St.

Paul College of Ilocos Sur

(Member, St. Paul University System)
St. Paul Avenue, Bantay, 2727 Ilocos Sur
College of Nursing

SCHOOL YEAR 2020-2021

NCM 103: Fundamentals of Nursing Practice

LEARNING COMPETENCIES:
In this lesson you will be able to do the following:
1. Identify the 4 measurable objective data or vital signs
2. Describe factors that affect the vital signs and their accurate methods of measurement
3. Identify the variations in normal body temperature, pulse, respirations, and blood
pressure.
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 the pulses.
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 other health
care provider.
9. Demonstrate appropriate documentation and reporting of vital signs.
10. Verbalize and demonstrate comprehensively 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.

CORE VALUES: COMMITMENT, COMMUNITY & CHARISM

As Paulinians, you will be able:

 deepen your sense of responsibility and accountability in assessing

your patient’s vital sign and the proper use of equipment
 communicate within the family and the community effectively in terms of its role
in vital signs monitoring and the proper use of equipments.
VITAL SIGNS
Introduction
The four measurable objective data or traditional vital signs are: body temperature,
pulse, respirations, and blood pressure. Some agencies have designated pain as a fifth vital
sign, to be assessed at the same time as each of the four. It should be thoughtful, scientific
assessment and be evaluated with reference to client’s present and prior health status, their
usual vital sign results, and accepted normal standards.
 When and how often to assess a specific client’s vital signs are chiefly nursing
judgments, depending on the client’s health status. Some agencies have policies about
when to take clients vital signs. The primary care provider may specifically order a vital
sign (e.g., ‘Blood pressure q2h”). ordered vital sign measurements, however, should be
considered a minimum; a nurse should assess vital signs more often if the client’s health
status requires it.
TEMPERATURE
 Body Temperature reflects the balance between the heat produced and the heat lost
from the body, and is measured in heat
units called degrees. There are two kinds
of body temperature: core temperature and
surface temperature.
Core Temperature

 Is the temperature of the deep tissues of the

body, such as the abdominal cavity and
pelvic cavity
 Relatively constant
Surface temperature

 Is the temperature of the skin, the

subcutaneous tissue, and fat
 Rises and falls in response to the
environment
The Purpose of Assessing Body Temp:

 Establish baseline data for subsequent evaluation

 To identify whether the core temperature is within normal range
 To determine changes in the core temperature in response to specific therapies(e.g.,
antipyretic medication, immunosuppressive therapy, invasive procedure)
 Monitor clients at risk for imbalanced body temperature (e.g., clients at risk for infection
or diagnosis of infection; those who have been exposed to temp. extremes).
Factors that affect Body Temperature:
1. Age
Infant and older people, particularly those over 75 years, are at risk of hypothermia.
 Infants are greatly influence by the temp. of the environment and must be protected
from extreme changes. Children’s temp. vary more than those of adults do until puberty.
Many older people,over 75 years are at risk of hypothermia (temp. below 36 0 C, or 96.80
F) for a variety of reasons, such as in adequate diet, loss of subcutaneous fat, lack of
activity, and reduced thermoregulatory efficiency.
2. Diurnal

variations (circadian rhythms)

Variations between the early AM and the late PM
Point of highest body temp is usually at 4:00 PM and 6:00 PM
3. Exercise
Can increase to as high as 38.30 C (1010 F to 1040 F) measured rectally.

4. Hormones
Women usually experience more than fluctuations than men. In women, progesterone
secretion at the time of ovulation raises body temp. by about 0.3 0 C to 0.60 C (0.50 F to
1.00 F) above basal temp.

5. Environment
Extreme weather

6. Stress
Stimulation of the sympathetic nervous system can increase the production of
epinephrine and norepinephrine, thereby increasing metabolic activity and heat
production. Nurses should anticipate that a highly stressed or anxious client could have
an elevated body temp. for that reason
Alterations in Body Temperature:
Pyrexia, Hyperthermia or Fever

 Body temperature above usual range

  Client who has a fever is referred to as febrile
 The one who does not is afebrile
 Hyperpyrexia is a very high fever, such as 410 C (105. 08 F)
Hypothermia

 Core body temperature below the normal

 Three physiologic mechanisms hypothermia are:
a. Excessive heat loss,
b. Inadequate heat production to counteract heat loss
c. Impaired hypothalamic function
Types of Fever
1. Intermittent fever
 Temperature alternates at regular intervals between periods of fever and periods
of normal or subnormal temperatures
2. Relapsing fever
 Short febrile periods of a few days are interspersed with periods of 1 or 2 days of
normal temperature.
3. Constant fever
 Body temperature fluctuates minimally but always remain above normal
 Increase of temp not less than 20 C [3.60 F] which occurs over the 24- hour period
4. Fever spike
 Temp that rises to fever level rapidly following a normal temp and then returns to
normal within few hours
 Bacterial blood infections
Phases of Fever
Onset (cold or chill Phase)

 Increased PR/RR
 Shivering
 Complaints of feeling cold
 Cyanotic nail bed
 “Gooseflesh”appearance of
the skin
 Cessation of sweating
Course (Plateau Phase)

 Absence of chills
 Glassy- eyed appearance
 Increased PR/RR and thirst
 Delirium, or convulsions
 Herpetic lesions of the mouth
 Loss of appetite
 Malaise, weakness, and aching muscles
Defervescence (Fever Abatement/ Flush Phase)

 Skin that appears flushed and feels warm

 Sweating, decreased shivering and possible dehydration
Sites to Obtain Body Temp.
1. Rectal- anus
2. Oral- under the tongue
3. Axillary- in the armpit
4. Tympanic- in the ear
5. Temporal artery- scans the surface of the forehead

Nursing Interventions for Clients with Fever

 Monitor vital signs.
 Assess skin color and temperature.
 Monitor white blood cell count, hematocrit value, and other pertinent laboratory reports
for indications of infection or dehydration.
 Remove excess blankets when the client feels warm but provide extra warmth when the
client feels chilled.
 Provide adequate nutrition and fluids (e.g., 2,500- 3,000 mL/ day) to meet the increased
metabolic demands and prevent dehydration.
 Measure intake and output.
 Reduce physical activity to limit heat production, especially during the flush stage.
 Administer antipyretics (drugs that reduce the level of fever) as ordered.
 Provide oral hygiene to keep the mucous membranes moist.
 Provide a tepid sponge bath to increase heat loss through conduction.
 Provide dry clothing and bed linens.

HYPOTHERMIA
It is a core body temp. below the lower limit of normal.
3 Physiological mechanisms of hypothermia:
a. Excessive heat loss
b. Inadequate heat production to counteract heat loss
 c. Impaired hypothalamic thermoregulation
CLINICAL MANIFESTATIONS

 Decreased body temp., pulse, and respirations

 Severe shivering (initially)
 Feelings of cold and chills
 Pale, cool, waxy skin
 Frostbite (discolored, blistered nose, fingers, toes)
 Hypotension
 Decreased urinary output
 Lack of muscle coordination
 Disorientation
 Drowsiness progressing to coma
Nursing Interventions for Clients with Hypothermia
 Provide a warm environment
 Provide dry clothing
 Apply warm blankets
 Keep limbs close to body.
 Cover the client’s scalp with a cap or turban.
 Supply warm oral or intravenous fluids.
 Apply warming pads.
Temperature Scales
Conversion of temp. from Fahrenheit to Celsius

- Deduct 32 from Fahrenheit reading and then multiply by the fraction 5/9; that is

C = (Fahrenheit temp. -32) x 5/9

For example, when the Fahrenheit reading is 100: C= (100 -32) x 5/9= (68) x 5/9 =
37.8
To convert from Celsius to Fahrenheit, multiply the Celsius reading by the fraction 9/5 and then
add 32; that is:
F= (Cesius temp. X 9/5) + 32
For example, when the Celsius reading is 40: F= (40 x 9/5) + 32= (72 = 32)= 104

Assessing Body Temperature

The most common sites for measuring body temp. are oral, rectal, axillary, tympanic membrane,
and skin/ temporal artery.
 Advantages and Disadvantages of Sites Used for Body Temperature Measurements

Site Advantages Disadvantages

Oral Accessible and Thermometers can break if bitten
convenient Inaccurate if client has just ingested hot
or cold food or fluid or smoked.
Could injure the mouth following oral
surgery.

Rectal Reliable measurement Incovenient and more unpleasant for

clients; difficult for client who cannot turn
to the side.
Could injure the rectum.
Presence of stool may interfere with
thermometer placement.

Axillary Safe and noninvasive The thermometer may need to be left in

place a long time to obtain an accurate
measurement.

Tympanic membrane Readily accessible; Can be uncomfortable and involves risk of

reflects the core temp.; injuring the membrane if the probe is
very fast inserted to far.
Repeated measurements may vary. Right
and left measurements can differ.
Presence of cerumen can affect the
reading.

Temporal artery Safe and noninvasive; Requires electronic equipment that

very fast maybe expensive or unavailable.
Variation in technique needed if the client
has perspiration on the forehead.

PULSE
 Is a wave of blood created by contraction of the left ventricle of the heart. Generally, the
pulse wave represents the stroke volume output or the amount of blood blood that enters
the arteries with each ventricular contraction.

 Compliance of the arteries is their ability to contract and expand. When the person’s
arteries lose their distensibility, as can happen with age, greater pressure is required to
pump the blood into the arteries.
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.
 For example: 65 ml x 70 beats per minute = 4.55 L per minute.

 When adult is resting, the heart pumps about 5 liters of blood each minute.

 Peripheral pulse (located away from the heart)

 Apical pulse (central pulse/ point of maximal impulse (PMI)

Purposes in Assessing the PR:

 To establish baseline data for subsequent evaluation

 To identify whether the pulse rate is within normal range
 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
Factors Affecting Pulse Rate
1. Age- increased age, decreased PR
2. Gender- after puberty, male’s pulse rate is slightly lower than the female’s
3. Exercise- PR increases with activity
4. Fever- PR increases
 In response to the lowered BP (vasodilation)because of the increased metabolic
rate
 Medications
5. Hypovolemia- loss of blood from the vascular system normally increases the pulse rate.
6. Stress
7. Position changes
 Blood pooling results in a transient decrease in the venous blood return to the
heart and a subsequent reduction in blood pressure and increase in heart rate.
8. Pathology
 Some heart conditions or those that impair oxygenation can alter the resting
pulse rate
TERMINOLOGIES
1. Tachycardia- excesive fast heart rate (over 100 beats/ min in adult)
2. Bradycardia- heart rate of an adult less than 60 beats/min
3. Pulse rhytm- pattern of the beats and the intervals between the beats
Equal time elapses between beats of a normal pulse
4. Dysrhythmia/ arrhythmia- pulse with irregular rhythm
It consist of random, irregular beats or a predictable pattern of irregular beats
(documented as ‘regularly irregular”). When dysrhythmia is detected, the apical
pulse should be assess. An electrocardiogram (ECG) is necessary to define the
dysrhythmia further.
5. Pulse volume- it is the pulse strength or amplitude, refers to the force of blood with each
beat. Usually, the pulse volume is the same with each beat.
6. Full or bounding pulse- forceful/full blood volume that is obliterated only with difficulty.
7. Weak, feeble/thready- pulse that is readily obliterated with pressure from the fingers
Pulse Sites
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.
2. Carotid, at the side of the neck where the carotid artery runs between the trachea and
the sternocleidomastoid muscle.
3. Apical, at the apex of the heart. In an adult, this is located on the left side of the chest,
about 8 cm (3 in.) to the left of the sternum (breastbone) at the fifth intercostal space
(area between the ribs). In order adults, the apex may be further left if conditions are
present that have led to enlarged heart. Before 4 years of age, the apex is left of the
midclavicular line; between 4 and 6 years, it is at the MCL. For a child 7 to 9 years of
age, the apical pulse is located at the fourth or fifth intercostal space.
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.
6. Femoral , where the radial artery passes alongside the inguinal ligament.
7. Popliteal, where the popliteal artery passes behind the knee.
8. Posterior tibial, on the medial surface of the ankle where the posterior tibial artery
passes behind the medial malleolus.
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.

 The radial site is most commonly used in adults. It is easily found in most people and
readily accessible. Some reasons for use of each site are given on the table below:
 Pulse Site Reasons for Use
Radial Readily accessible

Temporal Used when radial pulse is not accessible

Carotid Used during cardiac arrest/ shock in adults

Used to determine circulation to the brain

Apical Routinely used for infants and children up to 3 years of

age
Used to determine discrepancies with radial pulse
Used in conjunction with some medications

Brachial
Used to measure blood pressure
Used during cardiac arrest for infants
Femoral
Used in cases of cardiac arrest/ shock
Used to determine circulation to a leg
Poplitheal
Used to determine circulation to the lower leg
Posterior tibial
Used to determine circulation to the foot
Dorsalis pedis
Used to determine circulation to the foot

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. A Doppler ultrasound stethoscope is used for
pulses that are difficult to assess.
A pulse is normally palpated by applying moderate pressure with the three middle fingers of the
hand. The pads on the most distal aspects of the finger are the most distal aspects of the finger
are the most sensitive areas for detecting a pulse. With excessive pressure, one can obliterate a
pulse, whereas with too little pressure one may not be able to detect it.
Before the nurse assesses the resting pulse, the client should assume a comfortable position.
The nurse should be aware of the following:

 Any medication that could affect the heart.

 Whether the client has been physically active. If so, wait 10 to 15 min. until the client has
rested and the pulse has slowed to its usual rate.
 Any baseline data about the normal heart rate for the client. For example, a physically fit
athlete may have a resting heart rate below 60 beats/ min.
  Whether the client should assume a particular position (e.g., sitting). In some clients,
therate changes, the rate changes with the position because of changes in blood flow
volume and autonomic nervous system activity.

 When assessing the pulse, the nurse collects the ff. data: rate, rhythm, volume, arterial
wall elasticity, presence/absence of bilateral equality

RESPIRATION
 The act of breathing

 Inhalation or inspiration (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
 Costal breathing- type of
breathing involves the external intercostal muscles and other accessory muscles,
such as the sternocleidomastoid muscles. It can be observed by the movement
of the chest upward and outward.
 Diaphragmatic breathing- involves the contraction and 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

Purposes in Assessing Respirations

 To acquire baseline data against which future measurements can be compared

 To monitor abnormal respirations and respiratory patterns and identify changes
 To monitor respirations before or after administration of a general anesthetic or any
medication that influences resp.
gas movement/ diaphragm

Two Types of Breathing:

1. Costal (thoracic) breathing
 Involves the external intercostal muscles and other accessory muscles, such as
the sternocleidomastoid muscles
2. Diaphragmatic breathing
 Involves the contraction and relaxation of the diaphragm
 Observed through movement of the abdomen
Terminologies:
1. Eupnea- breathing that is normal in rate and depth (16-20 cpm)
2. Bradypnea- slow respirations (less than 16 cpm)
3. Tachypnea or polypnea abnormally fast respirations (above 20cpm)
4. Apnea- absence of breathing
5. Hyperventilation- very deep, rapid respirations
6. Hypoventilation- very shallow respirations.
Mechanic and Regulation of Breathing
Normal breathing is automatic and effortless.
A normal adult inspiration lasts 1 to 1.5 seconds, and an expiration lasts 2 to 3 seconds
 Respiration is controlled by (a) respiratory centers in the medulla oblongata and the
pons of the brain and (b) chemoreceptors located centrally in the medulla and
peripherally in the carotid and aortic bodies. These centers and receptors respond to
changes in the concentrations of oxygen (O2), carbon dioxide (CO2), and (H+) in the
arterial blood.
During inhalation, the following processes normally occur:

- diaphragm contracts (flattens), the ribs move upward and outward, and the sternum
moves outward, thus enlarging the thorax and permitting the lungs to expand.
During exhalation

- The diaphragm relaxes, the ribs move downward and inward, and the sternum
moves inward, thus decreasing the size of the thorax as the lungs are compressed.
Factors Affecting Respirations
 Several factors influence resp. rate. Those that increase the rate include:
exercise (increases metabolism), stress (readies the body for “fight or flight”), increase
environmental temperature, and lowered oxygen concentration at increased altitudes.
Factors that may decrease the resp. rate include decreased environmental temp.,
certain medications (e.g., narcotics), and increased intracranial pressure.

 The depth of a person’s respirations can be established by watching the movement of

the chest. Respiratory depth is generally described as normal, deep or shallow.

 Tidal volume- Deep resp. are those in which large volume of air is inhaled and exhaled,
inflating most of the lungs. Shallow resp. involved the exchange of a small volume of air
and often the minimal use of lung tissue. During a normal inspiration and expiration, an
adult takes about 500mL of air.
 Body position also affects the amount of air that can be inhaled. People in a supine
position experience two physiological processes that that suppress respiration: an
increase in the volume of blood inside the thoracic cavity and compression of the chest.
Consequently clients lying on their back have poorer lung aeration, which predisposes
them to stasis of fluids and subsequent infection. Certain medications also affect the
resp. depth. For example, narcotics such as morphine and large doses of barbiturates
such as penthobarbital depress the resp. centers in the brain, thereby depressing the
resp. rate and depth.

 Respiratory rhythm- refers to the regulatory of the expirations and the inspirations.
Normally, respirations are evenly spaced. Respiratory rhythm can be described as
regular or irregular. An infant’s respiratory rhythm may be less regular than an adult’s.

 Respiratory quality or character- refers to those aspects of breathing that are different
from normal, effortless breathing.
 Amount of Effort exert- Usually, breathing does not require noticeable effort.
Sometimes, however, clients can breathe only with substantial effort referred to as
labored breathing
 Sound of breathing- normal breathing is silent, but a number of abnormal sounds such
as a wheeze are obvious to the nurse’s ear. Many sounds occur as a result of the
presence of fluid in the lungs and are most clearly heard with stethoscope.

 Pulse oxymeter- measures the amount of hemoglobin in arterial blood that is

saturated with oxygen (O2 Sat) and digital readout on client’s pulse rate.

 Resting respirations should be assess when the client is relaxed because exercise
affects resp., increasing their rate and depth. Anxiety is likely to affect resp. rate and
depth as well. Resp. may also need to be assessed after exercise to identify the client’s
tolerance to activity.

 Before assessing a client’s resp., a nurse should be aware of the following:

 The client’s normal breathing patterns
 The influence of the client’s health problems on respirations
 Any medications or therapies that might affect respirations
 The relationship of the client’s resp. to cardiovascular function

o The rate, depth, rhythm, quality and effectiveness of respirations should be assessed.
The resp. rate is normally described in breaths per min. Breathing that is normal in rate
and depth is called eupnea. Abnormally slow resp. are referred to as bradypnea, and
abnormally fast resp. are called tachypnea or polypnea. Apnea is the absence of
breathing.
Altered Breathing Patterns and Sounds

Breathing Patterns Breath Sounds

Rate Audible Without Amplification
 Tachypnea- quick, shallow breaths  Stridor- a shrill, harsh sound heard during
 Bradypnea- abnormally slow breathing inspiration with laryngeal obstruction
 Apnea- cessation of breathing  Stertor- snoring or sonorous respiration, usually
due to a partial obstruction of the upper airway
Volume  Wheeze- continuous, high- pitch musical squeak
 Hyperventilation- overexpansion of the or whistling sound occurring on expiration and
lungs characterized by rapid and deep sometimes on inspiration when air moves through
breaths narrowed or partially obstructed airway
 Hypoventilation- underexpansion of the  Bubbling- gurgling sounds heard as air passes
lungs, characterized by shallow through moist secretions in the respiratory tract
respirations
Rhythm Chest Movements
 Cheyne- Stokes breathing- rhythmic  Intercostal retractions- indrawing between the ribs
waxing and waning of respirations, from  Substernal retraction- indrawing beneath the
very deep to very shallow breathing and breastbone
temporary apnea  Suprasternal retraction- indrawing above the
clavicles
Ease or Effort
 Dyspnea- difficult and labored breathing Secretions and Coughing
during which the individual has a  Hemoptysis- the presence of blood in the sputum
persistent, unsatisfied need for air and  Productive cough- a cough accompanied by
feels distressed expectorated secretions
 Orthopnea- ability to breath only in  Nonproductive cough- a dry, harsh cough without
upright sitting or standing positions secretions
Blood Pressure
 Arterial blood pressure is a measure of the pressure exerted by the blood as it flows
through the arteries.
A result of several factors: the pumping action of the heart, the peripheral vascular resistance
(the resistance supplied by the blood vessels through which the blood flows), and the blood
volume and viscosity.
Arterial BP: 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).

There are two types of blood pressure.

[Link] pressure: is the pressure of the blood as a result of contraction of the ventricle (is
the pressure of the blood at the height of the blood wave);
2. Diastolic blood pressure: is the pressure when the ventricles are at rest.

Pulse pressure: is the difference between the systolic and diastolic pressure

 Blood pressure is measured in mm Hg and recorded as fraction using a bp apparatus

(sphygmomanometer, stethoscope). A number of conditions are reflected by changes in
blood pressure.

 An increase in blood pressure is called hypertension

 A decrease is called hypotension.
Conditions Affecting Blood Pressure
Fever Increase
Stress "
Arteriosclerosis "
Obesity "
Exposure to cold Increase
Hemorrhage Decrease
Low hematocrit "
External heat "
Sites for Measuring Blood Pressure
1. Upper arm using brachial artery (commonest)
2. Thigh around popliteal artery
3. Fore -arm using radial artery
4. Leg using posterior tibial or dorsal pedis
Determinants of Blood Pressure
-Arterial blood pressure is the result of several factors: the pumping action of the heart, the
peripheral vascular resistance (the resistance supplied by the blood vessels through which the
blood flows), and the blood volume and viscosity.
1. Pumping Action of the Heart
-When the pumping action of the heart is weak, less blood is pumped into arteries (lower
cardiac output), and the blood pressure decreases.
-When the heart’s pumping action is strong and the volume of blood pumped into the circulation
increases (higher cardiac output), the blood pressure increases.
2. Peripheral Vascular Resistance
-can increase blood pressure. The diastolic pressure especially is affected. Some factors that
create resistance in the arterial system are the capacity of the arterioles and capillaries, the
compliance of the arteries, and the viscosity of the blood.
 - The internal diameter or capacity
of the arterioles and the
capillaries determines in great
part the peripheral resistance of
the blood in the body. The smaller
the space within the vessel, the
greater the resistance. Normally,
the arterioles are in the state of
partial constriction. Increased
vasoconstriction, such as occurs
with smoking, raises the blood
pressure, whereas decreased
vasoconstriction lowers the blood
pressure.
- If the elastic and muscular tissues of the arteries are replaced with fibrous tissue, the arteries
lose much of their ability to
constrict and dilate. This condition,
most common in middle-aged and
older adults, is known as
arteriosclerosis.

3. Blood Volume
-When the blood volume decreases (for example, as a result of a haemorrhage or dehydration),
the blood pressure decreases because of decreased fluid in the arteries. Conversely, when the
volume increases ((for ex: as a result of rapid intravenous infusion), the blood pressure
increases because of the greater fluid volume within the circulatory system.

4. Blood Viscosity
-Blood pressure is higher when the blood is highly viscous (thick), that is, when the proportion of
red blood cells to the blood plasma is high. This proportion is referred to as haematocrit. The
viscosity increases markedly when the haematocrit is more than 60%- 65%.
Factors Affecting Blood Pressure

 Age
- Newborns have a systolic pressure of about 76 mmHg. The pressure rises with age, reaching
a peak at the onset of puberty, and then tends to decline somewhat.
-In older adults, elasticity of the arteries is decreased—the arteries are more rigid and less
yielding to the pressure of the blood. This produces an elevated systolic pressure. Because the
walls no longer retract as flexibility with decreased pressure, the diastolic pressure may also be
high.

 Exercise
-Physical activity increases the cardiac output and hence the blood pressure. For reliable
assessment of resting blood pressure, wait 20- 30- min. following exercise.

 Stress
-Stimulation of the sympathetic nervous system increases cardiac output and vasoconstriction
of the arterioles, thus increasing the blood pressure reading; however, severe pain can
decreased blood pressure greatly by inhibiting the vasomotor center and producing vasodilation.

 Race
-African Americans older than 35 years tend to have higher blood pressures than Europian
Americans of the same age although the exact reasons for these differences are unclear
(Covelli, Wood, & Yarandi, 2012).

 Sex
-After puberty, females usually have lower blood pressures than males of the same age; this
difference is brought to be due to hormonal variations. After menopause, women generally have
higher blood pressure than before.

 Medications
-Many medications, including caffeine, 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.

 Medical conditions
-Any condition affecting the cardiac output, blood volume, blood viscosity, and/or compliance of
the arteries has a direct effect on the blood pressure.

 Temperature
-Because of increased metabolic rate, fever can increase blood pressure. However, external
heat causes vasodilation and decrease blood pressure. Cold causes vasoconstriction and
elevates blood pressure.

Hypertension
 - A blood pressure that is persistently above normal
- A single elevated bp reading indicates the need for reassessment. Hpn cannot be
diagnosed unless an elevated bp is found when measured twice at different times. It is
usually asymptomatic and is often a contributing factor to myocardial infarctions (heart
attacks).
 Primary hpn
-an elevated bp of unknown

 Secondary hpn
- an elevated bp of known cause
-The national guidelines for high blood pressure management recommend that hypertensive
individuals age 60 years older receive treatment toward a goal of less than 150/90 mmHg and
hypertensive individuals age 30 through 59 years have a diastolic goal of less than 90 mmHg.
For all other individuals, the goal is less than 140/90 mmHg.

Classification of Blood Pressure

Category Systolic BP (mmHg) Diastolic BP (mmHg)

Normal < 120 <80
Prehypertension 120- 139 80- 89
Hypertension, stage 1 140- 159 90- 99
Hypertension, stage 2 >160 >100

Hypotension
-BP is below normal with a systolic reading consistently between 85 and 110 mmHg in an adult
whose normal pressure is higher than this.
Orthostatic hypotension
-is a blood pressure that decreases when the client sits or stands. It is usually the result of
peripheral vasodilation in which blood leaves the central body organs, especially the brain, and
moves to the periphery, often causing the person to feel faint.
-also can be caused by analgesics such as meperidine hydrochloride (Demerol), bleeding,
severe burns and dehydration.
-It is important to monitor hypotensive clients carefully to prevent falls. When assessing for
orthostatic hypotension:
o Place the client in a supine position for 10 min.
o Record the client’s blood pressure.
o Assist the client to slowly sit or stand. Support the client in case of faintness.
o Immediately recheck the blood pressure in the same sites as previously.
o Repeat the pulse and blood pressure after 3 min.
o Records the results. A drop in blood pressure of 20 mmHg systolic or 10 mmHg diastolic
indicates orthostatic hypotension.
Some Points to Consider in Blood Pressure Assessment Sites
-The bp is usually assessed in the client’s upper arm using the brachial artery and a standard
stethoscope. Assessing the blood pressure on a client’s thigh is indicated in these situations:

 The bp cannot be measured on either arm (e.g., because of burns or other trauma)
 The blood pressure in one thigh is to be compared with the blood pressure in the other
thigh.
BP is not measured on a particular client’s limb in the following situations:

 The shoulder, arm, or hand (or the hip, knee, or ankle) is injured or diseased.
 A cast or bulky bandage is on any part of the limb.
 The client has had surgical removal of breast or axillary (or inguinal) lymph nodes on
that side.
 The client has an intravenous infusion or blood transfusion in that limb.
 The client has an arteriovenous fistula (e.g., for renal dialysis) in that limb.

Methods of Measuring Blood Pressure

Blood pressure can be assessed directly or indirectly

 Direct (invasive monitoring) measurement involves the insertion of catheter in to the

brachial, radial, or femoral artery. The physician inserts the catheter and the nurse
monitors the pressure reading. With use of correct placement, it is highly accurate.

 Indirect (non invasive methods)

A. The auscultatory
B. The palpatory, and the auscultatory method is the commonest method used in health
activities.
 When taking blood pressure using stethoscope, the nurse identifies five phases in series
of sounds called Korotkoff's sound:

Phase 1: The pressure level at which the 1st joint clear tapping
sound is heard, these sounds gradually become more intense. To
ensure that they are not extraneous sounds, the nurse should
identify at least two consecutive tapping sounds.
Phase 2: The period during deflation when the sound has a
swishing quality
Phase 3: The period during which the sounds are crisper and more
intense
Phase 4: The time when the sounds become muffled and have a
soft blowing quality
Phase 5: The pressure level when the sounds disappear

The purpose in assessing BP is:

 To obtain base line measure of arterial blood pressure for subsequent evaluation
 To determine the clients homodynamic status
 To identify and monitor changes in blood pressure resulting from a disease
process and medical therapy

EQUIPMENT
 Stethoscope
 Blood pressure cuff of the appropriate size
 Sphygmomanometer

BP Cuff Sizes

Blood pressure cuffs come in various sizes because the bladder must be correct width and
length of the client’s arm. If the bladder is too narrow; the bp reading will be erroneously
elevated; if it’s too wide, the reading will be too low..
Selected Sources of Error in BP Assessment
1. Bladder cuff too narrow
2. Bladder cuff too wide
 3. Arm unsupported
4. Insufficient rest before the assessment
5. Repeating assessment too quickly
6. Cuff wrapped too loosely or unevenly
7. Deflating cuff too slowly
8. Failure to use the same arm consistently
9. Arm above level of the heart
10. Assessing immediately after a meal or while client smokes or has pain
11. Failure to identify auscultory gap

References:
Books
 o Kozier & Erb (2020), Fundamentals of Nursing (10th Edition), Pearson Publishing House,
Ca.
Url’s:
o [Link]
tempearature-pulse-rate-respiration-rate-blood-pressure retrieved on February 13, 2021
o [Link]
ContentTypeID=85&ContentID=P00866 retrieved on February 13, 2021
o [Link] retrieved on February 13,
2021