Retdem: • Note the depth and regularity of respirations

• Record the time rate, depth, and regularity of

Explanation: respiration.

Handwashing

• Wet hands with water PULSE

• Apply soap ● The pressure of the blood feels

• Rub hands palm to palm against the wall of an artery as the

• Fingers interlaced and back of hands heart alternately contracts (beats)

• Clean thumbs and relaxes (rests).

• Clean fingernails ● More easily felt in arteries that

• Rub wrists come fairly close to the skin and

can be gently pressed against a

• Rinse hands with water
bone.
• Dry hands with a clean towel
● The same in all arteries throughout
Pulse Rate:
the body
• Carry out beginning procedure actions

• Place the patient in a comfortable position.

PULSE SITES:
• The palm of the hand should be down
1. TEMPORAL - is superior (above) and lateral to (away
• the arm should rest on a flat surface.
from the midline) of the eye. The pulse is taken at
• Locate the radial pulse using the first three
temporal bone area.
fingers and never the thumb as it also
2. CAROTID - at the side of the neck below the tube of the
contains a pulse.
ear (where carotid artery runs between the
• When the pulse is felt, apply pressure.
trachea and the sternoclidiomastoid muscle)
• Using the second watch, count for one
3. APICAL - at the apex of the heart: routinely used for
minute.
infant and children < 3 years
• It can be done for a one-half minute and
In adults - left midclavicular line
multiplied by two but one minute is essential
under the 4th, 5th, 6th intercostals
if pulse is irregular.
spaces.
• Record the result on a pad and wash hands.
Children < 4 years - left

midclavicular line
Respiratory rate:
4. BRACHIAL - at the inner aspect of the biceps muscle of
• When the pulse rate is counted, we van leave our
the arm or medially in the antecubital space (elbow
fingers on the radial pulse and start counting the
crease)
number of times the chest rises and falls during
5. RADIAL - on the thumb side of the inner aspect of the
one minute.
wrist - readily available and routinely used.
• Count one exhalation and one exhalation as one

respiration
6. FEMORAL - along the inguinal ligament. Used for transient decrease in the venous blood return to heart

infants and children and subsequent decrease in BP, increases heart rate.

7. POPLITEAL - behind the knee. By flexing the knee

slightly

8. POSTERIOR TIBIAL - on the medial surface of the ankle

9. PEDAL (DORSALIS PEDIS) - palpated by feeling the

dorsum (upper surface) of the foot on an imaginary line

drawn from the middle of the ankle to the surface

between the big and 2nd toes.

Factors Affecting Pulse Rates:

1. AGE: as age increases, the PRgradually decreases.

Newborn to 1month - 130 bpm (range: 80-180

bpm). Adult - 80 bpm (Range: 60-100 bpm)

2. SEX: after puberty, the average males’ PR is slightly

lower than female.

3. EXERCISE: PR increases with exercise

4. FEVER: increases PR in response to the lowered bpm

that results from peripheral vasodilation - increased

metabolic rate.
APICAL PULSE (CENTRAL PULSE)
5. MEDICATIONS: digitalis preparation decreases PR,
● It is located at the apex of the heart
Epinephrine - increases PR
● Is measured by counting the heart contractions
6. HEAT: increases PR as a compensatory mechanism
● The stethoscope is placed over the apex (tip) of the
7. STRESS: increases the sympathetic nerve stimulation -
heart.
increases the rate and force of heartbeat.
● Listen for the heart sounds that indicate closing of the
8. POSITION CHANGES: when a patient assumes a sitting
valves.
or standing position, blood usually pools in dependent
● These sounds occur as the heart pumps blood to the
vessels of the venous system. Pooling results in a
arteries. The sounds should occur at the same
rate as the pulse that is felt as an expansion of the radial while the second person counts the radial pulse for 1

artery. minute. The rates are then compared.

● Apical pulse rates are checked:

How the apex of the heart is found: - Whenever a pulse deficit exists or is suspected.

● In the Left side of the front of the chest. Between the - Before the registered nurse administers drugs that alter

5th and 6th ribs. the heart rate or rhythm.

● Men, below the Left nipple - In children whose rapid rate might be difficult to count at

● Women, under the Left breast. the radial artery.

● Listen carefully for two sounds: “lub dub” - For one full minute.

● The louder sound (lub) corresponds to the contraction - On any child 12 months of age or younger.

of the ventricles pushing the blood forward through the - Whenever you are uncertain of the accuracy of the radial

arteries, and closing the AV valves to prevent the pulse or it is irregular.

backflow of blood. This is the sound to be counted. ● Pulse deficit are found in some forms of heart disease.

● The softer sound (dub) corresponds to the relaxation of

the ventricles as they fill with blood for the next

contraction and the closing of the semilunar valves to

prevent backflow from the arteries.

● When documenting an apical pulse

reading, write “AP” after the value

APICAL-RADIAL PULSE RATE

● Is a comparison of the apical rate

and the radial rate.

● Usually they are the same.

● Sometimes the contraction of the

heart is so weak that it fails to send enough blood to the

arteries to expand them. When this happens, no pulse is

felt. In this case, the number of loud sounds does not

correspond with the number of pulses felt in the

RESPIRATION MONITORING
radial artery.
RESPIRATION

● Is the act of breathing (intake of oxygen, removal of

PULSE DEFICIT
carbon dioxide)
● The difference between the apical pulse and the radial
● The main function of respiration is to supply the cells in
pulse.
the body with oxygen and to rid the body of
● Two people measure the heart rate and the radial pulse
excess carbon dioxide.
at the same time. The nurse measures the apical pulse
● When respirations are inefficient, there is less oxygen in breathing

the blood available for body needs. In addition, carbon ● APNEA - a period of no

dioxide is released less efficiently. respirations

● The skin takes on a bluish or dusky color and the ● CHEYNE-STOKES

patient develops a condition known as cyanosis. RESPIRATION - a period of

● TWO PARTS TO EACH dyspnea followed by periods of

RESPIRATION: apnea.

- One inspiration (inhalation) followed by one expiration ● STERTOROUS - snoring-like

(exhalation). respirations

VENTILATION ● RALES - (crackles) moist

● Refers to the movement of air in and out of the lungs. respirations. At times, fluid

● HYPERVENTILATION: Very deep, rapid respiration (mucus) will collect in the air

● HYPOVENTILATION: Very shallow respiration passages. This causes a bubbling

type of respiration. Rales are

DIFFERENT BREATHING PATTERNS: common in the dying patient.

● NORMAL - (Eupnea) regular, ● WHEEZING - difficult breathing

16-20 breaths per minute. accompanied by a whistling or

● SHALLOW - breaths that only sighing sound due to narrowing of

partially fill the lungs. bronchial tubes (as in asthma) or

● TACHYPNEA - rapid, shallow an increase of mucus in the

breathing bronchi

● HYPERPNEA - intrinsic, deep Respiration should be checked for:

breathing (happens during or after ● RATE - number of respiration per

exercise) minute

● DIAPHRAGMATIC BREATHING ● RHYTHM - regularity

- consciously uses diaphragm to ● SYMMETRY - ability of the chest

help take deep breaths. to expand equally as air enters each

● COSTAL (THORACIC) - shallow lung.

breathing which uses intercostal ● VOLUME - depth of respiration

muscles (external muscles) and ● CHARACTER - terms used to

other accessory muscles describe the character of

(sternoclodiomastoid). Movement respirations include:

of the chest - upward and - Regular

downward. Commonly used for - Irregular

adults. - Shallow

● DYSPNEA - difficult or labored - Deep

- Labored (difficult) pulse while counting.

RESPIRATORY RATE

● The rate of respiration is

determined by counting the rise

and fall of the chest for one minute,

using a watch equipped with a

second hand.

● The Average rate for Adults is 16-20

respirations per minute.

● If the rate is more than 25 per

minute, it is said to be accelerated.

Accelerated respirations should be

reported.

● If the rate is less than 12 per Factors affecting Respiratory Rates:

minute, it is too slow. It should be ● Stress

reported. ● Emotions

● Remember that, if possible, ● Elevated Temperature

respirations should be counted ● Sex

without the patient’s knowing that ● Age

you are doing so; the rate and ● Exercise

volume may change if the patient ● Position

knows they are being counted. ● drugs

● You might count respirations

before or after counting the radial NOTE:

pulse. Continue pressing on the ● TPR Rates of Temperature, Pulse

and Respiratory rates and character

are recorded in a notebook and

then transferred to the patient’s

chart or medical record.

BLOOD PRESSURE

BLOOD PRESSURE

● It is the measure of the force or

pressure exerted by blood against

the wall of blood vessels.

● It includes arterial, venous and

capillary pressures.
● ARTERIAL BLOOD PRESSURE: of the ventricles of the heart

- It is a measure of a pressure exerted

by the blood as it flows through the

arteries.

- Arterial Blood Pressure (BP) =

Cardiac output (CO) x total

peripheral resistance (TPR)

Blood Pressure depends on the:

● Volume - amount of blood in the

circulatory system

● Force of the heartbeat.

● Condition of the arteries. - arteries

that have lost their elasticity

(stretch) give more resistance. The

pressure is greater in these arteries.

● Distance from the heart. - Blood

pressure in the legs is lower than in

the arms.

● Pressure varies with contraction

(systole) and relaxation (diastole)