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Stressors that Affect Circulation
NUR101 LECTURE # 9
FALL 2009
K. BURGER, MSEd, MSN, RN, CNEPPP by Sharon Niggemeier RN BSN MSN
Circulatory Needs
Blood circulation affects all aspects of well being.
Circulation is monitored through assessment of Vital Signs along with other collected data.
The patient’s physiological status is reflected by their vital signs.
Vital Signs Signs of Vitality and
Life Deviations from normal
ranges can indicate chg in health status.
TPR & BP = VS T-temperature P-pulse R-respirations BP- blood pressure VS-vital signs
CNS Regulates VS Hypothalamus:
Controls temperature Anterior Hypothalamus
-Dissipation of heat
Posterior Hypothalamus-conservation of heat
Medulla: Vasomotor center
controls BP through vasoconstriction or vasodilation
Cardiac center controls pulse
Respiratory center controls respirations(rate and depth)
Relationship Between VS
R = 1/4 PR 20 = P 80
P = diastolic BPP 80 = 120/80
T increases = an increase in P R and BP
Factors Influencing VSAgeGenderRaceDietWeightHeredityMedicationsActivity
More Factors Influencing VS
PainHormonesStressEmotionsCircadian
Rhythms
Guidelines for Assessing VSSystematicNormal RangeBaselineRecheckClient NormDxTreatmentsMonitor prn
Temperature Regulation
Thermal BalanceHeat ProductionHeat LossCore vs Surface
Heat Production
By product of metabolismB.M.R.- Basal Metabolic RateMuscle activityExposure to increased
temperatureHormones: Thyroxine, Epinephrine
Heat Loss (Transfer)
Conduction - direct transfer of heat by contact
Heat Loss-ConvectionHeat
dissemination via motion. A fan blows warm air across a warm body.
Heat Loss-RadiationHeat given off by
rays from the body. Heat loss from an uncovered head.
Main form of heat loss.
Heat Loss-Evaporation
Conversion of a liquid to a vapor. Perspiration vaporizes from the skin.
Diaphoresis
????What are some other ways heat is lost from body???
FeverPyrexia
100.4 – 104.0 FHyperpyrexia
Above 104.0 F
Fever PatternsIntermittentRemittentConstantRelapsing
?? Fever Terminology ??Which term can be used to describe a fever that: Is constantly elevated with little fluctuation Fluctuates but does not come down to normal Returns to normal for a day or two, but then
goes up again Alternates between normal and fever
Resolutions of Pyrexia
Crisis- sudden return to normal body temp.
Lysis- gradual return to normal body temp.
S/S of Fever
Loss of appetite Delirium
Headache SeizuresDehydration Thirst
Flushed face ?????Rapid pulse Decreased urinary output
(OLIGURIA)
Temperature ranges
Oral- 96.8 – 100.4 F 98.6 = average norm
Axillary- approximately 1 degree lower
Rectal- approximately 1 degree higher
Fever
Onset- (Chill)Course ( Flush)Abatement (fever subsides)
Assessing TemperatureGlassElectronicTympanicTape/PatchDisposable (ie: Clinidot)
Oral Temperature
Most common site Place against sublingual artery Contraindicated in oral surgery/infection Wait 15 min. if pt. ate/drank
or smoked Electronic- blue probe
Axillary Temperature Preferred for children under 6 yrs. routinely
used on infants. Place in center of axilla against artery off
the subclavian. Blue probe -electronic thermometer Document 102.4 A
Rectal TemperatureLast resort for assessing temperaturePlace against inferior rectal arteryContraindicated rectal surgery/cardiac
pt.Lubricate thermometers REMEMBER PPE
(Continued) Rectal Temperature
Electronic thermometers: Red Probe only Insert : ½ - 1 inch adult
¼ - 1/2 inch child
Left position is bestDocument 102.8 R
Electronic ThermometersCheck for baseline number- specific
number after being turned on.Error indicators- low battery # completeness- digital display clearly
shows entire numbers If probe cover breaks- discard, check
pt.mouth/axilla/rectum for broken pieces.
Do not use bent probes.
??? Nursing Diagnoses ???
Nursing Interventions Temperature
Check VS frequently
Assess skin Note change in
LOC Seizure
precautions ? Monitor I & O REDUCE
COVERINGS
Encourage fluidsTepid bathsAdminister
antipyretics Promote comfort
& RESTHypothermia
blanket
Heat Stroke
Hot, dry skinDizzinessAbdominal painDeliriumEventual LOC
Hypothermia
Mild (93.2 – 96.8 F)Moderate (86.0-93.2 F)Severe ( below 86.0 F)
Evaluations-Temperature
Is patient afebrile?Are interventions working? i.e cool
compresses, tepid bath, antipyretics?
S/S of infection present?
Nurse’s Notes
5/31/02
4:15pm Reports headache, feeling “on fire”, face flushed, skin warm, T-104.6 A P-100 R- 20 BP- 150/80. Dr. Arrid notified. Tylenol 650mg po administered as per telephone order. Fluids encouraged, tepid bath given. S.Niggemeier RN-----------------------------
4:45pm T-102.2 A P- 88 R-18 BP 130/78 taking fluids, feels “better than before”. S.Niggemeier RN-----------------------------
Pulse-Physiology SA node- creates electrical impulses
causing contraction of Left ventricle. A wave of blood is pumped into the
arteries. Throbbing sensation is felt - Pulse Pulse rate should = the heart rate Pulse rate is the number of pulsations felt
in a minute. Pulse usually = diastolic pressure
Pulse RatesNewborn 120-150 Infant 80-140Child 75-110Adult 60-100Pulse rates ????? as age increases
Cardiac Output CO=SV x HR Cardiac output (CO)
is the amount of blood pumped/min by the heart and = approximately 5000ml or 5L/min
Stroke Volume (SV) is the amount of blood ejected from the L ventricle with each contraction.
Heart rate (HR) is the number of times the heart contracts.
Inversely related- when SV goes up the HR goes down.
?? CARDIAC OUTPUT ??CV (5000) = SV(70) X HR
In the above equation, what would the client’s heart rate be?
If a client had a weak heart (ie:CHF) that was only able to eject a SV of 50, what would happen to the client’s HR?
If a client had a well-conditioned heart muscle (ie: athlete) that was able to eject a SV of 100, what would their HR be?
Pulse Sites Temporal Carotid Apical Brachial Radial Femoral Popliteal Dorsalis Pedis Posterior Tibia
Pulse assessment Rate -number of
beats /min Rhythm- pattern
of the rate. Regular or Irregular. Count irregular rhythm for 1 min.
Quality- strength of the pulse 0-4+
Pulse - Quality Scale 4+ bounding very strong, does not disappear
with moderate pressure 3+ normal, easily felt, 2+ weak, light pressure causes it to
disappear 1+ thready, not easily felt, disappears with
slight pressure 0- no pulse
??? NURSING DIAGNOSES
Nursing Interventions-Pulse
Monitor for symmetryNote pulse deficitPromote circulation – i.e. massage,
TEDS, Teaching – i.e don’t cross legs
Evaluations
Is pulse with normal range?All pulses presentEqually Bilateral?Are interventions to promote
circulation working? i.e. massage, TEDS etc.
Terminology Bradycardia- HR below 60/min Tachycardia- HR above 100/min Sinus Arrhythmia- HR increases on
inspiration and decreases on exhalation common in children and young adults
Dysrhythmia- abnormal rhythm Palpitation-aware of your HR without
feeling for it…usually rapid Pulse deficit- difference between apical
and radial pulses Apical-100 Radial-80 then the Pulse deficit is 20
Pulse Documentation
5/23/02 1:20am c/o palpitations. P-96 reg 3+. No pulse deficit.------------------- S.Niggemeier RN
Respirations Physiology
Process whereby CO2 and O2 are exchanged in the tissues.
Oxygenation of the bodyCO2 is the stimulus for breathing Inspiration - breathing in
Diaphragm contracts – pulls downExpiration- breathing out
Diaphragm relaxes – moves upNormal Tidal Volume = 500 ml
Respiration Rates
Newborn 40-60/min Child 20-30 School age 18-26 Adult 16-20 Respirations
decrease as age increases
Assessing Respiratory Status
Oxygenation status
Neurological state
Musculoskeletal status
Oxygenation status
Note S/S of hypoxia (oxygen deprivation
Cyanosis - bluish tinge caused by decrease in O2 in RBC.
Cyanosis is assessed by checking the mucous membranes of the conjunctiva (lower eyelids), under the tongue and inside the mouth..should be pink not pale or bluish
??Other signs of dyspnea??
Neurological state
Hypoxia results in neurological changes alert becomes anxious then irritable progresses to drowsiness eventually a coma
Musculoskeletal StatusAbnormalities that prevent the thorax
from expanding result in hindered respirations
ScoliosisLordosisPectus excavatumKyphosisPectus carinatum
Respiratory Assessment Rate- number of
breaths/min
Rhythm - even, labored
Quality- deep, shallow
Pulse Oximetry
Indirect measurement of arterial oxygen saturation of hemoglobin
95% - 100% normal range Below 90% = hypoxia Factors that interfere with accurate
measurement: dark nail polish, anemia,vasoconstriction (PVD, hypothermia), carbon monoxide poisoning, movement, excessive background light, tight probe
?? NURSING DIAGNOSES??
Nursing Interventions- Respirations
Elevate HOB (head of the bed)Promote calm atmosphereAdminister oxygen as neededRelaxation techniques
Evaluation- Respiratory
Rate within normal range?SOB?Dyspnea?Breathing less labored?Less cyanotic?
TerminologyApneaAdventitious soundsRales/cracklesGurgles /rhonchiStertorWheezeCheyne-Stokes
Terminology
BradypneaDyspneaHyperinflationHypoxiaOrthopneaTachypnea
Documentation
5/30/02 Reports dyspnea. R = 24, labored , shallow. HOB elevated. Dry crackles auscultated bilaterally. Dr. C. Stokes notified. O2 2L via NC applied. S. Niggemeier RN------------------------
Blood Pressure -Physiology
Blood pressure is the force against the arterial walls.
Maximum BP is achieved when the Left ventricle contracts - Systolic pressure
Lowest BP is when the heart rests - Diastolic pressure
Pulse pressure is the difference between the Systolic and Diastolic pressures BP 140/90 PP (pulse pressure) = 50
Maintaining and Regulating Blood Pressure
Peripheral Resistance
Pumping Action of heart (Cardiac Output)
Blood volume
Viscosity of blood
Elasticity of vessel walls
Hormonal factors: renin, aldosterone
Hypertension Elevated BP above
normal for sustained time
Unknown cause - primary or essential hypertension
Known cause- secondary hypertension
3 or more elevated readings to confirm DX
Hypertension Normal Blood
Pressure < 120/80
Prehypertension
Systolic 120-139
Diastolic 80-89
Stage 1
Systolic 140-159
Diastolic 90-99
Stage 2
Systolic >160
Diastolic >100
Hypotension
Low BP - systolic of 90-115 with no ill effects
Can be drug induced or illness related (MI, burns, blood loss)
Orthostatic Hypotension or Postural Hypotension = low BP when rising to an erect position, common after periods of bed rest
Terminology
Auscultatory GapDiastolicKorotkoff soundsPulse PressureSystolic
Direct BP Measurement
Measure BP by means of inserting a catheter (arterial line) into an artery and measure by machine
Used in critical care
Indirect BP Measurement Auscultating with
stethoscope and sphygmomanometer
Palpating- feeling for an estimated systolic
Doppler amplifies Korotkoff sounds
Electronic meters- monitor BP with no need for stethoscope
Sphygmomanometers
Aneroid-measures mmHg on calibrated dial
Mercury - measures mmHg via mercury filled cylinder (no longer used due to mercury hazardous material)
Cuff Sizes Stethoscope Use Vary in size Must use
appropriate size for pt.
Pedi cuff, small, medium, large etc..
Thigh cuffs
Use either bell or diaphragm to auscultate sounds
Make sure ear tips block out noise
Clean after each use with alcohol pads
Augment Korotkoff Sounds
Raise arm over head for 15 sec prior to retaking BP
Have pt. open/close hands - empties veins
Pump bulb up quicklyWait 30-60 sec between readings Don’t reinflate cuff once air is being
released it muffles sounds
Brachial Popliteal
Use either armPreferred siteEasy access
Use either thighLess preferredDifficult to accessSystolic pressure
will be 10-40 mmHg higher than brachial
Palpating BP
Cuff is inflated 30mmHg above the point where pulse is no longer palpated.
Release cuff and as air is releasing feel for return of pulse …that is the systolic
No stethoscope is used.No diastolic pressure can be assessed
Nursing Interventions- Blood Pressure
Monitor BP Administer antihypertensives as orderedTeaching - i.e. diet, exercise, stress,
etc.
Evaluation –Blood pressure
B/P within normal range?C/O headaches or other s/sTeachings regarding diet, weight,
exercise, stress etc being followed?
Terminology
A/R- apical radialFUO - fever unknown originPP -pulse pressureSOB - short of breathVS- vital signs
?? Documentation of VS ??
On what type of chart form are vital signs usually documented?