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OBSERVATION AND RECORDING
OBSERVATION AND RECORDING
The most important practical lesson that can be given to nurses is to teach them what to observe-how to observe-what symptoms indicate improvement –what the reverse- which are of importance –which are of none-which are the evidence of neglect – and of what kind of neglect. All these are what ought to make part, and an essential part , of the training of every nurse. (Florence Nightingale 1860/1969)
OBSERVATION AND RECORDING One of the most valuable qualities of a nurse is
that he/she must be observant. Observations is one of the many tools used in gathering data for planning nursing care for patients.
Observation is gathering data by using one or more of the five senses (sight, hearing, touch, smell and taste ) with an understanding of what has been detected. Without an understanding/ interpretation of what has been observed, the act of observation is useless.
OBSERVATION AND RECORDING What are some of the observations you make
about a friend that gives you some information about him/her?
It is a highly developed skill that uses knowledge from the physical and social science as its basis. Thus when a nurse must have a sound understanding of normal behaviour , she will then be able to recognize an abnormal one.
nurses work with other health team members and also run shifts. (list some members of the team)
OBSERVATION AND RECORDING For this reason, it is paramount that observations
made on patients are accurately communicated from the nurse who made the observation to other members of staff. On account of this, observations made are written for keeping as records.
records are written documents of events or proceedings. Health records are formal, legal and confidential documents that should be accessible only to the members of the health team involved in the patient’s care to use and deliver effective health care to the patient.
OBSERVATION AND RECORDING Records from observations should be
Factual – state exactly what has been observed and devoid of words like “ it appears , it seems, as if …” ; record exactly what was observed.
Complete – contain the important facts that should be known for effective planning. E.g. the correct unit of measurement (mg, g, ml, Fahrenheit (oF), oC ) medication orders-dose, frequency and duration of administration, review dates, types of surgery, etc.
OBSERVATION AND RECORDING Accurate – use the right instrument,
gadgets, procedures and observe the precautions necessary to get correct results. Records should be free from mistakes and other errors as much as possible.
Relevant/ Appropriate – record only information that has a bearing on the issue at stake. The nurse should use his/her knowledge and discretions to sieve relevant information from the irrelevant ones
OBSERVATION AND RECORDING Current – observations should be recorded
immediately with date and time as delay in recording can lead to omissions resulting in denial of the needed care to the client or commissions that may be detrimental. Recording observations instantly keeps it current and up to date.
Organized–chronological recording of observations make the records meaningful and also makes interpretation easier.
OBSERVATION AND RECORDING Confidential – the records of the patient should
be made accessible only to health care team members who need it to care for him/her.
Standard – records from observations should contain only standard and acceptable format and terminologies to avoid misinterpretation.
Why should we keep record of observations? For effective communication among members of
the health team for continuity of care.
OBSERVATION AND RECORDING To avoid duplication of effort. For research purposes To serve as a legal document For auditing and peer review of health
institutions For education purposes.
What do we observe in our patients/clients?
OBSERVATION AND RECORDING Vital signs Level of consciousness Amount of fluids input and output Blood sugar level Appearance of the client Activity level of the client Mental state of the patient Nutritional status of the client Facial expression Gestures Effects of medications Etc.
OBSERVATION AND RECORDING Though the senses are used in
observation, there are pieces of instruments that aid in the procedure E.g.
The thermometer The sphygmomanometer Stethoscope The glucometer
find the rest for our next meeting
observation and recording of vital signs
Vital signs are physiological data that enables health care workers to monitor the functioning of the body. The vital signs –temperature, pulse, respiration and blood pressure – reflect changes in body function that otherwise might not be observed.
since vital signs also known as cardinal signs reflect changes in body functions, they should not be monitored as a matter of routine but a thoughtful reflective scientific assessment.
observation and recording of vital signs
When Should Vitals Signs be Checked? During admission to establish a baseline for
comparison with later readings
When there is a sudden change in a client/ patient’s condition or patient reports symptoms e.g. fainting, palpitation, dizziness etc.
As a routine matter of routine in a health facility
Before and after surgery/invasive procedures e.g. blood transfusion, delivery, etc.
observation and recording of vital signs
Before and after administration of medications that can affect the cardiovascular and or the respiratory system
According to nursing or medical order for provision of individualized care.
before and after nursing interventions that could affect the vital signs e.g. ambulating a patient who had been on bed rest for long.
When client reports some symptoms
observation and recording of vital signs
Factors influencing vital signs1. Age2. Sex3. Race4. Geographical location/environment5. Lifestyle6. Disease conditions (thyrotoxicosis)7. Medication e.g. Paracetamol
VITAL SIGNS
Vital signs consist of : Temperature Pulse Respiration Blood pressureIn some institutions assessment of the level
of ; Oxygen saturation Pain level Consciousness level, are added.
VITAL SIGNS
Vital signs are checked to monitor the functions of the body. They reflect changes in function that otherwise might not be observed.
Vital signs must be looked at in total not individually/singly or as different entities to achieve the above
VITAL SIGNS
Temperature: It is the degree of hotness or coldness measured against a standard scale. It reflects the balance between heat production and heat loss.
The standard scales commonly used are:
the centigrade/degrees Celsius (OC) the Fahrenheit scale (OF)
Temperature checked in one scale can be converted into the other
VITAL SIGNS
To convert temperature checked in centigrade (OC) to Fahrenheit (OF), OF = ( OC x 9/5) + 32 OC = (OF - 32) x 5/9
Two (2) kinds of body temperature are:
The core body temperature and The surface body temperature.
VITAL SIGNS
Core temperature refers to the temperature of the deep tissues of the body as in the abdominal cavity, thoracic cavity, the cranium etc. It is relatively constant
Surface temperature is the temperature of the skin, the subcutaneous tissue and fat; it rises and fall in response to the environment.
VITAL SIGNS
Factors influencing vital signs1. Age2. Sex3. Race4. Geographical location/environment5. activity6. Disease conditions (thyrotoxicosis)7. Medication
VITAL SIGNS
ALTERATIONS IN BODY TEMPERATURE The normal body temperature is a range
between 36.2 OC – 37.2 OC. There are basically two main alterations in
body in body temperatures: Hyperthermia; Temperatures above the
normal range (pyrexia/fever) Hypothermia; Temperatures below the
normal range Temperatures below or above the normal
range needs interventions to restore it.
VITAL SIGNS
Readings may be: 1. Sub normal <36.2°C 2. Normal 36.2°C - 37.2°C 3. Pyrexia > 37.6°C - Mild (low) pyrexia 37.6 °C- 38.3ºC
- Moderate pyrexia 38.4°C - 39.4°C - High pyrexia 39.5°C - 40.0°C
- Hyperpyrexia > 40°C
VITAL SIGNS
Checking and recording of Temperature This refers to the use of instruments to
estimate the degree of hotness or coldness of the body.
Thermometers are used to check temperature.
There are many types of thermometers; the one used for checking body temperature is the clinical thermometer
OBSERVATION AND RECORDING OF VITAL SIGNS
Electronic thermometers
Mercury in glass thermometers
Chemical dot disposable thermometers
Electronic Chemical
VITAL SIGNS
Infrared thermometer (electronic)
Mercury in glass thermometer (chemical)
VITAL SIGNS
Skin thermometer (chemical)
Digital thermometer
VITAL SIGNS
Sites for Checking Surface Temperature Mouth Axilla groin Rectum Ear Skin (forehead)NB: rectal temperature is 0.5°C higher than
oral; axillary and tympanic temperatures are 0.5°C lower than oral temperatures
VITAL SIGNS
Checking and Recording of TemperatureRequirements; A clinical thermometer A gallipot containing clean cotton wool swabs A receiver for used swabs A gallipot containing clean water for rinsing the
thermometer (mercury in glass) Lubricant (for rectal thermometer) Temperature chart and pens (usually red and blue) A watch with second hand
VITAL SIGNS
The Procedure of Taking Temperature in the Axilla (steps using mercury in
glass thermometer) Explain procedure to the patient Provide privacy Take temperature tray to the patient’s side Make patient comfortable in a position that
can enable you work (either sitting or lying) Take the thermometer, dry with cotton wool
swab from the bulb towards the stem
VITAL SIGNS
Shake mercury thermometer till mercury falls below 35 OC.
Raise arm of client away from torso, inspect for lesion and if none, dry axilla by cleaning with dry cotton and discard swab.
Insert the thermometer in the axilla and lower the arm making sure the bulb is in between the skin folds (of the axilla) and place arm across patient’s chest.
leave the thermometer in situ for three (3) minutes or as indicated on it.
VITAL SIGNS
Remove the thermometer and wipe from the stem towards the bulb and check reading, holding the thermometer at an eye level
Record reading on the temperature chart, document in nurses’ note and report any abnormality to the in - charge
Thank patient and make him/her comfortable. Discard the tray Wash and dry hands Report any abnormality in the reading
appropriately.
VITAL SIGNS
NB: Patient must be still to prevent dislodging and breaking
of the thermometer. Site must be dry before the insertion of the
thermometer The skin surfaces must completely surround the bulb of
the thermometer.
Some Contraindications for Taking Temperature in the Axilla
Boil in the axilla Fracture of the bones of the arm Wound (burns, ulcers etc.) in the axilla
VITAL SIGNS
The Procedure for Taking Oral Temperature (Steps using electronic thermometer)
Explain procedure to the patient Provide privacy Take temperature tray to the patient’s side Make patient comfortable in a position that
can enable you work (either sitting or lying) Take the thermometer, dry with cotton wool
swab from the bulb towards the stem (mercury in glass thermometer) OR
VITAL SIGNS
Remove the thermometer from the container/charging unit and assemble if necessary (electronic)
Ask client to open his/her mouth; insert the thermometer gently with the probe placed in the posterior sublingual pocket lateral to the centre of the lower jaw
Ask client to hold the thermometer in place with closed lips
VITAL SIGNS
Leave the thermometer in situ for 3 minutes or until a signal (beep) indicates completion and reading appears on the digital display
Remove thermometer and wipe from stem towards the bulb with a swab/discard the probe used is disposable or ***
Check the reading Record the reading on the temperature chart, indicate site
e.g. ‘OT’ Return the thermometer into it’s container/charging system Leave patient comfortable. Discard tray. Wash and dry hands Report any deviations
VITAL SIGNS
Some Contraindications for Taking Temperature in the mouth
Difficulty in breathing Patient who fits/convulse frequently Patients with nose packs When there is disease or surgery done in the mouth Unconscious patient Psychiatric patients.
NB: unless electronic thermometers with disposable probe are used, patients must have individual thermometers.
VITAL SIGNS
The Procedure for Taking Rectal Temperature (Steps using electronic thermometer)
Explain procedure to the patient Provide privacy Take temperature tray to the patient’s side Make patient comfortable in the Sim’s
position with upper leg flexed and expose the anal region/area.
Donn disposable gloves
VITAL SIGNS
Lubricate the probe of the electronic thermometer from bulb upwards covering about 2.5cm.
With non-dominant hand part patient’s buttocks to expose the anus; let him breath slowly and relax.
Insert the bulb of the rectal thermometer gently in the direction of the umbilicus (to 3.5cm from bulb) if no resistance is met; otherwise stop the procedure.
Hold the thermometer in situ until a signal (beep) indicates completion and reading appears on the digital display
dispose off the probe used
VITAL SIGNS
Record the reading on the temperature chart, indicate site e.g. ‘RT’
Return the thermometer into it’s container/charging system
Wipe the client’s anal region and discard the tissue
Leave patient comfortable. Discard tray. Wash and dry hands Report any deviations
VITAL SIGNS
Some Contraindications for Taking Temperature in the rectum
Diarrhoea Disease condition of the rectum e.g
haemorrhoides Rectal surgeryRectal prolapse
NB: please read and make note on taking temperature at the rest of the sites not discussed.
VITAL SIGNS
PYREXIA/FEVER/HYPERTHERMIA Body temperature above the normal range
is termed pyrexia/hyperthermia/fever. A person who has fever is said to be febrile; otherwise, he is afebrile.
A very high fever of above 40OC is termed hyperpyrexia. A person is said to be spiking temperature or fever when his temperature rises rapidly from normal range to above normal then to normal within few hours.
TYPES OF PYREXIAConstant- continuous elevation of temperature
which does not vary more than 1.1 °C in a day.Remittent – there are variations of more than
1.1 °C in a day but the lowest temperature does not reach normal temperature
Intermittent / hectic/ swinging- it varies from normal to subnormal to moderate or hyper pyrexia with 1-3days, there is a variation of more than 1.1 ° C between the highest and the lowest temperature and the lowest being normal or below normal . E.g. In malaria and T.B
Irregular- does not fall into any clear group, it shows some characteristics of all the groups.
Inverse- highest temperature is recorded in the morning and lowest in the evening
VITAL SIGNS
When nursing a client with fever, interventions should be designed to support the body’s physiologic processes, provide comfort and prevent complications.
To achieve this the patient’s vital signs should be monitored closely.
VITAL SIGNS
Fever may run through the 3 stages:1. Onset/Cold/Chill Phase that is
characterized by Shivering Increased pulse rate Increased respiratory rate Cold skin with “goose-flesh” Complaints of feeling cold
VITAL SIGNS
Management-nursing measure during this phase is to aimed at helping the client to reduce heat loss:
Check and record vital signs Provide extra warmth (with extra
clothing, give warm drinks; switch off fan/ac etc and close nearby
louvers, windows, doors etc
VITAL SIGNS
2. Course/Hot/Plateau Phase is marked with Complaint of feeling hot Warm and dry skin Increased pulse and respiration Increased thirst Loss of appetite Drowsiness mild to moderate dehydration
VITAL SIGNS
Flushed skin Restlessness, Delirium and confusion may occur Convulsion may occur especially in
children Malaise, weakness and aching of the muscles
VITAL SIGNS
Management is aimed at helping the body to reduce the temperature to normal.
Monitor vital signs Remove excess blankets and extra clothing Tepid sponge patient Allow for good ventilation by opening
nearby windows, doors, louvers, switch on fans/ACs
Give antipyretics (drugs that reduce temperature
VITAL SIGNS
Give cold, nourishing and refreshing fluids frequently
Provide mouth care as there may be dry mouth with coated tongue; this is to keep the mucous membranes moist and boost appetite
Reduce physical activity to reduce heat production.
VITAL SIGNS
3. Termination/Flush/Fever Abatement Phase
Flushed and warm skin Sweating There may be dehydration
VITAL SIGNS
Management as the body works towards reducing its core temperature, nursing activities should also aim at increasing heat loss.
Tepid sponge or Help have a refreshing shower if possible Change wet clothing Encourage more fluids to replace fluid
lost
VITAL SIGNS
Hypothermia –this occurs when the body temperature is below the lower limit of the normal temperature range.
It may result from excessive heat loss from the body Inadequate heat production to counteract
heat loss Impaired function of the thermoregulatory
centre in the hypothalamus
VITAL SIGNS
This may manifest as: Decreased body temperature below the
normal range Severe shivering Pale and cold skin low blood pressure decreased urinary output Drowsiness and disorientation Poor muscle coordination
VITAL SIGNS
Management should be geared towards providing adequate warmth for the body.
Provide warm environment-close nearby windows/louvers/doors etc., switch off fans, ACs etc.
Provide additional clothing and remove wet clothes if any
Give warm drinks
VITAL SIGNS-THE PULSE
The pulse is the pressure wave due expansion and constriction of the arteries during the cardiac cycle. It is the palpable bounding felt in the arteries as a pulsation when the heart contracts and ejects blood into the aorta.
In a healthy person, the pulse reflects the heart beat. The pulse at the periphery is called the peripheral pulse while the apical pulse is that which is located at the apex of the heart.
VITAL SIGNS
Why should the pulse be checked? To assess the adequacy of blood flow to
an area To assess the rate, rhythm, volume and
tension of the pulse which reflect a health problem/disease state.
VITAL SIGNS
Sites for Assessing Pulse: Pulse can be felt wherever a superficial artery runs over a bone
Site Assessment criteria
Temporal- over the temporal bone, superior and lateral to the eye
Used mainly in children and when the radial pulse is inaccessible
Carotid –bilateral; under the lower jaw in the neck along the medial edge of the stenocleido-mastoid muscle
used in infants, during shock, cardiac arrest and when other pulses are not palpable and to assess cranial circulation
Apical –left midclavicular line at the 4th- 5th intercostal space
Used to auscultate heart sounds and assess apical radial deficit
VITAL SIGNSSite Assessment criteria
Brachial –at the anti-cubital fossa between grooves of biceps and triceps
Used to aucultate heart sounds and assess apical radial deficit
Radial-inner aspect of forearm on the thumb side of the wrist
Used mostly and routinely in adults to assess character of peripheral pulse
Ulna-outer aspect of forearm on finger side of the wrist
To assess circulation to ulnar side of hand.
femoral- groin, below inguinal ligaments, midpoint between symphysis pubis and the anterior superior iliac spine
to assess circulation to the legs and during cardiac arrest
Popliteal-behind the knee, at center in the popliteal fossa
To assess circulation to legs and to aucultate blood pressure
VITAL SIGNS
Site Assessment criteria
Posterior tibia- inner aspect of the ankle between Achilles tendon and tibia below the medial malleolus
To assess circulation to the feet
Pedal/Dorsalis pedis- over the instep, midpoint on an imaginary line from middle of ankle to interdigital space between the big and the 2nd toes
To assess circulation to the feet
NB-The radial pulse is the most commonly used as it is easily assessed with little disturbance to the patient
VITAL SIGNS
Radial pulse
Pulse over the Temporal regions
Brachial pulse
VITAL SIGNS
Popliteal pulse
Femoral pulse
VITAL SIGNS
VITAL SIGNS
Characteristics of Pulse Rhythm –refers to the pattern of the
beat, the interval between the beats; thus the regularity of the pulse. It describes how evenly the heart is beating
Volume-describes the strength; the amplitude of force exerted by the ejected blood against the arterial wall with each contraction.
VITAL SIGNS
Rate – obtained by counting the number of pulsing sensation in one (1) minute. For a normal adult, the pulse rate ranges 60-100 beats per minute. (Tachycardia, bradycardia)
Tension- the “feel” of the arterial wall. If the walls are tensile, they should be felt as straight pliant and soft under the fingers; not as gritty, twisted or irregular.
VITAL SIGNS
Factors that influence pulse Age, Exercise Temperature Sex Drugs Emotional stress Pain Some disease conditions
VITAL SIGNS
When checking the pulse: The patient should be made to assume a
comfortable position Instruct patient to be still for the duration of
checking the pulse. Patients who have undertaken vigorous activity
should rest at least 30 min. before their pulse is taken.
Never check pulse using the thumb because there is pulsation in the thumb itself which can be mistaken for the patient`s pulse
VITAL SIGNS
Assessing the Radial Pulse Assemble the requirements for the procedure-
watch with a second hand and stethoscope if needed.
Explain procedure to patient and gain consent Provide privacy where necessary Wash and dry hands Select the pulse point (using the radial pulse) Assist client into a comfortable position with
the palm facing downwards
Palpate the pulse with two or three middle fingers and count for 1minute noting the rhythm, volume and tension
Document findings Make patient comfortable and thank him Wash and dry hands
What is pulse deficit?
VITAL SIGNS-RESPIRATION
Respiration is a process by which there is gaseous exchange between the atmosphere and the cells of the body; there is intake of oxygen and output of carbon dioxide.
There are two types of respiration: Internal respiration External respiration
VITAL SIGNS
External Respiration – This is the interchange of oxygen and carbon dioxide in the alveoli of lungs and the pulmonary blood.
Internal Respiration – it takes place throughout the body. Internal respiration is the interchange of oxygen and carbon dioxide between the systemically circulating blood and the cells of the body tissues
VITAL SIGNS
Inhalation or inspiration is the intake of air into the lungs, exhalation or expiration is the breathing out of gases from the lung into the atmosphere. Ventilation is another name for the movement of air into or out of the lungs.
Two types of breathing are usually observed; Costal/Thoracic Breathing – occurs when
the intercostal muscle (chiefly) and other accessory muscles are used to move the chest upward and outward.
VITAL SIGNS
Diaphragmatic/Abdominal Breathing – this involves chiefly the contraction and the relaxation of the diaphragm observed as the movement o the abdomen. It is normally observable in children below seven years.
Normal breathing is automatic, slightly observable, effortless, regular, quiet (silent), and comfortable; neither too deep nor too shallow.
VITAL SIGNS
Characteristics of Respirations 1. Rate – One inspiration and expiration is
counted as one breath. Respiration is recorded in breaths per minute or cycles per minute. Respiratory rate varies for the different age groups.
Find the normal rate for children and adults.
It can also be affected by exercise, medication, pyrexia, anxiety and altitude.
Eupnoea refers to respiration that is easy with normal rate of breath per minute that are age specific.
VITAL SIGNS
Bradypnoea is the respiratory rate that is lower than the normal range. Tachypnoea is the respiratory rate higher than the normal range while apnoea is the absence of breathing.
2. Depth- the depth of a person’s respiration can be established by observing the movement of the chest. It is described as either normal, deep or shallow. Usually for an adult, about 500ml of air is inhaled and exhaled. With deep respiration, a larger volume of air is breathed in and out and this demands a full expansion of the lungs. In shallow respiration, only small volume of air exchange takes place.
VITAL SIGNS
Hypoventilation is characterized by shallow, slow respiration while hyperventilation is deep and rapid.
3. Rhythm – it is the regularity of both inspiration and expiration. It may be regular or irregular. Normal respiration is regular and even in rhythm.
VITAL SIGNS
4. Character of Respiration refers to those aspects of breathing which are different from the normal effortless breathing; thus the amount of effort required to breath, the sound associated with breathing and the skin colour of the patient. Orthopnoa is extreme difficulty in breathing unless sitting upright. Dyspnoea refers to difficulty in breathing with or without pain.
VITAL SIGNS
Factors that influence respiration Age, Exercise Temperature Drugs Emotional stress Pain Some disease conditions e.g. asthma
VITAL SIGNS
Assessing RespirationAssemble the requirements-watch with a second
hand, gloves if necessary Explain procedure to the patient Wash and dry hands Assist him/her to assume a comfortable positions Observe/palpate and count the respiratory rate;
place a hand against the client’s chest to feel the chest movements with breathing or place the client’s arm across the chest and observe the chest movements while supposedly taking the radial pulse.
VITAL SIGNS
Count the respiratory rate for 60 seconds; observing the depth, rhythm, noise or effort associated with the respiration.
Document observations (rate in breaths per minute-bpm or cycles per minute-cpm)
Make patient comfortable and thank him/her.
Assignment: find the normal respiratory rate for children and adults
VITAL SIGNS-BLOOD PRESSURE
Blood Pressure is the measure of the pressure of the blood as it pulsates through the arteries. Because the blood moves in waves, there are two blood pressure measurements
Systolic Pressure- the pressure of the blood as a result of contractions of the ventricles; it is the pressure at the height of blood wave.
Diastolic Pressure- the pressure when the ventricles are at rest; it is the pressure lowest pressure and is present at all times within the arteries
VITAL SIGNS
Pulse pressure is the difference between the diastolic and the systolic pressures
Depending on the client’s condition, and the resources available, blood pressure may be measured by either direct or indirect technique.
In the direct measurement of blood pressure, an intravenous catheter with an electronic sensor is inserted into an artery and the artery-transmitted pressure on an electronic display is read. It is an invasive procedure.
VITAL SIGNS
The indirect method- less expensive, convenient and easier to use- is the most used; it requires the use of the sphygmomanometer and the stethoscope.
The sphygmomanometer is a device that is used to check blood pressure. It has cuff-an inflatable rubber bag (bladder) which is covered with a cloth. The bladder has two tubes; one serves as an attachment for the bulb with a valve which used to inflate and deflate the cuff. The other tube is attached to the manometer/pressure gauge
VITAL SIGNS
Two types of manometers (manual) are commonly used
The aneroid manometer is a calibrated dial with a needle –like pointer that indicates the readings
The mercury manometer is a mercury filled calibrated cylinder; reading is done by looking at the meniscus at the eye level.
The electronic blood pressure apparatus eliminates the need for stethoscope as it measure and record readings on its monitor
TYPES OF SPHYGMOMANOMETERS
Mercury sphygmomanometer
Aneroid manometer
VITAL SIGNS
Dial of the aneroid manometer
Bulb with valve
VITAL SIGNS
Electronic Sphygmomanometer
VITAL SIGNS
The stethoscope is used to auscultate the blood pressure sounds. It has an earpiece that is inserted into the ears and the chest piece made of the diaphragm and the bell.
Two noninvasive indirect methods of measuring blood pressure are
auscultatory and the Palpatory methods
VITAL SIGNS
Sites for Checking the Blood PressureThe commonest site for blood pressure is the
upper arm over the brachial artery. However it is contraindicated in
injury or trauma to the arm, Cast or bulky bandage on the limb Surgical removal of the axilla as in breast
cancer Intravenous infusion on the arm etc. In case of the above, the popliteal artery
behind the knee on the thigh is use.
VITAL SIGNS
Factors that Affect Blood Pressure Age Sex Exercise Stress drugs/medications Disease state race
VITAL SIGNS
Procedure for Checking Blood Pressure
NB- for accuracy, the following precautions should be considered
Choose a cuff size that is the bigger the client’s arm circumference, wider and longer cuff should be.
The arm should be stretched out with palm up; both arm and manometer should be at the level of the heart (below or above the level of the heart, BP is higher or lower respectively)
VITAL SIGNS
During inflation of the cuff, compress until manometer register 30mmHg above diminished pulse point to ensure that cuff is inflated to a pressure greater than the client’s systolic pressure.
The same arm should be used consistently
Checking blood pressure immediately after meals, vigorous exercise or smoking gives inaccurate results
VITAL SIGNS
Steps in Checking Blood Pressure Assemble the needed items – stethoscope,
sphygmomanometer, alcohol swabs, gloves if needed, chart, pen and straight edge
Explain procedure to patient and gain consent
Assist patient into the desired position that is both comfortable and convenient for checking the BP accurately
Wash and dry hands; send equipment to the client’s side
VITAL SIGNS
Move clothing away to expose the upper extremity of the arm,
Position the arm at the heart level and extend arm with palm turned upwards
Locate the brachial artery in the anticubital space
Apply a totally deflated cuff smoothly over arm about 2.5cm above the anticubital space with the center of the cuff over the brachial artery
In case of mercury manometer, it should be placed vertically at heart level
VITALS SIGNS
Palpate the radial artery, turn valve clockwise to close and compress bulb to inflate cuff to 30mmHg above the point where palpated pulse disappears
Insert earpiece into the ears and let diaphragm hang loosely
Relocate the brachial pulse with the non-dominant hand and place the bell or diaphragm directly on it but not in contact with the cuff
With the dominant hand, slowly release valve (deflating cuff) and letting the mercury fall at 2-3mmHg per second
Checking the blood pressure
VITAL SIGNS
Listen for the Korotkoff’s sound while noting the manometer reading – a faint tapping sound which appears and increase in intensity is the systolic reading and the abrupt distinctive muffled sounds indicate the diastolic pressure.
After the above sounds are heard, completely and rapidly deflate the cuff
Remove the cuff and completely wait for at least 2 minutes before taking the another reading.
VITAL SIGNS
Inform the client of the findings and record ( the result in millimeters of mercury-mmHg)
Make client comfortable and replace displaced clothing
Dispose equipment appropriately Wash and dry hands, document and
report any abnormality to the in-charge.
VITAL SIGNS
QUESTIONS OR COMMENTS?
