Internalize the art of
assessing Pulse Rate
5. Develop understanding of
Pulse Volume & variation
of PR by age.
6. Apply with confidence the
procedure on taking the
Pulse and Apical Pulse
Rate of Clients.
c. RESPIRATION RATE (RR)
1. Understand importance/
purposes of checking
Respiratory Rate in
assessing the client’s
clinical condition.
2. Assess altered
breathing patterns & sounds
3. Recognize the factors
affecting Respirations
4. Identify the variations in
respiration by Age
5. Comprehend the measures
to promote respiratory
function
6. Perform with confidence
the procedure in
assessing and actual
performance of taking RR
D. BLOOD PRESSURE ( BP )
1. Understand importance/
purposes of checking Blood
Pressure in assessing the
client’s clinical condition.
2. Recognize the factors affecting
Blood pressure
3. Identify the determinants of
Blood Pressure
4. Detect the different
classification of Blood
pressure
5. Realize the common errors in
assessing Blood pressure
6. Perform with confidence the
procedure in assessing and
actual performance of taking
BP.
Forever yang//2013
 VITAL SIGNS: T-P-R / BP /PAIN ASSESSMENT

 Assessing & monitoring client’s clinical

condition is one of the reason & main object
where nursing care is required.

 Many nursing decisions are based on

assessment data performed by nurses
through vital sign measurement.

 Measurements of vital signs -indicate the

physiological functioning of the circulatory,
respiratory, neural & endocrine systems &
others.

 Data obtained from these measurement are to

be used in conjunction with client’s health
/medical history, physical assessment, for
medical practitioners caring for clients.
 Taking vital signs being Nurses’
fundamental function is
important to establish
BASELINE VALUES of client’s
usual as compared to current
measurement.

 Any discrepancy may indicate

potential threat to client’s
health condition of possible
occurrence of disease/illness.

 Remember to :
RECORD /DOCUMENT & REPORT
to appropriate personnel.
 What are vital signs?
• Vital signs are measurements of the body's
most basic functions.
• Reflect the function of our body processes
that are essential for life.
 Regulation of body temperature/heat -
TEMPERATURE
 Heart function-  PULSE / HEART RATE
 Breathing-in/ex-hale RESPIRATORY RATE
 Blood Circulation/pressure against walls of
arteries –  BLOOD PRESSURE

Vital signs are useful in : detecting or monitoring

medical problems and it can be measured in a
medical setting, at home, at the site of a medical
emergency, or elsewhere.
Explain the meaning of vital signs and the
abbreviations used for each vital sign.
Abbreviations:

• Temperature – T
 Pulse – P
 Respirations – R
 Blood Pressure – BP
o Vital signs - TPR and BP

9
TIMES TO ASSESS VITAL SIGNS –
1. On Admission to Health Agency as a Baseline data

2. When there is a change in health status or report abnormal

symptoms

3. Before & after surgery on an invasive procedure

4. Before & /or after administering a medication that could

affect respiratory or cardiovascular system, Ex : Digitalis

5. Before & after any nursing intervention that could affect the
vital sign . Ex: ambulating a client who has been on bed rest
or days following surgery
Body Temperature - reflects the balance between the heat produced
& the heat loss from the body, measured in Heat Units called “degrees”.

Factors affecting Body Temperature:

1. Age- Infants & elderly are both greatly influenced by extreme
environmental temperature , this is due to decrease in
Thermoregulatory controls.
2. Diurnal or Circadian Rhythm variation- refers to sleep-wake rhythm,
a pattern that varies from person-to person.
Body Temperature vary throughout the day-early am and late pm.
3. Exercise- increases body temperature

4. Hormones- ovulation due to Progesterone secretion raises BT.

5. Stress- stimulation of sympathetic Nervous system produce

epinephrine increase metabolic activity increase BT

6. Environment- externally affect’s the body’s Thermoregulatory

systems .
SITES IN ASSESSING BODY TEMPERATURE:

1. ORAL – this method reflects changing body temperature

more quickly than rectal method.
> Thermometer is placed under the tongue (sublingual).

 Advantages:- accessible & convenient

 Disadvantages:- glass thermometer can break if bitten.

- Inaccurate if client has just ingested hot or cold food,
fluid or SMOKE.

- Could injure mouth following oral surgery

2nd SITE for Body Temperature:

2. RECTAL -: readings are considered more accurate.

- readings are taken per rectal area.

 Advantages-: more reliable

 : inconvenient & unpleasant- for patients who cannot turn

who cannot turn to sides
-: could injure rectum following rectal surgery

-: Presence of stool/fees may interfere with

thermometer placement.

> If stool soft, thermometer might be

embedded in stool rather than the wall of
rectum
3rd SITE ASSESSING BODY TEMPERATURE:

3. AXILLARY -: preferred for infants / new-borns;

because it is accessible & offers no possibility of rectal
perforation

 Advantages-: safe & non-invasive

 Disadvantages-: thermometer must be left in place for a

longer period to obtain accurate measurement.
4th SITE FOR BODY TEMPERATURE:

4. TYMPANIC MEMBRANE-: nearby tissue in the ear

canal is another core body temperature.

 Advantages-: readily accessible ; reflects the core

temperature more faster.
 Disadvantages-: can be uncomfortable & involves risk for
injuring the membrane if probe inserted too far.

-: Repeated measurements may vary. Right & left

measurement may differ.

-: presence of cerumen /ear wax can affect the reading of

temperature.
5th SITE FOR BODY TEMPERATURE:

5. FOREHEAD-: using a chemical thermometer or a

Temporal Artery Thermometer.

> More useful for infants & children

 TYPES OF THERMOMETER:

1. Mercury-in-Glass Thermometer:
-oral, axilla, rectal Thermometer

2. Electronic Thermometer

3. Chemical Disposable Thermometer

4. Tympanic/Infrared Thermometer

5. Temporal Artery Thermometer

Normal Temperature Range
For Healthy Adult:
• Oral - 97.6 - 99.6 F (Fahrenheit) or 36.5 -37.5 C
(Celsius)

• Rectal - 98.6 - 100.6 F or 37.0 - 37.5 C

• Axillary - 96.6 - 98.6 F or 36.0 - 37.0 C

• Tympanic- 99.5 -98.6 F or 36.0 – 37.5 C

• Forehead – 94.0 F or 34.4 -37 C

19
 SAMPLE COMPUTATION:

To convert from Fahrenheit to To convert from Celsius to

Celsius: Fahrenheit :
- deduct 32 from the “F” reading
& then - Multiply “C” reading by the
- Multiply by the fraction 5_ fraction 9_ add 32 as shown:
as shown: 9 5
F= C x 9_ +32
C= F temp - 32 x 5_
5
9
F= 100 C = 37.7

= (100-32) x 5/9 = ( 37.7 x 9 )

5
= 68 x 5 = 340 = 37.7
9 = 67.86 + 32 = 99.89 ( 100 )
 ALTERATIONS IN BODY TEMPERATURE:

. PYREXIA/ HYPERTHERMIA / FEVER - body temperature

above the usual

. HYPERPYREXIA / HIGH FEVER - a very high fever

= 41 degree C or 108 F

. HYPOTHERMIA- core body temperature below the lower

limit of normal .

 FEBRILE- when a client has FEVER

 AFEBRILE- when a client do not have fever

4 COMMON TYPES OF FEVER:

1. INTERMITTENT FEVER – body temperature alternates @ regular

intervals between periods of fever & period of normal or
subnormal temperatures.

2. REMITTENT FEVER- a wide range of temperature fluctuations (

more than 2 degree C or 3.6 degree F) occurs over 24 hour
period, all of which are above normal.

3. RELAPSING FEVER- short febrile periods of a few days are

interspersed with periods of 1 or 2 days of normal temperature.

4. CONSTANT FEVER- body temperature fluctuates minimally but

remains above normal.

FEVER SPIKE- temperature that rises to fever level rapidly following a

normal temperature & then returns to normal within a few hours.
ASSESSING BODY TEMPERATURE:

PURPOSES:

1. To establish baseline data for subsequent evaluation

2. To identify whether the core temperature is within normal

range

3. To determine changes in the core temperature in response

to specific therapies. Ex: anti-pyretic medications,
immunosuppresive therapies, surgeries.

4. To monitor clients at risk for imbalanced body temperature

(Ex: clients at risk for infection, those who have been
exposed to temperature extremes)
ASSESSING BODY TEMPERATURE

Preparation
1 Assess:
• Clinical signs of Fever
• Clinical signs of Hypothermia
• Site most appropriate for measurement
• Factors that might later core body temperature.
2. Assemble equipment:
• Thermometer
• Thermometer sheath or cover
• Water-soluble lubricant for a rectal temperature
• Disposable gloves
• Towel for axillary temperature
• Tissues / wipes
ASSESSING BODY TEMPERATURE -2

Procedure
1. Introduce yourself and verify the client’s identity.
Explain to the client what you are going to do, why it is necessary and how the
client can cooperate.
2. Perform hand hygiene & observe other appropriate infection control
procedures.
3. Provide for client privacy.
4. Place the client in the appropriate position.
5. Place the thermometer.
 Apply a protective sheath or probe cover, if appropriate
 Lubricate rectal thermometer
ASSESSING BODY TEMPERATURE -2

6. Wait the appropriate amount of time.

Electronic and tympanic thermometer will indicate that the reading is
complete via a light or tone.
Check package instructions for length of time to wait prior to reading
chemical dot or tape thermometers.
7. Remove the Thermometer and discard the cover or wipe with a tissue , if
necessary.
8. Read the Temperature.
If the temperature is obviously too high, too low or inconsistent with the
client’s condition, re-check it with a thermometer known to be functioning
properly.
9. Wash the thermometer, if necessary and return it to the storage location.
10. Document the temperature in the client’s record.
10.7 Define pulse and discuss the way it is
measured.
Demonstrate counting the Radial pulse rate.

 Radial pulse (the pulse taken on your wrist)

 Pulse of the radial artery palpated at the wrist

over the radius.

 The radial pulse is the one most often taken and

recorded because of the ease with which it is
located and palpated.

FOREVER YANG 2013

Demonstrate measuring the Apical pulse .

 Apical pulse (taken near your heart with a

stethoscope).

• The apical pulse is the pulse heard at the apex of

the heart (which is the pointed lower extremity of
the heart)

 You can hear the apical pulse by placing your

stethoscope at the 5th intercostal space (spaces
between the ribs) on the left side just left of the
sternum.

FOREVER YANG 2013

PULSE – KEY CONCPETS-:

- is a wave of blood created by contraction of the left

Ventricle of the heart.

- Represents the Stroke Volume (SV) , Cardiac Output (CO) ,

amount of blood that enters the arteries with each
ventricular contraction.

- COMPLIANCE / DISTENSIBILITY- ability of the arteries to

contract & expand.

- CARDIAC OUTPUT- is the volume of blood pumped into the

arteries by the heart & = the result of the SV times HR
/minutes. CO = SV X HR
FACTORS AFFECTING PULSE RATE:
1. AGE- as age increases, PR gradually decreases
2. GENDER / SEX- after Puberty, the average male’s PR is
slightly lower than female’s PR
3. EXERCISE - PR increases normally with activity
4. FEVER- PR increases in response to the lowered BP that
results from peripheral vasodilation associated with
elevated body temperature & because of the increased
metabolic rate.
5. Medications- some medicines decreases PR while others
increases PR.
6. HYPOVOLEMIA-loss of blood from the vascular system
normally increases PR
7. STRESS- stress increases the rate as well as the force of
heart beat.
8. POSITION CHANGES – when a person is seated or
standing , blood usually pools on to dependent vessels of
the venous system. Pooling results in a transient decrease
in the venous blood return to the heart & a subsequent
reduction in BP & increase in HR.
9. PATHOLOGY- certain diseases such as heart problems or
oxygenation can alter the resting PR.
Sites For Taking Pulse

• Radial – base of
thumb
• Temporal – side of
forehead
• Carotid – side of neck
• Brachial – inner
aspect of elbow
• Femoral – inner
aspect of upper thigh
• Posterior Tibial-
Forever yang 2013
 Sites For Taking Pulse
(continued)

• Popliteal - behind knee

• Dorsalis pedis – top of
foot
• Apical pulse – over
apex of heart
–taken with
stethoscope
–left side of chest

Forever yang 2013

PULSE SITES:- continue

• PERIPHERAL PULSE- is a pulse located

away from the heart.

. APICAL PULSE- is a central pulse that is

located at the apex of the heart.

. PULSE DEFICIT- the discrepancy between

the Apical Pulse & Radial Pulse.
ASSESSING THE PULSE -:

1. PULSE RATE- number of Pulse beat per minute.

 Tachycardia- excessively fast HR (over 100 bpm-adult)

 Bradycardia- HR in adult less than 60 bpm

2. PULSE RHYTM-is the pattern of the beats & intervals

between the beats.

• Normal Pulse- should have equal time lapses between

beats
. Dysrhythmia/ Arrhythmia- pulse with irregular rhythm

3. PULSE VOLUME-also called the PULSE STRENGTH or

AMPLITUDE- refers to the force of blood with each
beat.
PULSE VOLUME -:

SCALE DESCRIPTION
0 Absent, Not discernible

1 Thready or weak, difficult to feel

2 Normal, readily detected, obliterated

by presence of strong pressure

3 Bounding, difficult to obliterate

VARIATIONS IN PULSE BY AGE -:

AGE PULSE AVERAGE (Ranges)

New born 130 ( 80-180)
1 year 120 ( 80—140)
5- 8 years 100 ( 75 – 120)
10 years 70 ( 50- 90 )
Teen 75 ( 50- 90 )
Adult 80 ( 60- 100)
Older Adult 70 ( 60- 100 )
 How to check your pulse:
As the heart forces blood through the arteries, you feel the beats by firmly
pressing on the arteries, which are located close to the surface of the skin
at certain points of the body.
The pulse can be found on the side of the lower neck, on the inside of the
elbow, or at the wrist.
When taking your pulse:
•Using the first and second fingertips, press firmly but gently on the arteries
until you feel a pulse.

•Begin counting the pulse when the clock's second hand is on the 12.

•Count your pulse for 60 seconds

•When counting, do not watch the clock continuously, but concentrate on

the beats of the pulse.

•If unsure about your results, ask another person to count for you .
ASSESSING PERIPHERAL PULSE -:

PURPOSES:

1. To establish baseline data for subsequent

evaluation

1. To identify whether PR is within normal range

2. To determine whether the rhythm is regular & the

Pulse Volume is appropriate

3. To compare the equality of the corresponding

peripheral pulses on each side of the body.

4. To monitor & assess changes in the client’s health

status

5. To monitor client’s at risk for pulse alterations

( eg. those with history of heart disease or
experiencing cardiac arrhythmias , haemorrhage,
acute pain, infusion of large volumes of fluids, fever)
ASSESSING PERIPHERAL PULSE -1

Preparation
1. Assess:
• Clinical signs of Cardiovascular alterations
• Factors that might alter pulse rate.
• Site most appropriate for assessment
2. Assemble Equipment
• Watch with a second hand or indicator
• If using Doppler Ultrasound Stethoscope (DUS) , assemble the
transducer probe, the stethoscope headset, transmission gel, and
tissue/wipes.
ASSESSING PERIPHERAL PULSE -2

Procedure
1. Introduce yourself and verify the client’s identity.
Explain to the client what you are going to do, why it is necessary and how
the client can cooperate
2. Perform hand hygiene and observe other appropriate infection control
procedures.
3. Provide client privacy
4. Select Pulse point
5. Assist the client to a comfortable resting position
Assessing Peripheral Pulse -: 3

6. Palpate and count the pulse. Place two or three middle fingertips
lightly and squarely over the pulse point.
• Count for 1 full minute . Record the pulse in beats per minute
on your worksheet. If taking a client’s pulse for the first time, if
obtaining baseline data or if the pulse is irregular, count for a
full minute. An irregular pulse also requires taking the Apical
Pulse.
7. Assess the Pulse rhythm and volume.
8. Document the pulse rate, rhythm and volume
and volume, and your actions in the client record.
ASSESSING Apical Pulse-:
Purposes:

1. To obtain HR of new born, infants & children

2 to 3 years old or of an adult with an
irregular peripheral pulse.

2. To establish baseline data for subsequent

evaluation

3. To determine whether the cardiac rate is

within normal range and the rhythm is
regular.

4. To monitor clients with cardiac disease and

those receiving medications to improve
heart actions.
ASSESSING APICAL PULSE -1

Preparation
1. Assess:
• Clinical signs of Cardiovascular alterations
• Factors that might alter pulse rate.
2. Assemble Equipment
• Watch with a second hand or indicator
• Stethoscope
• Antiseptic Wipes
• If using Doppler Ultrasound Stethoscope (DUS) , assemble the
transducer probe, the stethoscope headset, transmission gel, and
tissue/wipes.
ASSESSING APICAL PULSE -2

Procedure
1. Introduce yourself and verify the client’s identity.
Explain to the client what you are going to do, why it is necessary and how
the client can cooperate
2. Perform hand hygiene and observe other appropriate infection control
procedures.
3. Provide client privacy
4. Position the client appropriately in a comfortable supine position or assist to
a sitting position.
Expose the area of the chest over the apex of the heart.
ASSESSING APICAL PULSE -3

5. Locate the Apical Pulse

Palpate the Angle of Louis, just below the suprasternal notch and felt as a
prominence
Slide your index finger just to the left of the Client’s sternum and palpate the
second intercostal space
Place your middle or next finger in the third intercostal space and continue
palpating downward until you locate the fifth intercostal space
Move your index finger laterally along the fifth intercostal space towards the
Mid clavicular line. Normally , the apical pulse is palpable at or just medial
to the MCL.
ASSESSING APICAL PULSE -4

6. Auscultate and count heartbeats

Use antiseptic wipes to clean the earpiece and diaphragm of the stethoscope
Warm the diaphragm of the stethoscope by holding it I the palm of your
hand for a moment
Insert the earpieces of the stethoscope into your ears in the direction of the
ear canals or slightly forward to facilitate hearing
Tap your finger lightly on the diaphragm of the stethoscope to be sure it is
the active side of the head.
Place the diaphragm of the stethoscope over the apical impulse and listen
for the normal S1 and S2
If you have difficulty hearing the apical pulse, ask the supine client to roll
onto the left side, or the sitting client to lean forward
• If the rhythm is regular, count the heartbeats for 30 seconds and
multiply by 2.
• if the rhythm is irregular, count the beats for 60 seconds.
ASSESSING APICAL PULSE -5

7. Assess the rhythm and the strength of the heartbeat

Assess the rhythm of the heartbeat by noting the pattern of intervals between
the beats.
Assess the strength ( volume) of the heartbeat
Forever yang 2013
Define respiration and discuss how the respiratory rate is measured.
Respiration – act of breathing.
 process of taking in oxygen and expelling carbon dioxide from
lungs and respiratory tract

1. Inhalation/Inspiration- intake of air into the lungs

2. Exhalation/Expiration- breathing out or the movement of
gases from the Lungs to the atmosphere.
3. Ventilation- refer to the movement of air in & out of the Lungs
4. External respiration- refers to the interchange of oxygen &
carbon dioxide between the alveoli of the Lings & the
pulmonary blood.
5. Internal respiration- takes place throughout the body. It is the
interchange of these same gases between the circulating
blood & the cells of the body.
ALTERED BREATHING PATTERNS & SOUNDS :-
BREATHING PATTERNS:
1. RATE
• EUPNEA - breathing that is normal in rate & depth
• Tachypnea - quick, shallow breathing
• Bradypnea- abnormally slow breathing
• Apnea- cessation of breathing

2.VOLUME-
• HYPERVENTILATION- over expansion of Lungs- rapid and deep breath
• HYPOVENTILATION-under expansion of Lungs- shallow respirations.

3. RHYTHM-
• Cheyne-Stoke Breathing- rhythmic waxing and waning of respirations –
from very deep to very shallow breathing & temporary apnea

4. EASE OR EFFORT-
• Dyspnea- difficult & laboured breathing, during which the individual has a
persistent, unsatisfied need for air & feels distressed.
• Orthopnea- ability to breathe only in upright sitting or standing positions.
ALTERED BREATHING PATTERNS & SOUNDS
BREATH SOUNDS
• AUDIBLE WITHOUT AMPLIFICATION -:
 STRIDOR- a shrill ,harsh sound heard during inspiration with laryngeal
obstruction
 STERTOR- snoring or sonorous respiration, due to partial obstruction of
upper airway.
 WHEEZING- continuous high-pitched musical squeak or whistling sound
 BUBBLING-gurgling sound heard as air passes through moist secretions
in the respiratory tract.

CHEST MOVEMENTS:
 Intercostal retraction- in-drawing between ribs
 Substernal retraction- in-drawing beneath the breastbone
 Suprasternal retraction- in-drawing above clavicle

SECRETION & COUGHING:

 HEMOPTYSIS- presence of blood on the sputum
 PRODUCTIVE COUGH- cough accompanied by expectorated secretion
 NON=PRODUCTIVE COUGH-dry, harsh cough with out secretions
VARIATIONS IN RESPIRATION BY AGE :-

AGE PULSE AVERAGE (and ranges)

New born 35 (30-80)
1 year 30 (20-40)
5-8 years 20 (15-25)
10 years 19 (15-25)
Teen 18 (15-20)
Adult 16 (12-20)
Older Adult 16 (15-20)
FACTORS AFFECTING RESPIRATION:-

1. Exercise

2. Stress

3. Environmental Temperature

4. Medications
Factors Affecting Respiratory Rate
• Age
• Activity level
- Exercise
• Drugs (medication taken)
• Stress
• Illness
• Emotions
• Environmental
Temperature
 MEASURES TO PROMOTE RESPIRATORY
FUNCTIONS:

1. Deep breathing & coughing

2. Hydration
3. Medication
4. Percussion, vibration & postural drainage
5. Oxygen Therapy
 Measuring Respirations

• Qualities of normal respirations

–12-20 respirations per minute
–Quiet
–Effortless
–Regular
ASSESSING RESPIRATION-:

Purposes:

1. To acquire baseline data against which future measurements can

be compared.

2. To monitor abnormal respiration & respiratory pattern & identify

changes

3. To monitor respirations before or following the administration of

general anaesthetics or any medication that influences
respiration

4. To monitor clients at risk of respiratory alterations ( e.g. those

with fever, pain, acute anxiety, COPD , respiratory infections,
Pulmonary Edema, Emboli, chest trauma or constriction, brain
stem injury
ASSESSING RESPIRATION-1

Preparation
1. Assess:
• Skin and mucous membrane color
• Position assumed for breathing
• Signs of Cerebral anoxia
• Chest movements
• Activity tolerance
• Chest pain
• Dyspnea
• Medications affecting respiratory rate
2. Assemble equipment
• Watch with a second hand or indicator
ASSESSING RESPIRATION -2

Procedure
1. Introduce yourself and verify the client’s identity.
Explain to the client what you are going to do, why it is necessary and how
the client can cooperate
2. Perform hand hygiene and observe other appropriate infection control
procedures.
3. Provide client privacy
4. Observe or palpate and count the respiratory rate.
If you anticipate the client’s awareness of respiratory assessment, place a
hand against the client’s chest to feel the chest movements with breathing or
place the client’s arm across the chest and observe the chest movements
while supposedly taking the radial pulse.
Count the RR for one full minute. An inhalation and an exhalation count as
one respiration.
ASSESSING RESPIRATION - 3

5. Observe the depth, rhythm and character of respiration

Observe the respiration for depth by watching the movement of the chest
Observe the respiration regular or irregular rhythm
Observe the character of respirations- the sound they produce and the effort
they require
6. Document the RR, depth, rhythm and character on the appropriate record
Forever yang 2013
Define blood pressure and discuss how it is measured.
BLOOD PRESSURE -:

- The force exerted on arterial walls by blood flowing within a vessel.

- Measured in mmHg
- Recorded as a Fraction Ex: 120 - SYSTOLIC
80 - DIASTOLIC

- SYSTOLIC BP- is the pressure of the blood as a result of contraction

of the ventricles, that is, the pressure of the height of
the blood wave.

- DIASTOLIC BP- is the pressure when the ventricles are at rest.

- is the lower pressure present at all time within the
arteries.

PULSE PRESSURE- the difference between the Systolic & Diastolic

pressures. Normally, is about 40 mmHg
FACTORS AFFECTING BP :-

1. AGE – newborns have a mean systolic pressure of about 75 mmHg . The

pressure rises with age, reaching a peak at the onset of puberty & then
trends to decline somewhat.
2. EXERCISE- physical activity increases the CO , hence BP too
3. STRESS- stimulation of Sympathetic Nervous System increases CO &
vasoconstriction of the arterioles, thus increasing BP reading
4. RACE-African American males over 35 years have higher BP than
European American Male of the same age
5. GENDER-after puberty, females usually have lower BP than males of the
same age.
6. MEDICATIONS- certain medicines can either increase or decrease BP
7. OBESITY-predisposes people of all ages to increase BP

8. DIURNAL VARIATIONS- pressure is usually lower in the morning, when

metabolic rate is lowest, then rises throughout the day &
peaks in the late afternoon or early evening.

9. DISEASE PROCESS- any conditions affecting the CO , blood volume, blood

viscosity, &/or compliance of the arteries has a direct effect on the blood
pressure.
DETERMINANTS OF BP -:

1. Pumping action of the heart

2. Peripheral vascular resistance

3. Blood Volume

4. Blood viscosity
KOROTKOFF SOUND
CLASSIFICATION OF BP -:

CATEGORY SYSTOLIC BP DIASTOLIC

BP
Normal < 120 And < 80
Pre-Hypertension 120 – 139 Or 80-90
Hypertension 140-159 Or 90-99
Stage - 1
Hypertension > 160 Or > 100
Stage - II
COMMON ERRORS IN ASSESSING BP -:
1. Bladder cuff too narrow
2. Bladder too wide – erroneously low
3. Arm unsupported – erroneously high
4. Insufficient rest before assessment –
erroneously high
5. Repeating assessment too quickly –
erroneously high

6. Cuff wrapped too loosely or unevenly -

erroneously high

7. Deflating cuff too quickly -erroneously low

systolic & high diastolic reading
COMMON ERRORS IN ASSESSING BP -:

8. Deflating cuff too slowly-erroneously high

diastolic reading

9. Failure to use the same arm consistently-

inconsistent measurement

10. Arm above level of Heart - erroneously low

11. Assessing immediately after a meal while client

smokes or has pain- erroneously high

12. Failure to identify auscultatory gap - erroneously

low Systolic & low Diastolic pressure.
ASSESSING BP -:

PURPOSES:
1. To obtain a baseline measure of Arterial BP for
subsequent evaluation

2. To determine the client’s hemodynamic status ( e.g. SV of

the heart & blood vessel resistance.

3. To identify& monitor changes in BP resulting from a

disease process medical therapy (e.g. Presence or
history of cardiovascular disease, renal disease,
circulatory shock, or acute pain ; rapid infusion of fluids
or blood products )
ASSESSING PERIPHERAL PULSE -1

Preparation
1. Assess:
• Signs and symptoms of Hypertension
• Signs and symptoms of Hypertension
• Factors affecting BP.
• Client for allergy to latex cuff
2. Assemble Equipment
• Stethoscope or DUS .
• Blood pressure cuff of the appropriate size
• Sphygmomanometer
ASSESSING BP -2

Procedure
1. Introduce yourself and verify the client’s identity.
Explain to the client what you are going to do, why it is necessary and how
the client can cooperate
2. Perform hand hygiene and observe other appropriate infection control
procedures.
3. Provide client privacy
4. Position the Client appropriately.
The adult client should be siting unless otherwise specified. Both feet should
be flat on the floor.
The elbow should be slightly flexed, with the palm of the hand facing up and
the forearm supported at the heart level.
Expose the upper arm
ASSESSING BP -3

5. Wrap the deflated cuff evenly around the upper arm.

Locate the Brachial artery
Apply the center of the bladder directly over the artery
For an adult, place the lower border of the cuff approximately 2.5 cm ( 1
inch) above the antecubital space
6. If this is the client's initial examination , perform a preliminary palpatory
determination of systolic pressure.
Palpate the brachial artery with the fingertips
Close the valve on the bulb
Pump up the cuff until you no longer feel the brachial pulse.
Note the pressure on the sphygmomanometer at which then pulse is no
longer felt.
Release the pressure completely in the cuff and wait 1 -2 minutes before
taking further measurements
ASSESSING BP -4

7. Position the Stethoscope appropriately

Cleanse the earpieces with antiseptic wipe
Insert the ear attachments of the stethoscope in your ears so that they tilt
slightly forward.
Ensure that the stethoscope hangs freely from the ears to the diaphragm
Pace the bell side of the amplifier of the stethoscope over the brachial pulse.
Place stethoscope directly on the skin and not on the clothing over the site.
Hold the diaphragm with the thumb and index finger.
ASSESSING BP -5

8. Auscultate the Client’s BP

Pump up the cuff until the sphygmomanometer is 30 mm Hg above the
point where the brachial pulse disappeared
Release the valve on the cuff carefully so that the pressure decreases at the
rate of 2-3 mm Hg per second
As the pressure falls, identify the manometer reading at Korotkoff phase I ,
IV, V.
Deflate the cuff rapidly and completely
Wait 1-2 minutes before making further determinations.
Repeat the above steps once or twice as necessary to confirm the accuracy of
the reading.
9. If this is the client’s initial examination, repeat the procedure on the client’s
other arm.
10. Document – Record and report if necessary
 E- tool
For
Vital Sign
STUDENT PERFORMANCE EVALUATION TOOL
VITAL SIGNS
Name:_____________________________ Sec/Group No:________________ Date:________________
Area:______________________________ Faculty:__________________
Concept:___________________

DIRECTION: Rate the learner based on the competencies listed below

_____________________________________________________________________________________

KEY:
4 – Competent - Works competently & independently at all times even without guidance and
supervision.
3 – Very Good - Requires minimum guidance and supervision
2 – Satisfactory - Requires frequent guidance and supervision
1 – Needs Improvement - Requires close guidance and supervision
0 – Poor - Did not exhibit expected behavior even under close guidance and supervision

CRITERIA SCORE
A. ATTENDANCE AND ATTITUDE
1. Report on time and attend to activities punctually
2. Display proper grooming and wears complete
uniform
3. Behaves appropriately towards teachers, classmates
and clients
4. Accepts constructive criticism
B. PROCEDURE
1. Assemble all the equipment needed
2. Introduce yourself, and verify the client’s identity.
Explain to the client what you are going to do, why
it is necessary, and how the client can cooperate
3. Perform hand hygiene, and observe other
appropriate infection control procedure
4. Provide for client privacy
5. Place the client in a appropriate position
I Body Temperature
1. Clean the thermometer from bulb to stem
2. Insert the thermometer, wait for appropriate time
prior to reading
3. Remove the thermometer, clean from bulb to stem
with tissue
4. Read the temperature, ( if the temperature is
obviously too high, too low or inconsistent with the
client’s condition, recheck it with a thermometer
known to be function properly )
5. Wash the thermometer and return it to the
container
II Assessing Radial Pulse
1. Locate the radial pulse
2. Use watch with a second hand
3. Count the radial pulse rate for
60 seconds with one full minute
4. Document the rate, rhythm,
volume and elasticity of the
vessel walls
III Assessing Respiration

1. Presume that your still counting pulse,

Observe or palpate and count the
respiratory rate ( place a hand against the
client chest to feel the chest movements
with breathing.,) place the client’s arm
across the chest and observe the chest
movements while supposedly taking the
radial pulse
2. Count the respiratory rate for 30
seconds if the respirations are regular.
Count for 60 seconds if they are irregular.
An inhalation and an exhalation count as
one respiration
3. Observe the respiration for depth,
rhythm and character
4. Document the respiratory rate, depth,
rhythm, and character on the appropriate
record
IV. Assessing Blood Pressure
1. The adult client should be sitting unless
otherwise position in sitting on high fowlers
both feet should be flat on the floor
2. The elbow should be slightly flexed, with
the palm of the hand facing up and the
forearm supported at heart level
3. Expose the upper arm
4. Wrap the deflated cuff evenly around the
upper arm. Locate the brachial artery. Apply
the center of the bladder directly over the
artery for an adult, place the lower border of
the cuff approximately 2.5 cm ( 1inch ) above
the anticubital space
5. Palpate the brachial artery with the
fingertips
6. Position the stethoscope appropriately
7. Cleanse the earpiece with antiseptic wipe
8. Insert the ear attachment of the stethoscope
in your ear so that they tilt slightly forward
 8. Insert the ear attachment of the
stethoscope in your ear so that they tilt
slightly forward
9. Ensure that the stethoscope hangs freely
from the ears to the diaphragm
10. Place the bell side of the amplifier of the
stethoscope over the brachial pulse. Place
stethoscope directly on a skin, not on
clothing over the site. Hold the diaphragm
with the thumb and index fingers
11. Pump up the cuff until the
sphygmomanometer is 30 mmHg above the
point where the brachial pulse disappeared
from the usual BP of the client
12. Release the valve on the cuff carefully so
that the pressure decreases at the rate of 2-3
mmHg per second
13. As the pressure falls identify the
manometer reading at Korotkoff phase I,IV
and V
14. Remove the cuff
15. Wipe the cuff with an approved
disinfectant
16. Document and report pertinent
assessment data

TOTAL SCORE =
End of Today’s
Lecture

Thank you all

very much !