Vital Signs

Page 503

NRG 304
Kenneth M. Sabido, RN, MN
Kozier and Erb’s Fundamental of Nursing
10th Edition
 LEARNING OUTCOMES
AFTER COMPLETING THIS CHAPTER, YOU WILL BE
ABLE TO:
1. DESCRIBE FACTORS THAT AFFECT THE VITAL
SIGNS AND ACCURATE
MEASUREMENT OF THEM.
2. IDENTIFY THE VARIATIONS IN NORMAL BODY
TEMPERATURE, PULSE, RESPIRATIONS, AND BLOOD
PRESSURE THAT OCCUR FROM INFANCY TO OLD
AGE.
Kozier and Erb’s Fundamental of Nursing 10th Edition 2
 LEARNING OUTCOMES
3. VERBALIZE THE STEPS USED IN:
A. ASSESSING BODY TEMPERATURE.
B. ASSESSING A PERIPHERAL PULSE.
C. ASSESSING THE APICAL PULSE AND
THE APICAL-RADIAL PULSE.
D. ASSESSING RESPIRATIONS.
E. ASSESSING BLOOD PRESSURE.
F. ASSESSING BLOOD OXYGENATION
USING PULSE OXIMETRY. 3

Kozier and Erb’s Fundamental of Nursing 10th Edition

 LEARNING OUTCOMES
4. DESCRIBE APPROPRIATE NURSING CARE
FOR ALTERATIONS IN VITAL SIGNS.
5. IDENTIFY NINE SITES USED TO ASSESS
THE PULSE AND STATE THE REASONS
FOR THEIR USE.
6. LIST THE CHARACTERISTICS THAT
SHOULD BE INCLUDED WHEN
ASSESSING PULSES.

Kozier and Erb’s Fundamental of Nursing 10th Edition 4

 LEARNING OUTCOMES
7. DESCRIBE THE MECHANICS OF
BREATHING AND THE MECHANISMS
THAT CONTROL RESPIRATIONS.
8. RECOGNIZE WHEN IT IS APPROPRIATE TO
DELEGATE MEASUREMENT OF VITAL
SIGNS TO UNLICENSED ASSISTIVE
PERSONNEL.
9. DEMONSTRATE APPROPRIATE
DOCUMENTATION AND REPORTING OF
VITAL SIGNS.
5

Kozier and Erb’s Fundamental of Nursing 10th Edition

 BODY TEMPERATURE
➢REFLECTS THE BALANCE BETWEEN
THE HEAT PRODUCED AND THE
HEAT LOST FROM THE BODY.
➢MEASURED IN HEAT UNITS
CALLED DEGREES.
6

Kozier and Erb’s Fundamental of Nursing 10th Edition

TWO KINDS OF BODY TEMPERATURE

1. CORE TEMPERATURE
2. SURFACE TEMPERATURE

Kozier and Erb’s Fundamental of Nursing 10th Edition 7

TWO KINDS OF BODY TEMPERATURE
1. CORE TEMPERATURE

✓IS THE TEMPERATURE OF THE DEEP TISSUES OF THE

BODY, SUCH AS THE ABDOMINAL CAVITY AND
PELVIC CAVITY. IT REMAINS RELATIVELY
CONSTANT.
✓THE NORMAL CORE BODY TEMPERATURE IS A
RANGE OF TEMPERATURES
(FIGURE 29–1 •).

Kozier and Erb’s Fundamental of Nursing 10th Edition 8

▪THE BODY CONTINUALLY
PRODUCES HEAT AS A BY-
PRODUCT OF METABOLISM.
▪WHEN THE AMOUNT OF
HEAT PRODUCED BY THE
BODY EQUALS THE AMOUNT
OF HEAT LOST, THE PERSON
IS IN HEAT BALANCE.
Kozier and Erb’s Fundamental of Nursing 10th Edition 9
 5 FACTORS AFFECT THE BODY’S
HEAT PRODUCTION:
1. BASAL METABOLIC RATE.
➢ IS THE RATE OF ENERGY UTILIZATION IN THE
BODY REQUIRED TO MAINTAIN ESSENTIAL
ACTIVITIES SUCH AS BREATHING.
➢METABOLIC RATES DECREASE WITH AGE.
➢IN GENERAL, THE YOUNGER THE PERSON,
THE HIGHER THE BMR.
Kozier and Erb’s Fundamental of Nursing 10th Edition 10
Kozier and Erb’s Fundamental of Nursing 10th Edition 11
2. MUSCLE ACTIVITY.
• MUSCLE ACTIVITY, INCLUDING SHIVERING,
INCREASES THE METABOLIC RATE.
3. THYROXINE OUTPUT.
• INCREASED THYROXINE OUTPUT
INCREASES THE RATE OF CELLULAR
METABOLISM THROUGHOUT THE BODY.
Kozier and Erb’s Fundamental of Nursing 10th Edition 12
4. EPINEPHRINE, NOREPINEPHRINE, AND
SYMPATHETIC STIMULATION/ STRESS RESPONSE.
• THESE HORMONES IMMEDIATELY INCREASE THE
RATE OF CELLULAR METABOLISM IN MANY
BODY TISSUES.
5. FEVER.
FEVER INCREASES THE CELLULAR METABOLIC
RATE AND THUS INCREASES THE BODY’S
TEMPERATURE FURTHER. 13

Kozier and Erb’s Fundamental of Nursing 10th Edition

HEAT IS LOST FROM THE BODY
THROUGH:
✓RADIATION,
✓CONDUCTION,
✓CONVECTION
✓EVAPORATION
Kozier and Erb’s Fundamental of Nursing 10th Edition 14
 RADIATION
IS THE TRANSFER OF HEAT FROM THE
SURFACE OF ONE OBJECT TO THE
SURFACE OF ANOTHER WITHOUT
CONTACT.
E.G.
INFRARED RAYS
Kozier and Erb’s Fundamental of Nursing 10th Edition 15
 CONDUCTION
IS THE TRANSFER OF HEAT FROM
ONE MOLECULE TO A MOLECULE OF
LOWER TEMPERATURE.

E.G.
BODY IS IMMERSED IN COLD
WATER 16

Kozier and Erb’s Fundamental of Nursing 10th Edition

 CONVECTION
IS THE DISPERSION OF HEAT BY AIR
CURRENTS.

Kozier and Erb’s Fundamental of Nursing 10th Edition 17

 EVAPORATION
IS CONTINUOUS VAPORIZATION OF
MOISTURE FROM THE RESPIRATORY
TRACT AND FROM THE MUCOSA OF
THE MOUTH AND FROM THE SKIN.

Kozier and Erb’s Fundamental of Nursing 10th Edition 18

INSENSIBLE WATER LOSS
❖ CONTINUOUS AND UNNOTICED
WATER LOSS.
INSENSIBLE HEAT LOSS
❖THE ACCOMPANYING HEAT LOSS

INSENSIBLE HEAT LOSS ACCOUNTS FOR

ABOUT 10% OF BASAL HEAT LOSS.
Kozier and Erb’s Fundamental of Nursing 10th Edition 19
 REGULATION OF BODY TEMPERATURE
3 SYSTEMS THAT REGULATE BODY
TEMPERATURE:
1. SENSORS IN THE PERIPHERY & CORE
2. AN INTEGRATOR IN THE
HYPOTHALAMUS
3. AN EFFECTOR SYSTEM THAT ADJUSTS
THE PRODUCTION AND LOSS OF HEAT
20

Kozier and Erb’s Fundamental of Nursing 10th Edition

FACTORS AFFECTING BODY TEMPERATURE
1. AGE

2. DIURNAL VARIATIONS (CIRCADIAN RHYTHMS)

• HIGHEST BODY TEMPERATURE IS USUALLY

REACHED BETWEEN 4:00 PM AND 6:00 PM
• THE LOWEST POINT IS REACHED DURING SLEEP
BETWEEN 4:00AM AND 6:00AM
Kozier and Erb’s Fundamental of Nursing 10th Edition 21
3. EXERCISE
• HARD WORK OR STRENUOUS EXERCISE
CAN INCREASE BODY TEMPERATURE TO
AS HIGH AS 38.3°C TO 40°C
4. HORMONES
• WOMEN USUALLY EXPERIENCE MORE
HORMONE FLUCTUATIONS THAN MEN.
- PROGESTERONE SECRETION RAISES
BODY TEMPERATURE.
Kozier and Erb’s Fundamental of Nursing 10th Edition 22
5. STRESS
• INCREASE THE PRODUCTION OF
EPINEPHRINE AND NOREPINEPHRINE
THEREBY INCREASING METABOLIC
ACTIVITY AND HEAT PRODUCTION.
• A HIGHLY STRESSED OR ANXIOUS
CLIENT COULD HAVE AN ELEVATED
BODY TEMPERATURE.
6. ENVIRONMENT. 23

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ALTERATIONS IN BODY TEMPERATURE
THE NORMAL RANGE FOR ADULTS IS
CONSIDERED TO BE BETWEEN
36°C - 37.5°C (96.8°F TO 99.5°F)
THERE ARE TWO PRIMARY ALTERATIONS IN
BODY TEMPERATURE:
1. PYREXIA
2. HYPOTHERMIA. 24

Kozier and Erb’s Fundamental of Nursing 10th Edition

PYREXIA, HYPERTHERIA, FEVER
• A BODY TEMPERATURE ABOVE THE USUAL
RANGE.
• A VERY HIGH FEVER, SUCH AS 41°C
(105.8°F), IS CALLED HYPERPYREXIA
• THE CLIENT WHO HAS A FEVER IS REFERRED
TO AS FEBRILE
• THE ONE WHO DOES NOT IS AFEBRILE 25

Kozier and Erb’s Fundamental of Nursing 10th Edition

FOUR COMMON TYPES OF FEVERS:

1. INTERMITTENT
2. REMITTENT
3. RELAPSING
4. CONSTANT.
Kozier and Erb’s Fundamental of Nursing 10th Edition 26
 FOUR COMMON TYPES OF FEVERS:
1. INTERMITTENT
• THE BODY TEMPERATURE ALTERNATES AT
REGULAR INTERVALS BETWEEN PERIODS
OF FEVER AND PERIODS OF NORMAL OR
SUBNORMAL TEMPERATURES.
E.G. MALARIA
Kozier and Erb’s Fundamental of Nursing 10th Edition 27
 FOUR COMMON TYPES OF FEVERS:
2. REMITTENT
• THE BODY TEMPERATURE ALTERNATES AT
REGULAR INTERVALS BETWEEN PERIODS
OF FEVER AND PERIODS OF NORMAL OR
SUBNORMAL TEMPERATURES.

Kozier and Erb’s Fundamental of Nursing 10th Edition 28

 FOUR COMMON TYPES OF FEVERS:
3. RELAPSING FEVER
• SHORT FEBRILE PERIODS OF A FEW DAYS
ARE INTERSPERSED WITH PERIODS OF 1
OR 2 DAYS OF NORMAL TEMPERATURE.
• DURING A CONSTANT FEVER, THE BODY
TEMPERATURE FLUCTUATES MINIMALLY
BUT ALWAYS REMAINS ABOVE NORMAL.
Kozier and Erb’s Fundamental of Nursing 10th Edition 29
 FOUR COMMON TYPES OF FEVERS:
4. CONSTANT.
• THE BODY TEMPERATURE FLUCTUATES
MINIMALLY BUT ALWAYS REMAINS ABOVE
NORMAL.
E.G. TYPHOID FEVER

Kozier and Erb’s Fundamental of Nursing 10th Edition 30

FEVER SPIKE
• A TEMPERATURE THAT RISES TO
FEVER LEVEL RAPIDLY FOLLOWING A
NORMAL TEMPERATURE AND THEN
RETURNS TO NORMAL WITHIN A FEW
HOURS
Kozier and Erb’s Fundamental of Nursing 10th Edition 31
AN ELEVATED TEMPERATURE IS NOT A
TRUE FEVER.

TWO EXAMPLES
HEAT EXHAUSTION
HEAT STROKE.
Kozier and Erb’s Fundamental of Nursing 10th Edition 32
HEAT EXHAUSTION IS A RESULT OF
EXCESSIVE HEAT AND DEHYDRATION.
SIGNS:
oPALENESS,
oDIZZINESS,
oNAUSEA,
oVOMITING,
oFAINTING, A MODERATELY INCREASED
TEMPERATURE 33

Kozier and Erb’s Fundamental of Nursing 10th Edition

HEAT STROKE GENERALLY HAVE BEEN
EXERCISING IN HOT WEATHER, HAVE
WARM, FLUSHED SKIN, AND OFTEN DO
NOT SWEAT.

- 41.1°C (106°F) OR HIGHER

Kozier and Erb’s Fundamental of Nursing 10th Edition 34

 HYPOTHERMIA

IS A CORE BODY TEMPERATURE

BELOW THE LOWER LIMIT OF
NORMAL.

Kozier and Erb’s Fundamental of Nursing 10th Edition 35

3 PHYSIOLOGICAL MECHANISMS OF
HYPOTHERMIA:
1. EXCESSIVE HEAT LOSS,
2. INADEQUATE HEAT PRODUCTION
TO COUNTERACT HEAT LOSS,
3. IMPAIRED HYPOTHALAMIC
THERMOREGULATION.
Kozier and Erb’s Fundamental of Nursing 10th Edition 36
 37

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 38

Kozier and Erb’s Fundamental of Nursing 10th Edition

 TYPES OF THERMOMETER
Electronic
thermometers:
A. institutional model

B. one-piece home
electronic
thermometer

Kozier and Erb’s Fundamental of Nursing 10th Edition 39

 CHEMICAL DOT THERMOMETERS

Kozier and Erb’s Fundamental of Nursing 10th Edition 40

TEMPERATURE-SENSITIVE SKIN TAPE

41

Kozier and Erb’s Fundamental of Nursing 10th Edition

INFRARED OR TYMPANIC THERMOMETER

42

Kozier and Erb’s Fundamental of Nursing 10th Edition

TEMPORAL ARTERY THERMOMETER

43

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 44

Kozier and Erb’s Fundamental of Nursing 10th Edition

 ASSESSING BODY TEMPERATURE
PURPOSES
• TO ESTABLISH BASELINE DATA FOR
SUBSEQUENT EVALUATION.

• TO IDENTIFY WHETHER THE CORE

TEMPERATURE IS WITHIN NORMAL
RANGE.
Kozier and Erb’s Fundamental of Nursing 10th Edition 45
 ASSESSING BODY TEMPERATURE
PURPOSES
• TO DETERMINE CHANGES IN THE CORE
TEMPERATURE IN RESPONSE TO SPECIFIC
THERAPIES
(E.G., ANTIPYRETIC MEDICATION,
IMMUNOSUPPRESSIVE THERAPY,
INVASIVE PROCEDURE)
Kozier and Erb’s Fundamental of Nursing 10th Edition 46
 ASSESSING BODY TEMPERATURE
PURPOSES
• TO MONITOR CLIENTS AT RISK FOR
IMBALANCED BODY TEMPERATURE.

E.G.
CLIENTS AT RISK FOR INFECTION OR
DIAGNOSIS OF INFECTION
47

Kozier and Erb’s Fundamental of Nursing 10th Edition

 ASSESSMENT
ASSESS FOR:
• CLINICAL SIGNS OF FEVER
• CLINICAL SIGNS OF HYPOTHERMIA
• SITE AND METHOD MOST
APPROPRIATE FOR MEASUREMENT
• FACTORS THAT MAY ALTER CORE
BODY TEMPERATURE
Kozier and Erb’s Fundamental of Nursing 10th Edition 48
 IMPLEMENTATION
PREPARATION:

PREPARE ALL NEEDED EQUIPMENT AND

CHECK THAT ALL EQUIPMENT IS
FUNCTIONING NORMALLY.

Kozier and Erb’s Fundamental of Nursing 10th Edition 49

 PERFORMANCE
1. PRIOR TO PERFORMING THE PROCEDURE.
INTRODUCE SELF AND VERIFY THE CLIENT’S
IDENTITY USING AGENCY PROTOCOL.
EXPLAIN TO THE CLIENT WHAT YOU ARE
GOING TO DO. WHY IT IS NECESSARY, AND
HOW HE OR SHE CAN PARTICIPATE DURING
THE ASSESSMENT.
Kozier and Erb’s Fundamental of Nursing 10th Edition 50
 PERFORMANCE

DISCUSS HOW THE RESULTS WILL BE USED IN

PLANNING FURTHER CARE OR TREATMENTS.

Kozier and Erb’s Fundamental of Nursing 10th Edition 51

2. PERFORM HAND WASHING/HYGIENE AND
OBSERVE APPROPRIATE INFECTION
PREVENTION PROCEDURES. APPLY GLOVES IF
PERFORMING A RECTAL TEMPERATURE.

3. PROVIDE FOR CLIENT PRIVACY.

4. POSITION THE CLIENT APPROPRIATELY

E.G., LATERAL OR SIMS’ POSITION FOR
INSERTING A RECTAL THERMOMETER
Kozier and Erb’s Fundamental of Nursing 10th Edition 52
5. WIPE THE TIP OF THE THERMOMETER WITH AN
ALCOHOL SWAB IN A FIRM TWISTING MOTION
PRIOR TO PLACEMENT.
6. PLACE THE THERMOMETER.
*APPLY A PROTECTIVE SHEATH OR PROBE COVER IF
APPROPRIATE.
*LUBRICATE A RECTAL THERMOMETER.
(SEE ORAL METHOD, TYMPANIC METHOD,
AXILLARY METHOD, RECTAL METHOD IN BOX 29-4).
Kozier and Erb’s Fundamental of Nursing 10th Edition 53
7. PLACE THE TIP
(PROBE/THERMOMETER SENSOR) OF
THE THERMOMETER ON EITHER SIDE
OF THE FRENULUM, AND TURN THE
THERMOMETER ON.

54

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 55

Kozier and Erb’s Fundamental of Nursing 10th Edition

Kozier and Erb’s Fundamental of Nursing 10th Edition 56
Kozier and Erb’s Fundamental of Nursing 10th Edition 57
Kozier and Erb’s Fundamental of Nursing 10th Edition 58
Kozier and Erb’s Fundamental of Nursing 10th Edition 59
USE PROGRESS REPORT PER METHOD
8. WAIT THE APPROPRIATE AMOUNT OF TIME.

*ELECTRONIC AND TYMPANIC THERMOMETERS

WILL INDICATE THAT THE READING IS COMPLETE
THROUGH A LIGHT OR TONE.
CHECK PACKAGE INSTRUCTIONS FOR LENGTH OF
TIME TO WAIT PRIOR TO READING CHEMICAL DOT
OR TAPE THERMOMETERS.

Kozier and Erb’s Fundamental of Nursing 10th Edition 60

9. REMOVE THE THERMOMETER AND
DISCARD THE COVER OR WIPE HE TIP
(PROBE/THERMOMETER SENSOR) WITH AN
ALCOHOL SWAB FROM STEM TO
PROBE/THERMOMETER SENSOR IN A FIRM
TWISTING MOTION.
*IF GLOVES WERE APPLIED, REMOVE
AND DISCARD THEM.
PERFORM HAND HYGIENE. 61

Kozier and Erb’s Fundamental of Nursing 10th Edition

10. READ THE TEMPERATURE AND RECORD IT
ON YOUR WORKSHEET.

• RECHECK IF THE TEMPERATURE IS OBVIOUSLY TOO

HIGH, TOO LOW, OR INCONSISTENT WITH THE
CLIENT’S CONDITION, RECHECK IT WITH A
THERMOMETER KNOWN TO BE FUNCTIONING
PROPERLY.

11. WASH THE THERMOMETER IF NECESSARY

AND RETURN IT TO THE STORAGE LOCATION. 62

Kozier and Erb’s Fundamental of Nursing 10th Edition

12. DOCUMENT THE TEMPERATURE IN
THE CLIENT RECORD.
(E.G., VS MONITORING SHEET).

Kozier and Erb’s Fundamental of Nursing 10th Edition 63

 PULSE
❖ IS A WAVE OF BLOOD CREATED BY
CONTRACTION OF THE LEFT VENTRICLE
OF THE HEART.

❖ PULSE WAVE REPRESENTS THE STROKE

VOLUME OUTPUT
COMPLIANCE OF THE ARTERIES IS THEIR
ABILITY TO CONTRACT AND EXPAND.
64

Kozier and Erb’s Fundamental of Nursing 10th Edition

CARDIAC OUTPUT
IS THE VOLUME OF BLOOD PUMPED INTO
THE ARTERIES BY THE HEART AND EQUALS
THE RESULT OF THE STROKE VOLUME (SV)
TIMES THE HEART RATE (HR) PER MINUTE.

65

Kozier and Erb’s Fundamental of Nursing 10th Edition

CARDIAC OUTPUT

E.G.
65 ML X 70 BEATS PER MINUTE = 4.55L PER
MINUTE. WHEN AN ADULT IS RESTING, THE
HEART PUMPS ABOUT 5 LITERS OF BLOOD
EACH MINUTE.
“THE PULSE REFLECTS THE HEARTBEAT”
66

Kozier and Erb’s Fundamental of Nursing 10th Edition

PERIPHERAL PULSE
▪ IS A PULSE LOCATED AWAY FROM THE
HEART.
E.G.

IN THE FOOT OR WRIST, THE APICAL PULSE IS

CENTRAL PULSE
▪ IS LOCATED AT THE APEX OF THE HEART.
▪ALSO REFERRED TO AS THE POINT OF 67

Kozier and Erb’s Fundamental of Nursing 10th

MAXIMAL IMPULSE (PMI). Edition

FACTORS AFFECTING
THE PULSE

68

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 FACTORS AFFECTING THE PULSE

AGE
AS AGE INCREASES, THE PULSE RATE
GRADUALLY DECREASES OVERALL.
SEE TABLE 29–2 FOR SPECIFIC VARIATIONS IN
PULSE RATES FROM BIRTH TO ADULTHOOD.

69

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 70

Kozier and Erb’s Fundamental of Nursing 10th Edition

 FACTORS AFFECTING THE PULSE

SEX
AFTER PUBERTY, THE AVERAGE MALE’S PULSE
RATE IS SLIGHTLY LOWER THAN THE FEMALE’S.

71

Kozier and Erb’s Fundamental of Nursing 10th Edition

 FACTORS AFFECTING THE PULSE
EXERCISE
o THE PULSE RATE NORMALLY INCREASES WITH
ACTIVITY.
o THE RATE OF INCREASE IN THE
PROFESSIONAL ATHLETE IS OFTEN LESS THAN
IN THE AVERAGE PERSON BECAUSE OF
GREATER CARDIAC SIZE, STRENGTH, AND
EFFICIENCY. 72

Kozier and Erb’s Fundamental of Nursing 10th Edition

 FACTORS AFFECTING THE PULSE

FEVER
oTHE PULSE RATE INCREASES:
A. IN RESPONSE TO THE LOWERED BLOOD
PRESSURE THAT RESULTS FROM PERIPHERAL
VASODILATION ASSOCIATED WITH ELEVATED
BODY TEMPERATURE.
B. BECAUSE OF THE INCREASED METABOLIC
73

RATE.
Kozier and Erb’s Fundamental of Nursing 10th Edition
 FACTORS AFFECTING THE PULSE

MEDICATIONS SOME MEDICATIONS

DECREASE THE PULSE RATE, AND OTHERS
INCREASE IT.
CARDIOTONICS
•E.G., DIGITALIS DECREASE THE HEART
RATE, WHEREAS EPINEPHRINE INCREASES
IT. 74

Kozier and Erb’s Fundamental of Nursing 10th Edition

 FACTORS AFFECTING THE PULSE
HYPOVOLEMIA/DEHYDRATION
LOSS OF BLOOD FROM THE VASCULAR SYSTEM
INCREASES THE PULSE RATE.
IN ADULTS, THE LOSS OF CIRCULATING VOLUME
RESULTS IN AN ADJUSTMENT OF THE HEART RATE TO
INCREASE BLOOD PRESSURE AS THE BODY
COMPENSATES FOR THE LOST BLOOD VOLUME.

75

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 FACTORS AFFECTING THE PULSE
STRESS
✓IN RESPONSE TO STRESS, SYMPATHETIC
NERVOUS STIMULATION INCREASES THE
OVERALL ACTIVITY OF THE HEART.
✓STRESS INCREASES THE RATE AS
WELL AS THE FORCE OF THE HEARTBEAT. FEAR,
ANXIETY AND THE PERCEPTION OF SEVERE
PAIN STIMULATE THE SYMPATHETIC SYSTEM 76

Kozier and Erb’s Fundamental of Nursing 10th Edition

 FACTORS AFFECTING THE PULSE
POSITION
o WHEN A PERSON IS SITTING OR STANDING,
BLOOD USUALLY POOLS IN DEPENDENT
VESSELS OF THE VENOUS SYSTEM.
o POOLING RESULTS IN A TRANSIENT
DECREASE IN THE VENOUS BLOOD RETURN
TO THE HEART
77

Kozier and Erb’s Fundamental of Nursing 10th Edition

 FACTORS AFFECTING THE PULSE
POSITION
A SUBSEQUENT REDUCTION IN BLOOD
PRESSURE AND INCREASE IN HEART RATE.

PATHOLOGY. CERTAIN DISEASES SUCH AS

SOME HEART CONDITIONS OR THOSE THAT
IMPAIR OXYGENATION CAN ALTER THE
78

RESTING PULSE RATE.

Kozier and Erb’s Fundamental of Nursing 10th Edition
9 PULSE SITES

79

Kozier and Erb’s Fundamental of Nursing 10th Edition

1. TEMPORAL
WHERE THE TEMPORAL ARTERY PASSES OVER
THE TEMPORAL BONE OF THE HEAD.
THE SITE IS SUPERIOR (ABOVE) AND LATERAL
TO (AWAY FROM THE MIDLINE OF) THE EYE.

80

Kozier and Erb’s Fundamental of Nursing 10th Edition

2. CAROTID
AT THE SIDE OF THE NECK WHERE THE
CAROTID ARTERY RUNS BETWEEN THE
TRACHEA AND THE
STERNOCLEIDOMASTOID MUSCLE.

81

Kozier and Erb’s Fundamental of Nursing 10th Edition

3. APICAL
AT THE APEX OF THE HEART. IN AN ADULT,
THIS IS LOCATED ON THE LEFT SIDE OF THE
CHEST.

Kozier and Erb’s Fundamental of Nursing 10th Edition 82

4. BRACHIAL
AT THE INNER ASPECT OF THE BICEPS MUSCLE OF
THE ARM OR MEDIALLY IN THE ANTECUBITAL SPACE.

5. RADIAL
WHERE THE RADIAL ARTERY RUNS ALONG THE
RADIAL BONE, ON THE THUMB SIDE OF THE INNER
ASPECT OF THE WRIST. 83

Kozier and Erb’s Fundamental of Nursing 10th Edition

6. FEMORAL
WHERE THE FEMORAL ARTERY PASSES
ALONGSIDE THE INGUINAL LIGAMENT.

84

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7. POPLITEAL
WHERE THE POPLITEAL ARTERY PASSES
BEHIND THE KNEE.

85

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8. POSTERIOR TIBIAL
ON THE MEDIAL SURFACE OF THE ANKLE
WHERE THE POSTERIOR TIBIAL ARTERY
PASSES BEHIND THE MEDIAL MALLEOLUS.

86

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9. DORSALIS PEDIS
WHERE THE DORSALIS PEDIS ARTERY PASSES
OVER THE BONES OF THE FOOT, ON AN
IMAGINARY LINE DRAWN FROM THE MIDDLE
OF THE ANKLE TO THE SPACE BETWEEN THE
BIG AND SECOND TOES.

87

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 ASSESSING THE PULSE
➢ A PULSE IS COMMONLY ASSESSED BY
PALPATION (FEELING) OR AUSCULTATION
(HEARING)
➢ THE MIDDLE THREE FINGERTIPS ARE USED
FOR PALPATING ALL PULSE SITES EXCEPT THE
APEX OF THE HEART.
➢A STETHOSCOPE IS USED FOR ASSESSING
APICAL PULSES. 88

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 89

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 90

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 91

Kozier and Erb’s Fundamental of Nursing 10th Edition

THE PULSE RHYTHM
IS THE PATTERN OF THE BEATS AND THE
INTERVALS BETWEEN THE BEATS. EQUAL TIME
ELAPSES BETWEEN BEATS OF A NORMAL
PULSE.
DYSRHYTHMIA OR ARRHYTHMIA
A PULSE WITH AN IRREGULAR RHYTHM.

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• PATTERN OF IRREGULAR BEATS
(DOCUMENTED AS “REGULARLY IRREGULAR”).
• WHEN A DYSRHYTHMIA IS DETECTED, THE
APICAL PULSE SHOULD BE ASSESSED.
• AN ELECTROCARDIOGRAM (ECG) IS
NECESSARY TO DEFINE THE DYSRHYTHMIA

93

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 ASSESSING A PERIPHERAL PULSE
PURPOSES
• TO ESTABLISH BASELINE DATA FOR
SUBSEQUENT EVALUATION
• TO IDENTIFY WHETHER THE PULSE RATE IS
WITHIN NORMAL RANGE

94

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 ASSESSING A PERIPHERAL PULSE
PURPOSES
• TO DETERMINE THE PULSE VOLUME AND
WHETHER THE PULSE RHYTHM IS REGULAR
• TO DETERMINE THE EQUALITY OF
CORRESPONDING PERIPHERAL PULSES ON
EACH SIDE OF THE BODY

95

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 ASSESSING A PERIPHERAL PULSE
PURPOSES
• TO MONITOR AND ASSESS CHANGES IN THE CLIENT’S HEALTH STATUS
• • TO MONITOR CLIENTS AT RISK FOR PULSE ALTERATIONS (E.G., THOSE WITH
• A HISTORY OF HEART DISEASE OR EXPERIENCING CARDIAC ARRHYTHMIAS,
• HEMORRHAGE, ACUTE PAIN, INFUSION OF LARGE VOLUMES OF FLUIDS, OR
• FEVER)
• • TO EVALUATE BLOOD PERFUSION TO THE EXTREMITIES

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EQUIPMENT
•CLOCK OR WATCH WITH A SWEEP
SECOND HAND OR DIGITAL SECONDS
INDICATOR
• IF USING A DUS: TRANSDUCER PROBE,
STETHOSCOPE HEADSET (SOME
MODELS), TRANSMISSION
•GEL, AND TISSUES/WIPES 97

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PREPARATION
• IF USING A DUS, CHECK THAT THE
EQUIPMENT IS FUNCTIONING NORMALLY.

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 ASSESSING A PERIPHERAL PULSE
1. PERFORM THE STEPS 1-3 OF ASSESSING
THE TEMPERATURE.
2. SELECT THE PULSE POINT. NORMALLY,
THE RADIAL PULSE IS TAKEN, UNLESS IT
CANNOT BE EXPOSED OR CIRCULATION TO
ANOTHER BODY AREA IS TO BE ASSESSED.

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3. ASSIST THE CLIENT TO A COMFORTABLE
RESTING POSITION. WHEN THE RADIAL
PULSE IS ASSESSED, WITH THE PALM FACING
DOWNWARD, THE CLIENT'S ARM RESTS
ALONGSIDE THE BODY OR THE FOREARM
RESTS AT A 90-DEGREE ANGLE ACROSS THE
CHEST. FOR THE CLIENT WHO CAN SIT, THE
FOREARM RESTS ACROSS THE THIGH, WITH
THE PALM OF THE HAND FACING
100

DOWNWARD OR INWARD.
Kozier and Erb’s Fundamental of Nursing 10th Edition
4. PALPATE AND COUNT THE PULSE.
PLACE TWO OR THREE MIDDLE
FINGERTIPS LIGHTLY AND SQUARELY
OVER THE PULSE POINT.
RATIONALE:
USING THE THUMB IS CONTRAINDICATED
BECAUSE THE NURSE’S THUMB HAS A PULSE
THAT COULD BE MISTAKEN FOR THE CLIENT’S
PULSE.
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5. COUNT FOR 15 SECONDS AND MULTIPLY
BY 4. RECORD THE PULSE IN BEATS PER
MINUTE ON YOUR WORKSHEET.
IF TAKING A CLIENT’S PULSE FOR THE FIRST
TIME, WHEN OBTAINING BASELINE DATA,
OR IF THE PULSE IS IRREGULAR, COUNT FOR
A FULL MINUTE. IF AN IRREGULAR PULSE IS
FOUND, ALSO TAKE THE APICAL PULSE. 110

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6. ASSESS THE PULSE RHYTHM AND
VOLUME

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7. DOCUMENT THE PULSE RATE, RHYTHM,
AND VOLUME IN THE CLIENT RECORD (E.G.,
TPR SHEET, VITAL SIGNS MONITORING
SHEET).
RECORDS IN THE NURSE'S NOTES PERTINENT
RELATED DATA SUCH AS VARIATION IN PULSE
RATE COMPARED TO NORMAL FOR THE
CLIENT AND ABNORMAL SKIN COLOR AND
TEMPERATURE. 112

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 RESPIRATION

IS THE ACT OF BREATHING.

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 RESPIRATION
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.
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 RESPIRATION
VENTILATION
✓ IS ALSO USED TO REFER TO THE
MOVEMENT OF AIR IN AND OUT OF THE
LUNGS.

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TWO TYPES OF BREATHING:

1. COSTAL (THORACIC) BREATHING

2. DIAPHRAGMATIC (ABDOMINAL)
BREATHING.

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TWO TYPES OF BREATHING:
1. COSTAL (THORACIC) BREATHING
➢ INVOLVES THE EXTERNAL INTERCOSTAL
MUSCLES AND OTHER ACCESSORY
MUSCLES, SUCH AS THE
STERNOCLEIDOMASTOID MUSCLES.
➢ MOVEMENT OF THE CHEST UPWARD AND
OUTWARD.
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TWO TYPES OF BREATHING:
2. DIAPHRAGMATIC (ABDOMINAL)
BREATHING.
➢ INVOLVES THE CONTRACTION AND
RELAXATION OF THE DIAPHRAGM.

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2. DIAPHRAGMATIC

➢ MOVEMENT OF THE ABDOMEN, WHICH

OCCURS AS A RESULT OF THE
DIAPHRAGM’S CONTRACTION AND
DOWNWARD MOVEMENT.

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THANK
YOU!
Kozier and Erb’s Fundamental of Nursing 10th Edition
120