General Survey Includes Observation of 30 - 60 mmhg (normal)

the Client: 🗸Blood pressure is 120/80; pulse pressure

1. physical development and bodybuild of is 40 mmhg
client a.) narrow/ low pulse pressure
2. gender and sexual development of client - low pp = (<25 mmhg)
3. apparent age as compared to reported - severe heart failure, arterial stenosis,
age of client trauma, blood loss
4. skin condition and color b.) wide/ high pulse pressure
5. dress and hygiene - consistently high = arteriosclerosis
6. posture and gait prompt to perform *isolated systolic hypertension - when
musculoskeletal assessment systolic is high but diastolic is normal; can
7. level of consciousness, awareness of occur naturally with age or can be caused
client (conscious, semi-conscious, by variety of health condition (anemia,
unconscious) diabetes, etc)
8. behaviors, body movement, and affect
*Affect - internal motion SYSTOLIC BP
9. facial expressions – sadness, surprise, - maximum pressure
anger - exerted on the arterial wall at the peak of
10. speech the contraction of the left ventricle
11. Vital signs - pressure on arteries when heart beats
DIASTOLIC BP
VITAL SIGNS - minimum pressure
🗸WHO – bp should be routinely - exerted when the left ventricle is at rest
measured in sitting or supine followed by - pressure in the arteries when the heart
standing position provided arm is leveled rests in between beats
at the right atrium
🗸force exerted by the blood against the
vessel walls
🗸millimeters of mercury (mmHg). 110/80
mmhg
🗸normal cardiac cycle reaches a peak
followed by a trough or a low point in the
cycle
Systole: left ventricle pumps blood into
the aorta
Trough: during diastole as the ventricle
relax
Diastolic pressure: minimal pressure
exerted against the arterial walls
🗸systolic reading before the diastolic
PULSE PRESSURE - diff between
systolic and diastolic pressure

*Sphygmomanometer
– aneroid, mercurial, digital
*Areas available for bp reading
● Posterior tibial artery
● Above popliteal artery
● Brachial artery
● Radial artery
BP taking on hand
1. wash hands
- reduces transmission of microorganisms
2. support client's forearm (while client
is sitting or lying) with the palm turned
up
- if arm dangles, client may perform
isometric exercises; can increases diastolic
pressure to 10%
3. expose upper arm fully by removing
constricting clothing
- ensures proper cuff application
4. palpate brachial artery. position cuff
2.5 cm (1inch) above site of brachial
pulsation (antecubital space). with cuff
fully deflated, wrap the cuff evenly and
snugly around upper arm
- inflating bladder directly over brachial
artery ensures proper pressure is applied
during inflation
loose fitting cuff cause false high reading
5. be sure manometer is positioned
vertically at eye level. observer should
be no farther from 1m away.
- eye level placement ensures accurate
reading of mercury level
*6. palpate brachial or radial artery
with fingertips of one hand while
inflating cuff rapidly to pressure
30mmhg above at which pulse
disappears. slowly deflate cuff and note
point where pulse reappears
- identifies approximate systolic pressure
and determines maximal inflation point for
accurate reading
- prevents auscultatory gap ( period of
diminished korotkoff sound)
*7. deflate cuff fully and wait for 30 secs
- prevent venous congestion (blockage of
vein) and false high reading
8. place stethoscope, earpieces in ears,
and be sure sounds are clear, not
muffled.
- each earpiece should follow the angle of
the aircanal to facilitate hearing
9. relocate brachial artery and place
bell ir diaphragm chest piece over it. do
not allow chest piece to touch cuff or
clothing
- proper stethoscope placement ensures
optimal sound reception.
- stethoscope improperly positioned
causes muffled sounds that often results in
false low systolic pressure and false high
diastolic pressure
10. close valve or pressure valve 17. assist client in returning in
clockwise until tight comfortable position and cover upper
- tightening of valve prevents earleak arm if previously clothed
during inflation - restores client's comfort
11. inflate cuff to 30mmHg above 18. inform client of bp reading
palpated systolic pressure - promote participation in care and
- ensures accurate reading of systolic understanding of health status
pressure 19. wash hands
12. slowly release valve and allow - reduces transmission of microorganism
mercury to fall at rate of 2-3 mmhg/sec 20. record findings
- too rapid or slow a decline in mercury
level can cause inaccurate reading bp taking on foot
13. note point on manometer when first 1. Wash hands
clear sound is heard 2. Assist client to prone position. If
- first korotkoff sound indicate systolic unable to assume position, assist client
pressure to supine position with knee slightly
14. continue deflating the cuff gradually flexed.
noting point at which muffled or – Prone position provides best access
dampened sound appears in children to popliteal artery.
and point of manometer at wc sounds 3. Remove any constricting clothing
disappears in adults from the leg.
- 4th korotkoff sound involves distinct 4. Locate popliteal artery behind knee.
muffling of sounds and is recommended 5. Apply large leg cuff 2.5 cm or 1 inch
by American Heart Association as above artery around posterior aspect of
indication of diastolic pressure in children. middle thigh. Center arrows marked on
AHA recommends recording 5th korotkoff cuff over artery.
sound as diastolic pressure in adults
15. deflate cuff rapidly and completely.
remove from client's arm unless
measurement must be repeated wait
2-3 mins if bp reading needs to be
repeated
- rapid cuff deflation causes arterial
occlusion or blockage causing numbness
and/or tingling sensation in client's arm
16. if this is the first assessment of
client, repeat procedure on the other
arm, left arm first
- comparison of the pressure on both arms
serves to detect any circulatory problem (
normal 5-10 mmhg difference exist bn
arms)
6. Follow steps 4 through 13 of molecules breakdown occurs and heat is
auscultation method using released in the form of energy
POPLITEAL ARTERY.
7. Note systolic and diastolic pressure. TYPES of TEMP
8. Assist client in returning in 1. SHELL TEMP OF BODY
comfortable position. - INCLUDES SKIN, SUBCUTANEOUS
9. Inform client of BP reading. TISSUE, AND LIMBS
10. Wash hands. - TEMP OF THE "CORE" IS
MAINTAINED CLOSE TO 37C (98.6F)
AT MOST TIMES, WHEREAS, THE
TEMPERATURE "SHELL" FLUCTUATES WIDELY
- TEMPERATURE CAN BE ACCDG TO ENVIRONMENTAL
MEASURED IN FAHRENHEIT AND CONDITIONS
CELSIUS
- ORAL, RECTAL, or axillary 2. CORE TEMP OF BODY
- appropriate site for the patient's age and - temp of the internal environment of the
physical condition body
don't use oral on seizure patients - includes organs such as the heart, liver,
- route: document it on the patient's chart and blood
per axilla, per oral, per rectal
- under the control of the hypothalamus, MEASURING DEVICE
the body's core temp is maintained within 1. Clinical thermometer
- or +0.6 degrees C - used to measure body temperature
anterior hypothalamus - begins Types
thermolytic response; decrease in body a. Glass
temp b. Mercury
posterior hypothalamus - begins a c. Infrared (tympanic and forehead)
thermogenic response; elevation in body d. Chemical
heat and conservation e. Digital

HOW IS BODY HEAT PRODUCED?

1. exercise, walking, doing activities
increase heat in body, decrease heat once
we perspire
2. metabolism of food (during eating)
heat increases due to kinetic energy in the
cells

HOW IS BODY HEAT LOST?

1. through the skin, during perspiration of
the sweat glands by evaporation
2. lungs - during ventilation, inhalation
and expiration, when there is an increase
in the respiration process, glucose
 - 2-3 mins; until digital thermometer
sounds
considerations
– wait 15 mins after intake of food or fluid
or smoking
– patient needs to be able to breathe
through nose ( no oral pathology; recent
oral surgery, and not for comatose
FEB 2001 "Mercury reduction and
patients)
disposal act"
not with oxygen therapy by mask; causes
- aims to reduce use of mercury in
decrease in reading
commercial use globally
affects nervous, digestive, and immune
AXILLA ROUTE
system of individual (very toxic)
-(safest) non invasive but least accurate
due to environmental factors
MEASUREMENT
- 35.9 to 36.9 (96.7 to 98.5)
freezing point - 32F (0C)
- FOR INFANTS, YOUNG CHILDREN,
melting point - 212F (100C)
AND
normal body temperate range - 35.9 to
PATIENTS WITH IMPAIRED IMMUNE
38.1 (96.7F to 100.5 F)
SYSTEM
-DEPENDS ON THE ROUTE USED
- 5 minutes: until thermometer sounds
FOR MEASUREMENT
Normal body temperature – 36.5 TO
RECTAL ROUTE
37.5 (98F to 100F) (ORAL, AXILLA,
- very reliable measurement
RECTAL)
- use clean gloves and lubricant (if
possible or necessary)
SHELL: 35.8 - 37.4 (96.6F - 99.3F)
- 37.1 to 38.1 ( 98.7 to 100.5)
CORE: 36.4 - 37.3 (97.5F - 100.4F)
- FOR INFANTS, YOUNG CHILDREN,
HYPERTHERMIA: >41.1 (>106F)
AND
hypothermia: <35 (<95)
CONFUSED OR UNCONSCIOUS
PATIENTS
> rectal route on nursery or newborns
when 1st time
>check for imperforate anus - anus doesn't
have a hole (type of malformation)
- 2-3 mins or when it sounds
CONSIDERATION
ORAL ROUTE
-use only when other routes are not
-most accessible site; most comfortable for
practical
client; can’t be used all the time
-never force thermometer in the rectum for
- 36.5 to 37.5
clients with coagulation disorders
- FOR ADULTS AND OLDER
(bleeding disorders, disruption in blood
CHILDREN WHO ARE AWAKE,
clotting)
ALERT, ORIENTED, AND
COOPERATIVE
TYMPANIC ROUTE
-comfortable, non invasive, very reliable
and quick
- 36.8 to 37.8 (98.2 to 100)
FOR ADULTS AND CHILDREN WHO
ARE
CONSCIOUS AND COOPERATIVE
AND FOR
CONFUSED AND UNCONSCIOUS
PATIENTS
- 2-3 seconds or when thermometer
sounds
CONSIDERATION
- change covering of probe for every client
1. Poikilothermic – the inability to
maintain a constant core temperature
independent of ambient temperature,
markedly influences both the mental and
physical function of affected patients
2. Homeothermic – having a relatively
uniform body temperature maintained
nearly independent of the environmental
temperature
FACTORS AFFECTING BODY
TEMPERATURE
1. food
2. age (infants and young children have
fluctuating temp) (older indiv have lower
temp compared to adult temp)
3. climate
4. gender (female; hormone secretion
cause body temp fluctuation throughout
menstrual cycle)
5. exercise and activity (muscle
contraction produces heat in body)
6. emotions (anger cause increase in temp,
especially core temp)
7. illness and injury (infection causes
increase in body heat) (hemorrhage cause
decrease in body temp, especially external
hemorrhage)
CONVERSION OF TEMPERATURE
°C TO ° F:
– °C TEMP x 1.8 THEN ADD 32
°F TO °C:
– °F-32 THEN DIVIDE BY 1.8
Temperature (STEPS)
1. perform hygiene
- reduces transmission of microorganism
- clean thermometer before and after use
(circular twisting motion)
Before: start from tip going up with the
use of alcohol, soap and water, and cotton
balls,
After: Other tip towards probe
2. provide privacy (especially for rectal)
-minimises embarrassment and promotes
comfort to the client
3. wear protective gears as necessary
(clean gloves on oral and rectal route)
4. assist client to a comfortable position
that provides easy access and courtesy
according to temp measurement site
- ensures client comfort and accuracy of
temperature reading
axilla and oral: (supine, sitting, high
fowlers and fowlers)
rectal: (side lying position); left hand
retracts buttocks, right hand inserts
thermometer
*newborn ½ to 1 inch inserted for 1 min
or until thermometer sounds
*children and adults - 1 inch or less
depending on size of client
5. move clothing or gown away from
client's shoulder and arm (expose axilla,
make sure the certain area is clean and
dry). hand the client tissue to expose
axilla
- wet axilla may cause too low reading
6. Secure the thermometer in
measurement site or insert probe into
the center of the axilla lower client's
arm into the thermometer and place
arm across client's chest
- maintain proper position of thermometer
against blood vessels in the axilla
7. leave thermometer probe in place
until audible signal indicates completion
and client's temperature appears on
digital display (within seconds or 1
minute)
- use another thermometer if no reading or
below average reading
8. remove thermometer probe on
measurement site and inform client of
temperature reading
- promotes understanding of the health
status of the client
9. assist client in fixing or replacing the
gown
- restores client's comfort > Apical - 4th to 5th intercostal space
10. return thermometer to storage after
cleaning appropriately 🗸Use the pads of index and middle/ring
11. perform hand hygiene fingers.
thank client then perform hand hygiene 🗸Press the area over the pulse until you
- reduces transmission of microorganism feel the pulsation
12. document the assessed temperature 🗸If the rhythm is regular, count the beats
for 30 seconds then multiply by two to get
PULSE RATE (Beats per Minute) the number of beats per minute.
– Reflects the amount of blood ejected 🗸If irregular or the patient has pacemaker,
with each heart beat. count the beats for 1 minute.
– Note the rhythm, amplitude and tempo 🗸When taking the PR for baseline data,
Rate: 60- 100 bpm/adults count 1 full minute.
Rhythm - a beat or throb, a measure, 🗸Never use the thumb in taking the PR.
movement, recurrence of an action, > Thumb has a pulse of its own
standard comparison. 🗸When palpating the carotid artery, avoid
> Regular = Normal pulse; even tempo exerting too much effort.
and rhythm > May cause fainting or bradycardia
Amplitude: occur in moves, largeness, > Palpate carotid artery slightly if BP is
fullness. too high
> range of the PR which represents the
strength of the left ventricular contraction Pulse Deficit
of the heart 🗸Is a clinical sign wherein, one is able to
find a difference in count between heart
rate and peripheral pulse.
🗸This occurs even as the heart is
contracting, the pulse is not reaching the
periphery.
🗸Auscultate apical while palpating the
radial pulse.
🗸An apical pulse will never be lower than
the radial pulse.
> Atrial Fibrillation - when atria beat
irregularly
APICAL- RADIAL= PULSE DEFICIT
> Presence of pulse deficit = issue with
cardiac function or efficiency
> A volume of blood pumped from the
heart may not be sufficient to meet the
needs of body tissues
Factors that affect pulse rate:
1. Age – younger has higher PR than older
2. Blood pressure – lower BP = increased
PR
3. Illness- When the body’s immune
system becomes compromised changes in
heart rate can occur. Particularly
if septic shock sets in, the heart rate will
naturally quicken to meet oxygen
demands.
> Septic Shock – condition occurring
during severe sepsis
4. Emotional Stress – fear, nervous =
increased PR and RR
5. Exercise
6. Medications – all types of
over-the-counter medications or drugs and
prescription drugs; herbal supplement,
illegal drugs (cocaine)
> Ephedrine (CNS stimulant) – Prevents
low BP
> Beta blockers – treat chest pain
(Angyna)
> Valerian – treat insomnia, migraine,
fatigue, etc; slows down PR
7. Body temperature – the pulse
increases approximately 10 beats per
minute for every I degree F or .56 degrees
Celsius increases in body temperature.
This condition causes a temporary
increase in the heartbeat and pulse.
8. Food intake – digestion increases the
pulse slightly.
Steps:
1. Perform hand hygiene
R: reduces transmission of
microorganisms.
2. Provide privacy
3. Assist client in assuming sitting or
supine position.
4. Assist client in assuming sitting or
supine position.
If supine: Place forearm across lower
chest with wrist extended straight
If sitting: bend client’s elbow 90 degrees
and support lower arm in chair or on
nurses arm. Slightly extend wrist with
palm down.
> Arm should be at heart level
R: Relaxed position of lower arm and
extension of wrist permits full exposure of
artery to palpation.
5. Place tips of first two middle or three
fingers of hand over groove along radial
or thumb side of client’s inner wrist.
R: fingertips are most sensitive part of
hand to palpate arterial pulsation. NURSE
thumb has its own pulse
6. Lightly compressed against radius,
obliterated pulse initially, and then
relaxed pressure so pulse becomes
easily palpated.
R: Pulse is more accurately assessed with
moderate pressure; too much pressure
accelerates puls or stops blood flow
7. Determine strength of pulse. Noted
thrust of vessel against fingertips was
either bounding, strong, weak or
thready.
> Bounding – strong, throbbing felt on
artery due to forceful heartbeat
> Normal – regular and nothing is wrong
with chest; anemia; anxiety
> Thready – light, weak, usually rapid,
hardly perceptible
R: Strength reflects volume of blood
ejected against arterial wall with each
heart contraction.
8. After pulse can be felt regularly, look
at watch’s second hand and begin to
count rate. When sweep hand hits
number start counting with zero, then
one, two and so on.
R: Rate is determined accurately only after
nurse is assured pulse can be palpated.
9. Assist client to return in comfortable
position
R: Promote sense of wellbeing of client
10. Inform findings to client as needed.
R: Promotes client’s understanding of
health status
11. Performed hand hygiene/ Wash
hands.
Respiratory Rate (Cycle per Minute)
🗸Inhalation and Exhalation
🗸Measured in breaths per minute/ Cycle
per minute (CPM)
Tachypnea- rapid breathing
Bradypnea- slow breathing
Apnea- absence of breathing
Dyspnea- difficulty of breathing
Orthopnea- sensation of breathlessness in
recumbent position
> relieved by sitting or standing position
Steps:
1. Performed hand hygiene
R: reduces transmission of
microorganisms
2. Provide privacy as necessary
3. Place client’s arm in relax position
across the abdomen or lower , or place
nurse’s hand directly over client’s
upper abdomen.
R: Position used during assessment of
pulse, allows nurse to be unnoticeable.
Client’s/Nurse’s hand rises and falls
during respiratory cycle
4. Observe complete respiratory cycle
(1 inspiration, 1 expiration)
5. After cycle is observe , look at
watch’s second hand and begin to count
rate: when sweep hand hits number on
dial , begin time frame , counting one
with first full respiratory cycle.
R: Timing begins with count of one.
Respiration occur more slowly than pulse
thus, timing does not start with 0
6. If rhythm is regular in adult, count
number of respirations
in 30 seconds and multiply by 2.
🗸In infant or young child count
respiration for 1
minute
🗸If adult has irregular rhythm or
abnormally slow or
fast rate, count 1 minute.
R: Respiratory rate is equivalent to
number of respirations per minute.
🗸Young infants and children/ breathe
irregularly 1 whole minute.
7. Note depth of respiration.
🗸This can be assessed subjectively by
observing degree of chest wall
movement while counting rate.
🗸Depth should be shallow, normal, or
deep
R: Reveals volume of air moving to and
from lungs.
8. Note rhythm of ventilatory cycle.
🗸Normal breathing is regular and
uninterrupted.
🗸Infants breathe less regularly.
🗸Young child may breathe slowly for a
few seconds and then suddenly breathe
fast.
🗸Sighing should not be confused with
abnormal rhythm.
R: character of ventilations can reveal
specific types of
alterations.
10. Perform hand hygiene.
R: Reduces transmission of
microorganisms.
11. Discuss findings with client as
needed.
12. Document vital signs taken.