Introduction
• The most frequent measurements obtained by health
Vital Signs
• Many factors such as the temperature of the
environment, the patient’s physical exertion,
and the effects of illness cause vital signs to
change, sometimes outside an acceptable
range.
• Assessment of vital signs provides data to
identify nursing diagnoses, implement planned
interventions, and evaluate outcomes of care.
• An alteration in vital signs signals a change in
physiological function and the need for medical
or nursing intervention.
care providers are those of temperature, pulse, blood
pressure (BP), respiratory rate, and oxygen saturation.
• As indicators of health status, these measures indicate
the effectiveness of circulatory, respiratory, neural,
and endocrine body functions.
• Because of their importance they are referred to as
vital signs.
• Pain, a subjective symptom, is often called the fifth
vital sign and is frequently measured with the others
• Measurement of vital signs provides data to
determine a patient’s usual state of health (baseline
data).
GUIDELINES FOR MEASURING VITAL SIGNS
• Vital signs are a part of the assessment database.
• in a complete physical assessment
• or obtain them individually to assess a patient’s condition.
• Establishing a database of vital signs during a routine physical examination
serves as a baseline for future assessments.
• The patient’s needs and condition determine when, where, how, and by whom
vital signs are measured.
• We need to measure them correctly, also need to know expected values
interpret patient’s values, communicate findings appropriately, and begin
interventions as needed.
 Vital Signs

provide
reflect the information to evaluate
be a quick to monitor a
body’s present to evaluate to identify the patient’s
and efficient patient’s
physiological condition homeostatic problems response to
way condition
status balance in intervention
status

SectionⅠ
Guidelines for Taking Vital Signs Guidelines for Taking Vital Signs
5. use an organized, systematic
• be functional and appropriate 4. control or minimize approach when taking vital signs
1. select equipment : environmental factors may affect
• based on the patient’s condition and characteristics vital signs
• each procedure requires following a step-
by-step approach to ensure accuracy

2. know the patient’s
normal range of vital signs
• serve as a baseline for comparison with findings taken 6. the frequency of vital signs 7. use vital sign assessment to
assessment determine indications for
later medication administration
• based on the physician and the patient’s
condition • cardiac drugs

3. know the patient’s • Some illnesses or treatments cause predictable vital

medical history, therapies, sign changes. 8. analyze the results of vital sign
and prescribed medications • Most medications affect at least one of the vital signs. measurement 9. verify and communicate
• not interpret them in isolation significant changes in vital signs
 Definition of body temperature

R=Respiration Body temperature is the heat of the body.

BP=Blood reflects the balance between

P=Pulse
Pressure
the amount of heat
produced by body
processes

T- Vital Pa=Pain
Temperature
Signs the amount of heat
lost to the external
environment

Definition of body temperature Regulation

• core temperature : temperature of deep tissues (cranium, thorax,
abdominal and pelvic cavity ), relatively constant
• Surface temperature : the temperature of the skin, the subcutaneous
and the fat tissue , fluctuates from 36℃ to 38℃
• Physiological and behavioral mechanisms regulate the balance between
heat lost and heat produced, or thermoregulation.
• For the body temperature to stay constant and within an acceptable
range, various mechanisms maintain the relationship between heat
production and heat loss.
 Neural and Vascular Control.
The hypothalamus, controls body temperature the same way a thermostat works in the home. If the posterior hypothalamus senses that body temperature is lower than
the set point, the body initiates heat-conservation mechanisms.
A comfortable temperature is the “set point” at which a heating system operates.

Vasoconstriction (narrowing) of blood vessels reduces blood flow to the skin

The hypothalamus senses minor changes in body temperature. and extremities.

The anterior hypothalamus controls heat loss, and the posterior hypothalamus controls heat
production. Compensatory heat production is stimulated through voluntary muscle
contraction and muscle shivering.
When nerve cells in the anterior hypothalamus become heated beyond the set point, impulses are
sent out to reduce body temperature.
When vasoconstriction is ineffective in preventing additional heat loss,
Mechanisms of heat loss include sweating, vasodilation (widening) of blood vessels, and inhibition of shivering begins.
heat production.

The body redistributes blood to surface vessels to promote heat loss. Disease or trauma to the hypothalamus or the spinal cord, which carries
hypothalamic messages, causes serious alterations in temperature control.

Heat Production Heat Loss

Heat is lost through physical mode. The main heat loss part of the
body is skin. (70%) (R29%,elimination1%)
Heat production occurs
The main heat production during rest, voluntary
Radiation Conduction Convection Evaporation
Heat is produced in the
organs of the body are liver movements, involuntary
body through metabolism.
and skeletal muscles. shivering, and nonshivering
thermogenesis
 Radiation
• Radiation is the transfer of heat between two objects
without direct contact by electromagnetic waves.
• Heat radiates from the skin to any surrounding cooler
object.
➢ increase T difference between two objects
➢ Increase radiating surface area heat loss
➢ Increase the extent of vasodilation
Convection
• Convection is the transfer of heat away by air or liquid
movement.
• Heat is first transferred to air or liquid molecules
directly in contact with the skin. Air or liquid currents
carry away the warmed air or liquid.
• Heat loss velocity depends on
➢ current velocity
➢ T difference between the object and air or liquid
Conduction
• Conduction is the transfer of heat from one object to another with direct
contact.
• When the warm skin touches a cooler object(solid; gas; liquid), heat is
lost.
• Heat loss velocity depends on
➢ Heat conducting capability
➢ T difference between the two objects
➢ Contacting area
Evaporation
Evaporation is the transfer of heat energy when a liquid is
changed to a gas.
The body continuously loses heat by evaporation. --R;skin
300-400ml/d
By regulating sweating, the body promotes additional
evaporative heat loss. --febricide
Evaporation is the main heat loss mode when environment
temperature is higher than body temperature.
 Factors which
Normal Blood Temperature
increase metabolic rate or
(37℃ )
Environmental temperature
Regulation of Body Temperature
(to or toward) Increased blood temperature
above level at which “thermostat”
in hypothalamus is set (37℃ )

• Neural and Vascular Control Decreased blood

temperature Stimulated thermal receptors
Of heat-dissipating center
in hypothalamus, initiating
impulses that lead to
• Behavioral Control Increased heat
Loss by evaporation

Increased sweat
secretion

Increased heat Dilation of skin

Loss by radiation blood vessels

Heat loss mechanisms to maintain normal body temperature

Behavioral Control Behavioral Control

• environmental temperature fall: • The ability of a person to control body temperature depends on

add clothing
➢the degree of temperature extreme

move to a warmer place
raise the thermostat setting
increase muscular activity by running
sit with arms and legs tightly wrapped together
➢ the person’s ability to sense feeling comfortable or uncomfortable-
-infants, older adults
➢ thought processes or emotions--depression
➢ the person’s ability to remove or add clothes
—infants, children
Factors Affecting Body Temperature Factors Affecting Body Temperature
Measurement Circadian
Age:
site rhythms :
• Hormonal influences :
drops between 2 With age,T tends
progesterone: raise the body temperature
and 6 AM to fall .

• Exercise :increase body temperature

infancy:
peaks between 1
and 6PM
temperature
regulation is
• Medications:
labile
anaesthetic: depress T regulation center T
aging: control
mechanisms
promote vasodilation
deteriorate

febrifuge: T

Factors Affecting Body Temperature Alterations in Body Temperature

• Stress: Stimulate sympathetic nervous system

• Fever or Hyperthermia
-- epinephrine and norepinephrine production ,
-- metabolic activity heat production --T
• Hypothermia
• Environment: the extent of exposure,
air temperature and humidity
the presence of convection currents

• Ingestion of hot/cold liquids

• Smoking: increase body temperature
 Fever or Hyperthermia
Fever process and manifestation
A body temperature above the usual
range is called fever.
Fever-chill phase: Plateau phase : Fever break phase:
A true fever results from an
alteration in the hypothalamic set
point. • heat production>heat • heat production=heat • heat production<heat
loss; loss; loss;
Pyrogens such as bacteria and virus • experience tiredness, • warm, dry, R , P , • skin -- warm, flushed,
cause a rise in body temperature. paleness, dryness, headache, faint, diaphoresis (2
chills, shivers, and feels inappetence patterns)
cold (2 patterns)
Fever is an important defense
mechanism.

Classification of Fever (Oral) Patterns of Fever

℃ ℉ • Is the modality of a temperature curve.

Mild 37.5℃-37.9℃ 99.5℉-100.2℉ • Differ depending on the causative pyrogen.

• The increase or decrease in the amount of pyrogens results in fever
Moderate 38.0℃-38.9℃ 100.4℉-102.0℉
spikes and declines at different times of the day.
Severe 39.0℃-39.9℃ 102.2℉-105.6℉
• The duration and degree of fever depends on the pyrogen’s strength
Profound >41℃ >105.8℉ and the ability of the individual to responds.

----serve a diagnostic purpose.

Patterns of Fever Constant Fever

Constant Remittent
Fever Fever demonstrates little
sustains between fluctuation of less than
39~40℃ 1℃ within 24 hours. (
pneumonia , typhoid)
Irregular Intermitt
Fever ent fever

Remittent Fever Intermittent fever

fluctuates greatly in 24 hours, may

has great fluctuation cannot return to suddenly rise above the normal then
suddenly fall to or below the normal
above the normal normal temperature
with more than 1℃ level. (septicemia ,
in 24 hours rheumatic fever)
alternates regularly between a period of
fever and a period of normal temperature
levels (malaria, tuberculosis)
 Irregular Fever Hypothermia
A body temperature below the lower limit of normal 35℃ is called
hypothermia．
• irregularity alternates between a period of fever

and a period of normal temperature values.

Heat loss during prolonged exposure to cold overwhelms the body’s
ability to produce heat，causing hypothermia．
( influenza , cancer)

Hypothermia may be intentionally induced during surgical procedures

to reduce metabolic demand and the body’s need for oxygen．

Classification of Hypothermia Manifestation of Hypothermia

℃ ℉ 34.4-35℃: falls below 34.4℃ progress---

Mild 33.1℃-36℃ 91.5℉-96.8℉

• uncontrolled • heart and • cardiac
shivering，loss respiratory dysrhythmias，
Moderate 30.0℃-33℃ 86.1℉-91.4℉ of memory， rates • loss of
depression, • blood pressure consciousness
Severe 27℃-30℃ 80.6℉-86.0℉
poor judgment fall skin ---- ，
cyanotic • unresponsive to
Profound <27℃ <80.6℉ painful stimuli
Nursing Process
Assessment
and Thermoregulation
Intervention Assessment Mouth, rectum,
Sites: axillary tympanic
membrane

Glass
Thermometer

Implementa Nursing
tion Diagnosis Electronic
Thermometers
Thermometer

Planning Disposable
Thermometer

Glass Thermometer Electronic Thermometer

VCD
 Disposable Thermometer

require an individualized care plan -- maintaining

Nursing Diagnosis normothermia and reducing risk factors．

Nursing diagnosis Diagnostic foundation

education is important
Hyperthermia Increase body temperature above usual range
Flushed skin, skin warm to touch
Increased pulse and respiratory rate objects: restoring normothermia
Herpetic lesions of the mouth
Hypothermia Decreased body temperature Planning
Pale, cool skin minimizing complications
Decreased pulse and respiratory rate
Feelings of cold and chill
promoting comfort
Ineffective Older adults or infants, weak inability to adapt

thermoregulation to environmental temperature

care plan should support goals
 Examples for goals and outcomes
Examples for goals and outcomes
• Goal Minimize complications of altered body temperature.

Goal Outcome • Outcomes

patient’s blood pressure, pulse, and respirations
are within normal limits
patient’s skin integrity maintained
patient’s nutritional intake meets body needs
Temperature patient’s mucous membranes are moist
Restore and maintain maintained within patient is able to participate in ADL activities
normothermia. normal range during patient’s skin is warm and pink
environment changes. patient reports sense of rest and comfort

Examples for goals and outcomes Implementation

Goal Outcomes • Nursing measures for patient with a fever

• Reduce risk of altered • Patient identifies risk

body temperature.
• Nursing Interventions for patient with hypothermia
factors for altered body
temperature patient
practices measures to
prevent body
temperature alteration
 Nursing measures for patient with a fever Nursing measures for patient with a fever
Assessment
•Obtain body temperature during each phase of febrile episode． Intervention
•Assess for contributing factors such as dehydration infection or environmental temperature．
•Identify physiological response to temperature. • 1.Promote heat loss and lower the temperature.
Obtain a11 vital signs． Limit physical activity--heat production
Observe skin color．
reduce external covering--heat loss
Assess skin temperature．
physical therapies: ice packs ; bathing with alcohol- water solutions
Observe for shivering and diaphoresis．
Assess patient comfort and well-being． medication
•Determine phase of fever—chill plateau fever break． Take temperature after lowering the temperature physically for 30 minutes, record the readings.

2.Intensify observation of the patient’s conditions.

• take temperature
1 time/4h--severe fever,
4 time/day T<38.5℃ 3. Provide nutrients to meet increased energy needs
1-2 times/day for three days after body temperature returns normal.
•Observe patient’s face color, pulse, respiration, diaphoresis and other signs when taking patient’s
• Provide measures to stimulate appetite and offer well-balanced meals．
temperature.
• Assess for contributing factors such as dehydration，infection，or environmental
temperature． • Provide fluids at least 3000ml per day for patient with normal cardiac and renal functional

• Observe therapeutic effect. compensate fluids lost through insensible water loss and sweating．
• Observe the intake of liquids and the output of urine.
•Contact physicians promptly when find abnormal conditions.
 • 5.Provide psychological care.
• 4.Promote comfort and prevent complications.
• Meet patient’s reasonable requirements.
• Allow rest periods.
• Provide health education about fever.
• Control temperature of the environment without inducing shivering．
• 6.Obtain blood cultures when ordered.
• Provide oral hygiene and keep oral moist to prevent oral infection.

• Keep clothing and bed sheet dry to increase comfort and heat loss through conduction and • 7.Provide supplemental oxygen therapy as ordered to improve oxygen
convection．
delivery to body cells when ordered ．

Nursing Interventions for patient With

Evaluation
Hypothermia
• Control environment temperature at 22~24℃.
• all nursing goals have been met
• Elevate body temperature.
• use other evaluative measures such as palpation of the skin and
• Patients are monitored closely for cardiac irregularities and
electrolyte imbalances. Observe the vital signs, take assessment of pulse and respirations
temperature once at least per hour until the temperature • If therapies are effective，body temperature will return to a normal
returned normal and stability. range，other vital signs will stabilize and the patient will report a
• Eliminate pathogeny. sense of comfort．
• Health education.
Section Ⅲ Pulse Physiology and Regulation

• Physiology and Regulation The pulse is the rhythmical throbbing of arteries

produced by the regular contraction of the heart.
• Character of The Pulse and
The number of pulsing sensations occurring in 1 minute is
Observation of Abnormal Pulse
the pulse rate．
• Nursing process and Pulse Determination
Healthy adult pulse rate can range between 60-100 beats
per minute in quiet state.

Forming of Pulse
https://www.youtube.com/watch?v=RYZ4daFwMa8 Forming of Pulse

❑Electrical impulses from the sinoatrial node travel through heart muscle to stimulate cardiac ❑The expansion and retraction of the aorta sends a wave through the walls of the arterial system
contraction． that can be felt as a light tap on palpation. The pulse is the palpable bounding of the blood
flow．
❑Approximately 60 to 70 ml (stroke volume) of blood enters the aorta with each ventricular
contraction．

❑The arterial walls expand to compensate for the increase in pressure.

❑As the ventricle of the heart is in diastole, arterial walls return to original status by its own elasticity
and peripheral resistance.

❑https://www.youtube.com/watch?v=CWFyxn0qDEU
Factors Influencing Pulse Rate

• Age Normally Pulse Rates at Varies Ages • Sex : After puberty, the average male pulse rate is slightly lower than the female. 5 times/min

Age normal range of pulse rate (beats/min) • Exercise

• Temperature: Fever ; Hypothermia
Infants 120-160
• Emotions: Acute pain ,anxiety -- pulse rate
Toddlers 90-140
Unrelieved severe pain-- pulse rate
Preschoolers 80-110 • Drugs : atropine digitalis
School ages 75-100 • Postural changes: Standing or sitting , Lying down
Adolescent 60-90 • Hemorrhage:
Adult 60-100 • Pulmonary conditions: poor oxygenation

Character of The Pulse and Observation of

Abnormal Pulse Rate
Abnormal Pulse
• Pulse Rate • Tachycardia is an abnormally elevated heart rate，above 100 beats per minute in
• Pulse Rhythm adults． (fever, anemia, hemorrhage, hyperthyroidism)

• Strength • Bradycardia is a slow rate, below 60 beats per minute in adults．(atrioventricular block,

• Equality increased intracranial pressure, hypothyroidism )

 Pulse Rhythm Abnormal Pulse Rhythm

• Normally a regular interval of time occurs between each pulse or heart

• Intermittent Pulse
beat．
• Pulse Deficit
• An interval interrupted by an early or late beat or a missed beat

indicates an abnormal rhythm or dysrhythmia．

Intermittent Pulse Intermittent Pulse

• one pulse missing during regular or irregular pulse patterns
• one pulse absents every one pulse-bigeminy
• one pulse absents two normal pulses be called -- trigeminy
• occur in cardiomyopathy, myocardial infarction, digitalis intoxication,
and transient symptoms caused by excited emotion or fear
• Threatens the heart ability to provide adequate cardiac output
• An electrocardiogram (ECG) is necessary to define the pulse
dysrhythmia.
• Children often have a sinus dysrhythmia, which is an irregular
heartbeat that speeds up with inspiration and slows down with
expiration.
Pulse Deficit Strength
• Refers to pulse rate is less than heart rate
• reflects the volume of blood ejected against the arterial wall with
• An inefficient contraction of the heart
each heart contraction and the condition of the arterial vascular
--fails to transmit a pulse wave to the peripheral pulse site --creates a
system leading to the pulse site
pulse deficit．
• To assess a pulse deficit simultaneously • normally remains the same with each heartbeat
--one nurse assess radial rates
--a colleague assess apical rates
• may be graded or described as strong，weak，thready，or
• It can be seen in patients with atria fibrillation. bounding

Abnormal Strength Bounding Pulse

• an increased stroke volume, which can be palpated by fingertips

Water slightly
Bounding Thready Alternating Paradoxical
Hammer
Pulse Pulse pulse Pulse
Pulse
• often be seen with fever, hyperthyroidism, and aortic valve

incompetence.
Thready Pulse Alternating pulse

• weak and diminished, which is barely by fingertips • alternates between increased and diminished patterns along with

• often occurs with massive hemorrhage, shock, and aortic stenosis strong and weak contraction of the ventricles

• common causes are hypertensive heart disease, myocardial

infarction

Water Hammer Pulse Paradoxical Pulse

• The abrupt distension and quick collapse of the pulse is palpated • The pulse is obviously weak or not palpable on inspiration.

following the increased cardiac output with resultant pulse pressure • It results from the declined strokes by the left ventricle on

surges. inspiration.

• It often occurs with hyperthyroidism, aortic valve incompetence. • Common causes are pericardial effusion and constrictive pericarditis.
 Nursing process and
Equality
Pulse Determination
• The nurse should assess both radial pulses to compare the • Assessment
characteristics of each. A pulse in one extremity may be unequal in
• Nursing Diagnosis
strength or absent in many diseases, such as thrombosis, aberrant
• Nursing Plan
blood vessels, or aortic dissection.
• The carotid pulse should not be measured simultaneously because • Implementation
excessive pressure may stop blood supply to the brain. • Evaluation

Assessment Nursing Diagnosis

the nurse should collect the following data: • Tachycardia; bradycardia; dysrhythmias ; activity intolerance;

• the patient’s general condition, such as age , sex, status of an illness and anxiety; fear; fluid volume deficit; gas exchange impaired;
treatment; Hyperthermia; and hypothermia
• the pulse rate, rhythm, strength, equality and factors influencing pulse

• arterial wall elasticity

Nursing Plan Implementation

• interventions based on the nursing diagnosis identified and the • Instruct the patients to rest to decrease heart energy consuming.

• Oxygen administration is provided, according to the patient’s condition.

related factors;

• the expected outcomes generally: • Observe the patients’ condition closely.

❖patients can tell the normal range and physiological changes of the pulse;

❖patients can cooperate with the treatment and care.

Implementation Implementation
• Health education:
• Instruct the patients to take medicine on time and observe the effect and side effect of the

medicine.
❖stop smoking and drinking
❖take light and digestible diet, keep bowels smooth;

• Tell the patients to keep first-aid medicine along with them. ❖teach the patients to monitor the pulse prior to taking medicines that affect the heart rate.
❖Tell the patients to report any notable changes of heart rate or rhythm to health care provider.
❖Teach the patients and family members the basic first-aid skills.
• Provide mental support, let the patients to keep steady mood.
Evaluation

• evaluate the therapeutic effect by assessing the pulse rate, rhythm, strength, and equality;

• evaluate the patients’ mental status, cooperation with treatment and nursing;

• evaluate the patients’ knowledge about health．

• Respiration is the act of breathing. External respiration refers to the
interchange of oxygen and carbon dioxide between the alveoli of the
lungs and pulmonary blood.
• Internal respiration, by contrast, takes place throughout the body; it
is the interchange of these same gases between the circulating
blood and the cells of the body tissues.

• Inhalation or inspiration refers to the intake of air into the lungs.
• Exhalation or expiration refers to breathing out or the movement of
gases from the lungs to the atmosphere.
• Ventilation is also used to refer to the movement of air in and out of
the lungs.

98
There are basically two types of
breathing:
• Costal (thoracic) breathing; involves the external intercostals muscles • Diaphragmatic (abdominal) breathing involves the contraction and
and other accessory muscles, such as sternocleidomastoid muscles. relaxation of the diaphragm, and it is observed by the movement of
the abdomen, which occurs as a result of the diaphragm's
contraction and downward movement.
• It can be observed by the movement of the chest upward and
outward.

Mechanics and Regulation of

breathing
• During inhalation, the diaphragm contracts (flattens), the ribs move
upward and outward, and the sternum moves outward, thus
enlarging the thorax and permitting the lungs to expand.
Respiration is controlled
• Respiratory centers in medulla oblongata and the pons of the brain.
• by chemoreceptors located centrally in the medulla and
• peripherally in the carotid and aortic bodies.

• During exhalation, the diaphragm relaxes, the ribs move downward • These centers and receptors respond to changes in the concentrations of
and inward, and the sternum moves inward, thus decreasing the size oxygen (O2), carbon dioxide (CO2) and hydrogen (H) in the arterial blood.
of the thorax as the lungs are compressed.

• Normally breathing is carried out automatically and effortlessly.

 Altered Breathing Patterns and Sounds
Factors Affecting Respiration
• Several factors influence respiratory rate. 1. Breathing Patterns Rate

• Those that increase the rate include exercise (increase • Tachypnea -----quick, shallow breaths. Usually more
metabolism), stress (readies the body for fight or than 24R/M
flight), increased environmental temperature, and
lowered oxygen concentration at increased altitudes. • Bradypnea------abnormally slow breathing. Usually
less than 10R/M
• Factors that may decrease the respiratory rate include • Apnea---------cessation of breathing.
decreased environmental temperature, certain
medications e.g. narcotics and increased intracranial
pressure.

Rhythm
Volume
• Hyperventilation------overexpansion of the lungs characterized by • Cheyne-stokes breathing------Rhythmic waxing and waning of
rapid and deep breath. respiration, from very deep to very shallow breathing and temporary apnea.

• Hypoventilation-------under-expansion of the lungs, characterized by Ease or Effort

shallow respirations.
• Dyspnea -----difficult and labored breathing during which the individual has
a persistent, unsatisfied need for air and feels distressed.

• Orthopnea-------ability to breathe only in upright sitting or standing

positions
BreathAudible
soundswithout amplification Secretions and coughing
• Stridor ------a shrill (high-pitch), harsh sound heard during inspiration with
laryngeal obstruction. • Hemoptysis -------the presence of blood in the sputum.

• Stertor-------snoring or sonorous (loud) respiration, usually due to a partial

obstruction of the upper airway. • Productive cough-------a cough accompanied by expectorated
secretions.
• Wheeze------continuous, highpitched musical squeak or whistling sound
occurring on expiration and sometimes on inspiration when air moves
through a narrowed or partially obstructed airway. • Nonproductive cough------a dry, harsh cough without secretions.
• Bubbling-------gurgling sounds heard as air passes through moist secretions
in the respiratory tract.

Blood pressure
Blood pressure Korotkoff’s Sounds
• Blood pressure is
• Arterial blood pressure is a measure of the pressure exerted by the blood as it flows
measured in millimeters
through the arteries.
of mercury (mmHg) and
recorded as a fraction.
• Because the blood move in waves.

• The systolic pressure is

There are two blood pressure: written over the diastolic
• Systolic pressure, which is the pressure of the blood as a result of contraction of the pressure.
ventricles, that is, the pressure of the height of the blood wave.
• Diastolic pressure, which is the pressure when the ventricles are at rest. Diastolic • The average blood
pressure is the lower pressure, present at all times within the arteries.
pressure of a healthy
• Pulse pressure, the difference between the diastolic and the systolic pressures. adult is 120/80 mmHg.
 First the nurse pumps the cuff 30 mm Hg above the point where
the pulse is no longer felt , that is the point when the blood flow in
the artery is stopped.
Measuring Blood Pressure
• Korotkoff’s Sounds
Phase 1
• Direct (Invasive Monitoring)
• First faint, clear tapping or thumping Phase 4
sounds Systolic pressure
• Muffled and have a soft,
blowing sound • Indirect
Phase 2
• Muffled (muted), whooshing, or Phase 5 • Auscultatory
swishing sound • Pressure level when the last • Palpatory
sound is heard
Phase 3 • Period of silence
• Blood flows freely • Diastolic pressure Sites
• Crisper and more intense sound • Upper arm (brachial artery)
• Thumping quality but softer than in • Thigh (popliteal artery)
phase 1

Factors Affecting Blood Pressure

• Age : Newborns have a mean systolic pressure of about 75 mm Hg.
The pressure rises with age, reaching a peak at the onset of puberty,
and then tends to decline somewhat. • Race: African American males over 35 years have higher blood
pressure than European American males of the same age.
• Exercise: Physical activity increases the cardiac output and hence the
blood pressure, thus 20 to 30 minutes of rest following exercise is
indicated before the resting blood pressure can be reliably assessed. • Gender: After puberty, females usually have lower blood pressure
than males of the same age this difference is thought to be due to
• Stress: Stimulation of the sympathetic nervous system increases hormonal variations.
cardiac output and vasoconstriction of the arterioles, thus increasing
the blood pressure reading.
After enopause women generally have higher blood pressure
than before.
• However, severe pain can decrease blood pressure greatly by
inhibiting the vasomotor center and producing vasodilatation.
• Medication: Many medications may increase or decrease the blood
pressure.
• Obesity: Both childhood and adult obesity predispose to
hypertension.
• Diurnal variations: Pressure is usually lowest early in the morning,
when the metabolic rate is lowest, then rises throughout the day and
peaks in the late afternoon or early evening.
• Disease process: Any condition affecting the cardiac output blood
volume, blood viscosity and/or compliance of the arteries has a direct
effect on the blood pressure.
Hypertension: A blood pressure that is persistently above normal.
• Primary hypertension an elevated blood pressure of unknown cause
• Secondary hypertension an elevated blood pressure of known cause.
Hypotension is a blood pressure that is below normal.
• Orthostatic hypotension is a blood pressure that falls when the client
sits or stands.

Common Errors in Assessing Blood Pressure • https://www.youtube.com/watch?v=JpGuSxDQ8js

• Bladder cuff too narrow
• Bladder cuff too wide
• Arm unsupported • https://www.youtube.com/watch?v=gUWJ-6nL5-8
• Insufficient rest before the assessment.
• Repeating assessment too quickly.
• Deflating cuff too quickly.
• Deflating cuff too slowly.
• Failure to use the same arm consistently.
• Arm above level of the heart.
• Assessing immediately after a meal or smoker or has pain.