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Chapter 29
Chapter 29 describes the factors thataffect the vital signs and explains how to accurately measure them.
The vital signs that will be looked at in detail include,body temperature, heart rate, respirations, and blood
pressure. This chapter explains the mechanisms of thermoregulation and the factors that affect heat
production in the body. Students will learn oral, rectal, axillary, tympanic membrane, and temporal artery
methods of measuring body temperature and the appropriate nursing care for alterations in normal body
temperature. Students will learn to identify nine sites used to assess the pulse, state the reasons for use of
each, and explain how to measure the apical pulse and the apical-radial pulse. This chapter also explains the
mechanics of breathing and the mechanisms that control respirations. Students will be able to identify the
components of a respiratory assessment. Lastly, students will understand the methods for measuring blood
pressure and differentiate between systolic and diastolic blood pressure, including the five phases of
Korotkoff sounds, and measurement of blood oxygenation using pulse oximetry or oxygen saturation.
Describe factors that affect the vital signs and accurate measurement of them (p.687, 699, 701, 708, 718,
1. The vital signs are body temperature, pulse, respirations, and blood pressure.
2. Vital signs monitor functions of the body and reflect changes that might not be observed. Assessing
vital signs should not be an automatic or routine procedure; this should be a thoughtful, scientific
3. When to assess vital signs (Box 29.2)
• On admission to a health care agency ornursing unit to obtain a baseline data
• When a client’s health status changes or he or she reports symptoms
• Before and after invasive diagnostic procedures or demanding treatments
• Before of after the administration of a medication thathas a direct effect or side effects, such as
altering respirations, heart rate, or blood pressure (i.e. digoxin, morphine, opioids)
• Before and after any nursing inventions that could affect the vital signs (i.e. ambulating a client on
bed rest)
• According to policy and standard procedure on the unit
4. Factors affecting body temperature include (p.699)
• Age: infants are greatly affect, children’s temperatures are more labile until puberty, older adults are
sensitive to extremes in environmental temperatures due to thermoregulatory controls
• Diurnal variations (circadian rhythms): Body temperature changes throughout the day and can vary as
much as 1°C (1.8°F) between early morning and late afternoon. The point of highest temperature is
usually reached between 1600 and 1800, hours and the lowest is reached during sleep between 0400
and 0600 hours.
• Exercise: Hard work or strenuous exercise can increase body temperature.
• Hormones: Women usually experience more hormone fluctuations than men. Progesterone secretion
at the time of ovulation raises body temperature by about 0.3°C to 0.6°C (0.5°F to 1.0°F) above basal
• Stress: stimulation of sympathetic nervous system increases production of epinephrine and
norepinephrine, which increases metabolic activity and heat production
Instructor’s Manual for Fundamentals of Canadian Nursing, Third Canadian Edition
Copyright © 2014 Pearson Canada Inc.
• Environment: Extremes in environmental temperature can affect a person’s temperature regulatory
system. If the temperature is very warm and the body temperature cannot be modified by convection,
conduction, or radiation, the person’s body temperature will increase. Similarly, if the client has been
outside in cold weather without suitable clothing or if there is a medical condition preventing the
client from controlling their temperature in the environment, the person’s body temperature will be
• Pyrexia: Pyrexia, or hyperthermia is a body temperature above the usual range. Hyperthermia is a
fever, and a very high fever (41°C or 105.8°F) is called hyperpyrexia. During a fever and the
resolution of a fever, the person goes through several phases as the core body temperature reaches the
new set point (Clinical Manifestation Box p.701 – onset: cold or chill stage, course: plateau phase, and
defervescence: fever abatement or flush phase).
• Hypothermia: Hypothermia is a core body temperature below the lower limit of normal due to
excessive heat loss, inadequate heat production to counteract heat loss, and impaired hypothalamic
thermoregulation (Clinical Manifestations Box on p.701).
5. Factors affecting the pulse include (p.708):
• Age: as age increases, pulse rate gradually decreases
• Sex: After puberty, the average male’s pulse rate is slightly slower than the female’s.
• Exercise: The pulse rate normally increases with exercise. The rate of increase in the professional
athlete is often less than the average person because of greater cardiac size, strength, and efficiency.
• Fever: Fever affects the pulse because the pulse rate increases in response to the lower blood pressure
that results from peripheral vasodilatation associatedwith elevated body temperature and because of
the increased metabolic rate.
• Medications and other ingestants: Some medications decrease the pulse (cardiotonics, i.e. digitalis and
beta-blockers; others increase the pulse (caffeine, nicotine,and epinephrine).
• Hypovolemia: Loss of blood from the vascular system(hemorrhage) normally increases the pulse rate.
Extensive diarrhea and vomiting or prolonged lackof fluid intake can cause increase pulse rate.
• Stress: Stress affects pulse because the sympatheticnervous stimulation increases the overall activity
of the heart. In addition, the rate and force of the heartbeat increases. Fear, anxiety, and the perception
of severe pain stimulate the sympathetic nervous system.
• Position change: When a person is sitting or standing, the blood usually pools in dependent vessels.
Pooling results in a transient decrease in the venous blood return to the heart and a subsequent
reduction in blood pressure and an increase in heart rate.
• Pathology: Certain diseases such as some heart conditions or those that impair oxygenation can alter
the resting pulse rate.
6. Several factors influence respiratory rate (p.718):
• Factors that increase the rate include exercise (increases metabolism), fever, stress (result of
epinephrine release, readies the body for “flight orfight”), increased environmental temperature, and
lowered arterial oxygen concentration.
• Factors that decrease the respiratory rate includedecreased environmental temperature, certain
medications (e.g., opioids, barbiturates), sleep, and increased intracranial pressure.
7. Two of the factors that affect depth of respirations include:
• Body position: The depth is suppressed due to an increase in the volume of blood inside the thoracic
cavity and the compression of the chest.
• Medications: Certain medications can depress the respiratory centre in the brain, thereby depressing
the respiratory rate and depth.
8. Factors affecting blood pressure include (p.722):
• Age: Pressure rises with age reaching a peak at the onset of puberty and then tends to decline. It rises
again in older adults because elasticity of the arteries is decreased, more rigid and less yielding to the
pressure of the blood, thereby elevating systolic pressure. Because the walls no longer retract as
flexibly with decreased pressure, diastolic pressure may also be high
• Exercise: Exercise increases the cardiac output and hence the blood pressure.
• Stress: Stress affects blood pressurebecause stimulation of the sympathetic nervous system increases
cardiac output and vasoconstriction of the arterioles, thus increasing the blood pressure reading.
However, severe pain can decrease blood pressure greatly inhibiting the vasomotor centre and
producing vasodilatation.
• Race: Black males over 35 years usually exhibit higher blood pressures compared to other men of the
same age.
• Obesity: Obesity predisposes both children and adults to hypertension.
Chapter 29: Vital Signs
Copyright © 2014 Pearson Canada Inc.
• Sex: After puberty, females usually have lower blood pressures than males of the same age caused by
hormonal variations. After menopause, women generally have higher blood pressures.
• Medications: Various medications may either increase (sympathomimetic decongestants and caffeine)
or decrease (opioids and beta-blockers) blood pressure.
• Sodium intake: high sodium intake can increase the release of natriuretic hormone, which indirectly
contributes to hypertension. Sodium stimulates vasopressor mechanism, causing vasoconstriction.
Sodium less than 2300mg is recommended for the prevention of hypertension
• Diurnal variations: Diurnal variations have an effecton blood pressure, which is usually lowest early
in the morning when the metabolic rate is lowest. It 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, or
compliance of the arteries has a direct effect on the blood pressure.
• Have the students monitor their own body temperatures in the morning on arising, in the late
afternoon (1600 and 1800 hours), and between 0400 and 0600 hours and report findings.
• Obtain baseline radial and apicalpulses, temperatures, and blood pressure and then have several
students run up and down a flight of stairs. Repeat the radial and apical pulses, body temperatures,
and blood pressures on these students and compare to baseline values.
• Have the students obtain vital signs on their assigned clients and compare and contrast findings based
on the factors that may affect vital signs.
Identify the normal range variations in body temperature, pulse, respirations, and blood pressure that
occur across the lifespan (p. 698-699, 707, 709, 717, 720, 722, and 729).
1. The body temperature of an infant is greatly influenced by the temperature of the environment.
Children’s temperatures continue to be more labilethan those of adults until puberty. Many older
people, particularly those over 75 years, are at risk of hypothermia (below 36 degrees Celsius) for a
variety of reasons such as inadequate diet, loss of subcutaneous fat, lack of activity, and reduced
thermoregulatory efficiency. Older adults are sensitive to extremes in environmental temperatures
because of decreased thermoregulatory controls.
2. As age increases, the pulse graduallydecreases. Table 29.3 on page 709
3. The respiratory rhythm of an infant may be less regular than an adult’s. Some newborns display
“periodic breathing” pausing for a few seconds between respirations. Table 29.3 on page 709
4. Newborns have a mean systolic pressure of about 75 mm Hg. The pressure rises with age, reaching a
peak at the onset of puberty, and then tends to decline somewhat. It rises again in older adults with half
of Canadians over age 65 years having hypertension. In older adults, elasticity of the arteries is
decreased, which produces an elevatedsystolic pressure. Because the wallsno longer retract as flexibly
with decreased pressure, the diastolic pressure may also be high.
• Discuss the standards for blood pressure in infants and children.
• Provide students with clinical situations, e.g., a crying infant, and have students decide the order in
which to obtain the vital signs, providing rationales for the order.
• Have students obtain vital signs on assigned clients comparing findings based upon age. Have
students compare findings to standards for the relevant age group.
Instructor’s Manual for Fundamentals of Canadian Nursing, Third Canadian Edition
Copyright © 2014 Pearson Canada Inc.
Describe the body’s system of thermoregulation and identify factors influencing the body’s heat
production (p.699).
1. The system that regulates body temperature has three main parts: sensors on the skin and in the body’s
core, an integrator in the hypothalamus, and an effector system that adjusts the production and loss of
2. Three physiological processes take place to increase the body temperature:shivering increase heat
production, sweating is inhibited to decrease heat loss and vasoconstriction decreases heat loss
3. The hypothalamic integrator, the centre that controls the core temperature is located in the anterior
region of the hypothalamus. Cold-sensitive receptors initiate effectors, such as vasoconstriction,
shivering and the release of epinephrine, which increase cellular metabolism and heat production. The
warmth-sensitive receptors signals initiate sweating, and peripheral vasodilation.
4. Among the factors that affect body temperature are the following: age, diurnal variations, exercise,
hormones, stress, and the environment.
• Provide students with clinical situations and have students decide the mechanism by which
temperature is being affected.
• Have students obtain vital signs on assigned clients and compare findings based upon age and other
relevant criteria.
Explain and distinguish oral, rectal, axillary, tympanic membrane, and temporal artery methods of
measuring body temperature and their relative merits (p.702 Table 29.2).
1. Body temperature may be measured using the oral, rectal, axillary, tympanic membrane, and skin or
temporal artery sites.
2. The oral site is accessible and convenient; however,the thermometer can break if bitten, can be
inaccurate if the client has just ingested hot or coldfood and fluid or smoked, (should wait 30 minutes)
and could injure the mouth following oral surgery.
3. The rectal site is very accurate; however, it is inconvenient and more unpleasant for clients, difficult
for clients who cannot turn to the side, and could injure the rectum following rectal surgery. The
presence of stool may interfere with thermometer placement. If the stool is soft, the thermometer may
be embedded in stool rather than against the wall of the rectum. The site is contraindicated for clients
who have diarrhea, diseases or surgery of the rectum, hemorrhoids, and clotting disorders.
Contraindicated in clients with cardiac arrhythmias or recovering from a myocardial infarction because
inserting a rectal thermometer can produce vagal stimulation, which can cause bradycardia and
4. The axillary site is safe and noninvasive; however, the thermometer must be left in place a long time to
obtain an accurate reading. This is the preferred sitefor assessing temperature in newborns; however, it
may be inaccurate when assessing fevers.
5. The tympanic membrane measurement is readily accessible, reflects the core temperature, and is very
fast. However, it can be uncomfortable and involves risk of injuring the membrane if the probe is
inserted too far. Repeated measurements may vary, right and left measurements can differ, and
presence of cerumen can affect the reading.
6. Temporal artery measurement is safe, noninvasive, and very fast; however, it requires electronic
equipment that may be expensive or unavailable. Variation in technique is needed if the client has
perspiration on the forehead. Body temperature may also be measured on the forehead with chemical
Chapter 29: Vital Signs
Copyright © 2014 Pearson Canada Inc.
thermometers. Most useful for infants and children on occasions when a more invasive measurement is
not necessary.
7. Body temperature may be measured using electronic, chemical disposable, infrared (tympanic),
scanning infrared (temporal artery) thermometers or temperature-sensitive tape. The traditional glass
mercury thermometer is rarely encountered in health care facilities since mercury is hazardous if
thermometer cracks or breaks, leaking out toxic mercury.
• After obtaining baseline readings, have several students drink ice water and others drink a hot
beverage and obtain new oral temperature readings. Compare the results.
• Have students locate research studies comparing various methods of obtaining body temperature.
Discuss their findings.
• Investigate the equipment available to obtain temperature readings in the clinical unit. Have the
students read the procedures for accurately using this equipment.
Outline appropriate nursing care for alterationsin body temperature (p.701-702, Box 29.3).
1. Nursing interventions for clients with fever include the following: monitor vital signs every 2 hours if
critically ill or as health status changes and client reports symptoms; assess skin colour and
temperature; monitor white blood cell count, hematocrit values, and other pertinent laboratory reports
for indication 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; measure
intake and output to meet increased metabolic demands and prevent dehydration; reduce physical
activity to limit heat production; administer antipyreticas ordered; provide oral hygiene to keep mucous
membranes moist and provide dry clothing and bed linens.
2. Nursing care for clients with hypothermia includes removing client from cold and providing a warm
environment, providing dry clothing, applying warm blankets and covering the head, keeping limbs
close to the body, supplying warm oral or intravenous fluids, and applying warming pads. For severe
hypothermia, an electric hyperthermia blanket is applied and warm intravenous fluids are given.
Rewarming the client can be dangerous and life threatening. Do not immerse a hypothermic patient in
warm or hot water, apply heating pads to extremities or rub or massage the patient. Focus is on heat
retention, restoring normal core body temperature and preservation of tissue.
• Have the students investigate the care for temperature alterations in different cultures.
• Have students review antipyretic medications.
• Discuss the role of fever in the body’s immunologic response to infection.
• Have the students provide examples of clients whose temperature readings were elevated or
decreased. Discuss factors contributing to the temperature alterations and the nursing care provided
for the clients.
Perform accurate body temperature assessment using the correct method for the client (p.706).
1. Please review Skill 29.1 Assessing Body Temperature (p.706).
Instructor’s Manual for Fundamentals of Canadian Nursing, Third Canadian Edition
Copyright © 2014 Pearson Canada Inc.
• Have the students perform temperature assessments on each other with available temperature
supplies. Discuss results and any variations from the different methods/routes.
• Discuss sources of errors when assessing body temperature. Table 29.2, p.702. Box 29.4, p. 705
• Have the students perform temperature assessments with supplies available in clinical.
• Discuss factors contributing to the temperature alterations and the nursing care provided for the
Identify nine sites commonly used to assess the pulseand state the reasons for use of each (p.709-710,
Figure 29.10 and 29.11, Table 29.4).
1. The nine sites used to assess the pulse are radial, temporal, carotid, apical, brachial, femoral, popliteal,
posterior tibial, and pedal (dorsalis pedis). The radial site is readily accessible. The temporal site is used
when the radial pulse is not accessible. The carotid siteis used during cardiac arrest or shock in adults
and is used to determine circulation to the brain. The apical site is routinely used for infants and
children up to 3 years of age. It is used to determine discrepancies with radial pulse, and it is used in
conjunction with some medications. The brachial site is used to measure blood pressure and is used
during cardiac arrest in infants. The femoral site is used in cases of cardiac arrest or shock and is used
to determine circulation to a leg. The popliteal site is used to determine circulation to the lower leg. The
posterior tibial is used to determine circulation to the foot. The dorsalis pedis (pedal, dorsal pedal) is
used to determine circulation to the foot.
• Provide the students with a drawing of the vascular system and havethem identify the pulse sites.
• Have the students locate the pulse sites on a partner.
• Have the students identify the pulse sites on their assigned clients, with the clients’ permission.
Discuss any difficulties in locating these.
Describe the characteristics that should be included when assessing pulses (p.711, Table 29.5).
1. When assessing the pulse, the nurse collects the following data: the rate, rhythm, volume, arterial wall
elasticity, and presence or absence of bilateral equality.
2. Rate is the number of beats per minute (BPM). An excessively fast heart rate (>100BPM in an adult) is
referred to as tachycardia and an excessively slow heart rate (< 60 BPM in an adult) is called bradycardia. If a person is tachycardia or bradycardia, the apical pulse should be assessed. 3. Rhythm is the pattern of beats and intervals between beats. Equal time elapses between beats of a normal pulse. A pulse with an irregular rhythm is referred to as a dysrhythmia or arrhythmia. 4. Pulse volume (also called pulse strength or amplitude) refers to the force of blood with each beat. Normally this is equal with each beat. This can range from absent to bounding. Table 29.5 5. Elasticity of the arterial wall reflects its expansibilityor its deformities. A healthy, normal artery feels straight, smooth, soft, and pliable. Chapter 29: Vital Signs Copyright © 2014 Pearson Canada Inc. 28-7 6. The nurse should assess the corresponding pulse on the other side of the body as a comparison when assessing the adequacy of the blood flow to areas of the body. SUGGESTIONS FOR CLASSROOM ACTIVITIES • Discuss the scientific basis for the characteristics that should be included when assessing pulses. • Divide the students into pairs and have one student obtain the radial pulse of his or her partner, noting the characteristics of the pulse. Have the student goup and down a flight of steps several times and have the partner reassess the pulse characteristics. Discuss findings. SUGGESTIONS FOR CLINICAL ACTIVITIES • Have the students obtain the radial pulse on their assigned clients, comparing right and left pulses and noting the characteristics of the pulse. Discuss findings based on each client’s physical and psychological condition. LEARNING OUTCOME 9 Perform accurate apical pulse and apical-radial pulse measurement (p.709, 714, 716). CONCEPTS FOR LECTURE 1. Apical pulse: See Skill 29.3. 2. Apical-radial pulse: See Skill 29.4. SUGGESTIONS FOR CLASSROOM ACTIVITIES • Have the students locate the landmarks for the apex of the heart on a skeleton. • Have the students practice locating the apex of the heart on a partner. • Have the students practice obtaining an apical-radial pulse on another student. SUGGESTIONS FOR CLINICAL ACTIVITIES • Have the students obtain an apical pulse on their assigned clients. Discuss any difficulties and findings. LEARNING OUTCOME 10 Describe the mechanics of breathing and the mechanisms that control respirations (p.717, Figure 29.13 and 29.14). CONCEPTS FOR LECTURE 1. During inhalation the following processes normally occur (Figure 29.13): • Diaphragm contracts (flattens) • Ribs move upward and outward • Sternum moves outward, thus enlarging the thorax and permitting the lungs to expand • Lasts 1 to 1.5 seconds 2. During exhalation the following processes normally occur: (Figure 29.14) • Diaphragm relaxes • Ribs move downward and inward • Sternum moves inward, thus decreasing the size of the thorax as the lungs are compressed • Lasts 2 to 3 seconds 3. Normally, breathing is carried out automaticallyand effortlessly. Respiration is controlled by respiratory centres in the medulla oblongata and the pons of the brain and by chemoreceptors located centrally in the medulla and peripherally in the carotid and aortic bodies. These centres and receptors respond to changes in the concentration of oxygen (O2), carbon dioxide (CO2), and hydrogen (H + ) in the arterial blood. Instructor’s Manual for Fundamentals of Canadian Nursing, Third Canadian Edition Copyright © 2014 Pearson Canada Inc. 29-8 SUGGESTIONS FOR CLASSROOM ACTIVITIES • Discuss how body positioning can assist a person with the mechanics of respiration. SUGGESTIONS FOR CLINICAL ACTIVITIES • Have students perform a respiratory assessment on assigned client and identifies any abnormalities. LEARNING OUTCOME 11 Identify the components of a respiratory assessment (p. 717-719, Box and Skill 29.5). CONCEPTS FOR LECTURE 1. The rate, depth, rhythm, quality, and effectiveness of respirations should be assessed. 2. Rate is described as breaths per minute. Breathing that is normal in rate and depth is called eupnea; abnormally slow respirations are called bradypnea;and abnormally rapid respirations are called tachypnea. Apnea is absence of breathing. Hyperventilation refers to very deep, rapid respirations. Hypoventilation refers to very shallow, slow respirations. 3. Depth can be established by watching the movement of the chest. Depth is generally described as normal, deep, or shallow. Tidal volume is the amount of air taken during normal inspiration and expiration, which is about 500mL 4. Body position affects amount of air inhaled. Supine position experience two physiological processes that suppress respiration: an increase in the volume of blood inside the thoracic cavity and compression of the chest. Lying on back creates poor lung aeration, which predisposes clients to stasis of fluids and subsequent infections, such as pneumonia. 5. Rhythm (or pattern) refers to regularity of inhalation and expiration. Normally respirations are equally spaced. Rhythm can be described as regular or irregular. 6. Quality (or character) refers to aspects of breathing that are different from normal, effortless breathing. Two such aspects are the amount of effort the client must exert to breathe and the sound of breathing. A client who can breathe only with substantial effort has laboured respirations. Normal breaths are silent, but a number of abnormal sounds such aswheezes can be produced that are audible. 7. Effectiveness is measured in part by the uptake of oxygen from air into the blood and release of carbon dioxide from blood into expired air. The amount of hemoglobin in arterial blood that is saturated with oxygen can be measured indirectly through pulse oximetry. SUGGESTIONS FOR CLASSROOM ACTIVITIES • Discuss how the nurse assesses each of the components of respiration. • Play audiotapes of clients experiencing difficulty breathing, e.g., wheezes, and crackles. • Use simulation models to program various breathingdifficulties and have class identify findings. • Discuss characteristics of sputum and of coughing. SUGGESTIONS FOR CLINICAL ACTIVITIES • Have the students assess the respirations of their assigned clients, paying attention to the components of the respiratory assessment. Compare and contrast findings based upon clients’ physical and psychological conditions. LEARNING OUTCOME 12 Perform accurate respiration rate and quality assessment (p. 719). CONCEPTS FOR LECTURE 1. Assessing Respiration: See Skill 29.5 2. Altered Breathing Patterns and Sounds: See Box 29.5 Chapter 29: Vital Signs Copyright © 2014 Pearson Canada Inc. 28-9 SUGGESTIONS FOR CLASSROOM ACTIVITIES • Have the students assess each other’s respiration rates using the crossed arm approach discussed in Skill 29.5. • Have the students document the respiratory rate, depth, rhythm and respiration characteristics of each other at rest as a baseline, after activity, and in different positions. SUGGESTIONS FOR CLINICAL ACTIVITIES • Have the students obtain a respiration rates on their assigned clients. Discuss any difficulties and findings. LEARNING OUTCOME 13 Summarize the physiology of blood pressure and what it indicates about client health (p.721-722). CONCEPTS FOR LECTURE 1. Arterial blood pressure is determined by blood flow and the resistance to blood flow as indicated in the following formula: MAP = CO x SVR. • MAP refers to mean arterial pressure – the pressure in the arteries throughout the cardiac cycle • CO refers to cardiac output • SVR refers to systemic vascular resistance 2. Cardiac output is the volume of blood pumped into the arteries by the heart. If weak, less blood is pumped into arteries and the blood pressure decreases. If strong, blood pumped into the circulation increases and blood pressure increases. 3. Systemic vascular resistance (SVR) is the resistance against which the heart must pump to eject the blood into the systemic circulation (excluding pulmonary vasculature), is influenced by the size of the arterioles and capillaries, the compliance of the arteries, the blood volume, and the blood viscosity. Increased SVR leads to increased blood pressureand decreased SVR leads to decreased blood pressure. The resistance in the peripheral vascular especially affects diastolic pressure. SUGGESTIONS FOR CLASSROOM ACTIVITIES • Have the students assess and document each other’s blood pressure. SUGGESTIONS FOR CLINICAL ACTIVITIES • Have the students obtain the blood pressure of assigned client. Discuss findings as it relates to the client’s diagnoses and health status. LEARNING OUTCOME 14 Identify noninvasive methods for measuring blood pressure, and differentiate between systolic and diastolic blood pressure, including the five phases of Korotkoff sounds (p.723-726). CONCEPTS FOR LECTURE 1. Blood pressure is assessed directly or indirectly. Direct (invasive monitoring) measurement involves the insertion of a catheter into the brachial, radial, orfemoral artery. Arterial pressure is represented as wavelike forms displayed on a monitor. Two non-invasive, indirect methods of measuring blood pressure are the auscultatory and palpatory methods. 2. The auscultatory method is most commonly used. The equipment required is a sphygmomanometer, a cuff, and a stethoscope. When taking a blood pressure using a stethoscope, the nurse identifies phases of sounds called Korotkoff sounds. First the nurse pumps the cuff up to about 30 mm Hg above the point where the pulse is no longer felt; then the pressure is slowly released (2 to 3 mm Hg/second) while the nurse observes the readings on the manometer and relates them to the sounds heard through the stethoscope. 3. The palpatory method is sometimes used when Korotkoff sounds cannot be heard and electronic equipment to amplify the sounds is not available, or to prevent misdirection from the presence of an Instructor’s Manual for Fundamentals of Canadian Nursing, Third Canadian Edition Copyright © 2014 Pearson Canada Inc. 29-10 auscultatory gap. In the palpatory method, instead of listening for the blood flow sounds; the nurse uses light to moderate pressure to palpate the pulsations of the artery as the pressure in the cuff is released. The pressure is read from the sphygmomanometer when the first pulsation is felt. 4. Blood pressure is usually assessed in the client’s upper arm using the brachial artery. Assessing the blood pressure on a client’s thigh is indicated if the blood pressure cannot be measured on either arm or when the blood pressure in one thigh is to be compared with the blood pressure in the other thigh. 5. Arterial blood pressure is a measure of the pressure exerted by the blood as it flows through the arteries. 6. The systolic blood pressure is the pressure of the blood as a result of the contraction of the ventricles— that is, the pressure of the height of the blood wave. 7. The diastolic blood pressure is the pressure when the ventricles are at rest. The diastolic pressure is the lower pressure present at all times within the arteries. 8. Blood pressure is measured in millimetres of mercury and recorded as a fraction. An example is 120/80. The systolic blood pressure in this example is 120 and the diastolic blood pressure is 80. The mathematical difference between the systolic and diastolic pressures is called the pulse pressure. A normal pulse pressure is about 40 mm Hg but can be as high as 100 mm Hg during exercise. A consistently high pulse pressure is associated with arteriosclerosis and a consistently low pulse pressure with severe heart failure, for example. The pulse pressure in the example above is 40 mm Hg. 9. Korotkoff sounds: Phase 1 is the pressure level at which the first faint, clear tapping or thumping sounds are heard. These sounds gradually become more intense. The first tapping sound heard during deflation of the cuff is the systolic blood pressure. Phase 2 is the period during deflation when the sounds have a muffled, whooshing, or swishing sound. Phase 3 is the period during which the blood flows freely through an increasingly open artery and the sounds become crisper and more intense and again assume a thumping quality but softer than in phase 1.Phase 4 is the time when the sounds become muffled and have a soft, blowing quality. Phase 5 is the pressure level when the last sound is heard. This is followed by a period of silence. The pressure at which the last sound is heard is the diastolic blood pressure in adults. SUGGESTIONS FOR CLASSROOM ACTIVITIES • Review the cardiac cycle relating it to blood pressure. • Give students several blood pressure readings and have the students identify the systolic, diastolic, and pulse pressure for each. • Play audio recordings of blood pressure sounds and have students identify the systolic and diastolic sounds. • Review clinical settings or situations in which three of Korotkoff sounds may be used to determine blood pressure and how this is recorded. SUGGESTIONS FOR CLINICAL ACTIVITIES • Have students review the blood pressure readings for assigned clients by identifying the systolic, diastolic, and pulse pressure. • Have the students obtain blood pressure readings on their assigned clients using both electronic and manual blood pressure equipment. Discuss any difficulties. Compare and contrast readings based upon the clients’ physical and psychological conditions. LEARNING OUTCOME 15 Perform accurate blood pressure measurement (p.726, 727-729). CONCEPTS FOR LECTURE 1. Assessing Blood Pressure: See Skill 29.6. 2. Selected Sources of Error in Blood Pressure Assessment: See Table 29.7. 3. Determining the appropriate Blood Pressure Cuff: Figure 29.18 4. Lifespan Considerations: p.729 Chapter 29: Vital Signs Copyright © 2014 Pearson Canada Inc. 28-11 SUGGESTIONS FOR CLASSROOM ACTIVITIES • Have the students chose the right size of blood pressure cuff for their partner. • Have students perform a two-step blood pressure manually, using the palpation method and an electronic indirect blood pressure monitoring device. • Have students perform a blood pressure reading on each other’s thighs. • Have students perform blood pressure assessments on simulated mannequins to determine the reading and rationale. SUGGESTIONS FOR CLINICAL ACTIVITIES • Have the students obtain a blood pressure on their assigned clients. Discuss any difficulties and findings. LEARNING OUTCOME 16 Discuss measurement of blood oxygenation by using pulse oximetry and the correct interpretation of oximetry measurements (p.730-732). CONCEPTS FOR LECTURE 1. A pulse oximeter is a non-invasive device that estimates a client’s arterial blood oxygen saturation (SpO2) by means of a sensor attached to the client’sfinger (see Figure 28.27), toe, nose, earlobe, or forehead (or around the hand or foot of a neonate). The pulse oximeter can detect hypoxemia before clinical signs and symptoms, such as the development of dusky skin colour and dusky nail bed colour. Normal SpO2is 95% to 100%, and a SpO2below 70% is life threatening. The pulse oximeter sensor has two parts: two light-emitting diodes (LEDs) that transmit red and infrared lights through nails, tissue, and venous and arterial blood, and a photodetector placed directly opposite the LEDs. The photodetector measures the amount of red and infrared light absorbed by oxygenated and deoxygenated hemoglobin in peripheral arterial blood and reports it as SpO2. The oximeter unit consists of an inlet connection for the sensor cable, a faceplate that indicates the oxygen saturation measurement (expressed as a percentage), and the pulse rate. Cordless units are available. Preset alarms signal high and low readings. 2. Factors affecting SpO2include hemoglobin, circulation, activity, and carbon monoxide poisoning. If the hemoglobin is fully saturated, the SpO2will appear normal even if the total hemoglobin level is reduced; the reading will not be accurate if the area under the sensor has impaired circulation; shivering and excessive movement of the sensor site may interfere with accurate readings; and the pulse oximeter cannot discriminate between hemoglobin saturated with oxygen and carbon monoxide. 3. Skill 29.7 presents the procedure for measurement of oxygen saturation. SUGGESTIONS FOR CLASSROOM ACTIVITIES • Have the students practice obtaining pulse oximetry readings on each other. Have several students place their hands in cold water or apply dark nail polish or move fingers and then obtain readings. Compare and contrast. SUGGESTIONS FOR CLINICAL ACTIVITIES • If possible, obtain pulse oximetry equipment used in the institution. Have the students read the procedure for the proper use of this equipment. Instructor’s Manual for Fundamentals of Canadian Nursing, Third Canadian Edition Copyright © 2014 Pearson Canada Inc. 29-12 KEY TERMS afebrile p. 700 apical pulse p. 708 apical–radial pulse p. 714 apnea p. 717 arrhythmia p. 711 auscultatory gap p. 726 basal metabolic rate (BMR) p. 698 blood pressure p. 721 body temperature p. 697 bradycardia p. 711 bradypnea p. 717 cardiac output p. 708 chemical thermogenesis p. 698 compliance p. 708 conduction p. 698 constant fever p. 700 convection p. 698 core temperature p. 697 costal (thoracic) breathing p. 716 diaphragmatic (abdominal) breathing p. 716 diastolic pressure p. 721 dysrhythmia p. 711 elasticity of the arterial wall p. 711 eupnea p. 717 evaporation p. 699 exhalation p. 716 expiration p. 716 external respiration p. 716 febrile p. 700 fever p. 700 fever spike p. 700 heat balance p. 698 heat exhaustion p. 700 heat stroke p. 700 hematocrit p. 722 hyperpyrexia p. 700 hypertension p. 722 hyperthermia p. 700 hyperventilation p. 717 hypotension p. 723 hypothalamic integrator p. 699 hypothermia p. 701 hypoventilation p. 717 inhalation p. 716 insensible heat loss p. 699 insensible water loss p. 699 inspiration p. 716 intermittent fever p. 700 internal respiration p. 716 Korotkoff sounds p. 725 malignant hyperthermia p. 700 orthostatic hypotension p. 723 peripheral pulse p. 708 point of maximal impulse (PMI) p. 708 pulse p. 708 pulse deficit p. 715 pulse oximeter p. 730 pulse pressure p. 721 pulse rhythm p. 711 pulse volume p. 711 pyrexia p. 700 radiation p. 698 relapsing fever p. 700 remittent fever p. 700 respiration p. 716 respiratory quality or character p. 718 respiratory rhythm or pattern p. 718 surface temperature p. 697 systematic vascular resistance (SVR) p. 721 systolic pressure p. 721 tachycardia p. 711 tachypnea p. 717 tidal volume p. 718 ventilation p. 716 vital signs p. 697 Chapter 29: Vital Signs Copyright © 2014 Pearson Canada Inc. 28-13 ANSWERS AND EXPLANATIONS FOR ASSESS YOUR LEARNING QUESTIONS 1.Answer:b. Check what the client’s temperature was the last time. Explanation: Although the temperature is slightly lower than expected for the morning, it would be best to determine the client’s previous temperature range. This may be a normal range for this client, so checking is always the first step. Depending on that finding, you might want to retake it in a few minutes (no need to wait 15 minutes as in Option a) or by using another thermometer (Option c) to see whether the first thermometer was functioning properly. Ensure that the client has not consumed anything cold in the past 30 minutes. Chart only after determining that the temperature has been measured properly, not immediately (Option d). Nursing Competency Category:Nursing Practice: Alterations in Health Question Type: Application 2.Answer:c. A client with a dysrhythmia Explanation: The apical rate would confirm the rate and determine the actual cardiac rhythm for a client with an abnormal rhythm; a radial pulse would reveal only the heart rate and suggest a dysrhythmia. For clients in shock (Option a), use the carotid or femoral pulse. The radial pulse is adequate for determining change in orthostatic heart rate (Option b). The radial pulse is appropriate for routine postoperative vital sign checks for clients with regular pulses (Option d). Nursing Competency Category:Nursing Practice: Alterations in Health Question Type: Application 3. Answer:b. 45 seconds Explanation:If the cuff is inflated to about 30 mm Hg over previous systolic pressure, that would be 168. To ensure that the diastolic has been determined, the cuff should be released slowly until the mid-60s mm Hg (and then completely) for someone with a previous reading of 74. The cuff should be deflated at a rate of 2 mm per heartbeat. At 2 mm/beat with a heart rate of 64, 128 mm Hg would be lowered in 1 minute; use cross-multiplication to find out how much time it would take to drop 90 mm Hg: 128 mm Hg in 60 seconds = 90 mm Hg in xseconds; x= 42.18 seconds. Thus, a range of 90 mm Hg will require approximately 45 seconds. Nursing Competency Category:Nursing Practice: Alterations in Health Question Type: Application 4. Answer:d. Axillary, tympanic, or temporal artery Explanation:For this client, the nurse could take an axillary, tympanic, or temporal artery temperature. Options (a) and (c): the facial drooping and difficulty swallowing mean that the oral route is not recommended. Option (b): although the rectal route could be used, it would require unnecessary moving and positioning of a client who cannot assist, and it would not provide a significant advantage over the other routes. Nursing Competency Category:Nursing Practice: Alterations in Health Question Type: Application 5. Answer:d. Absent posterior tibial and pedal pulses Explanation:The posterior tibial and pedal pulses in the footare considered peripheral and at least one of them should be palpable in normal individuals. Option (a): a bounding radial pulse is more indicative that perfusion exists. Options (b) and (c): apical and carotid pulses are central and not peripheral. Nursing Competency Category:Nursing Practice: Alterations in Health Question Type: Application 6. Answer:d. Counting the respirations for a full minute if they are irregular Explanation:The respiration cycle can be affected by many factors, so it is important to assess for 1 full minute cycle and not for only 15 seconds (Option c). Option (a): oxygen saturation does not indicate respiratory rate; pulse oximetry machines record heart rate and not respiratory rate. Option (b): hyperventilating before respiratory rate assessment can alter the actual resting respiratory rate. Instructor’s Manual for Fundamentals of Canadian Nursing, Third Canadian Edition Copyright © 2014 Pearson Canada Inc. 29-14 Nursing Competency Category:Nursing Practice: Alterations in Health Question Type: Application 7. Answer:c. Dyspnea Explanation:Dyspnea is the subjective experience of breathlessness or difficulty breathing. Option (b): laboured breathing is the objective (observed) behaviour that the nurse might note in a patient with dyspnea. Not all people with dyspnea demonstrate laboured breathing. Option (a): the patient may feel breathless because of a reduced volume of air in the lungs, which is assessed by depth of respiration. Option (d): the client is breathless all the time and not in relation to body position. Nursing Competency Category:Nursing Practice: Alterations in Health Question Type: Application 8. Answer:(b) Grade 2 hypertension: Systolic values 160-179 and/or Diastolic 100-109 Explanation: A single elevated blood pressure reading indicates the need for reassessment. Blood pressure that is consistently more than 140/90mmHg is considered high and diagnostic of hypertension. Due to the limit data and the unknown dates of the ‘two separate visits’, further assessment is needed. (p.721-723). Option (a) Grade 1 hypertension: Systolic values 140-159 and/or Diastolic 90-99 (c) Grade 3 hypertension: Systolic > 180 and/or Diastolic >110 (d) high normal Systolic 130-139 and/or Diastolic 85-89.
Nursing Competency Category:Nursing Practice: Alterations in Health
Question Type: Application
9. Answer:b. The client should aim to reduce sodium intake to 1200mg per day.
Explanation:According to the Canadian Hypertension Education Program (2012), individuals older than
71 years should be aware that adequate sodium intake is 1200mg per day (p.723). Option (a): relates to
hypotension. Option (c): to avoid all stress is not realistic, instead an individual should practice stress
management (see Chapter 24). Option (d): The individual should take part of regular physical activity
according to Canadian Physical Activity Guidelines (see Chapter 39).
Nursing Competency Category:Nursing Practice: Alterations in Health
Question Type: Application
10. Answer:d. Retake the oxygen saturation.
Explanation:Although an oxygen saturation of 70% would beconsidered life threatening, the other vital
signs do not indicate any problems with hypoxemia. For example, severe hypoxemia is generally
accompanied by compensatory tachycardia and tachypnea, neither of which the client she has. A check of
the equipment and retaking the oxygen saturation is merited in this case. Options (a) and (b): these would
be possible responses if the low saturation were accompanied by cardiac compromise and changes in
mental status. Option (c): auscultation of the lungs in someone who complains of dyspnea is merited but
clarification of the oxygen saturation needs to be made first.
Nursing Competency Category:Nursing Practice: Alterations in Health
Question Type: Application
1. What would you say to her when you were unable to hear the Korotkoff sounds?
Although each nurse develops his or her own approach with clients, general principles apply to such
situations. These include avoiding undue stress in the patient and indicating performance gaps that are
within the range of usual practice. The fact that she is alert, has warm skin, and normal colour indicate
that she has at least adequate blood pressure. It is possible that the stethoscope was poorly positioned
or that the hearing device was malfunctioning. A simple statement, such as “I will need to recheck
your blood pressure in a couple of minutes because I wasn’t able to hear as well as I would like” would
be more relevant and reassuring than “I’m really new at this, sorry” or “I am not very good at taking
blood pressure yet.” You should verify that the equipment is working properly and palpate the artery
before taking another measurement. Consider obtaining a blood pressure by manual palpation. If you
Chapter 29: Vital Signs
Copyright © 2014 Pearson Canada Inc.
feel anxious, you could ask another nurse to be present; if there is a teaching stethoscope, then you
may find it reassuring to have the nurse or a classmate listen with you.
2. What is your analysis of the blood pressure reading of 180/110 mm Hg? What further data do
you need to collect?
It is important to relate this finding to previous and expected values. Although the reading is elevated,
it cannot be analyzed independent of other variables. For example, has her blood pressure been
consistently high before, during, and immediately after her surgery? Is she in pain, which could
increase or decrease her blood pressure? Did the move from the stretcher to her bed influence the blood
pressure? Is she in a hypertensive crisis? Is she taking medication that can cause a sudden increase in
blood pressure? The most relevant data to collect would be two repeated blood pressure measurements.
If the values remain elevated, then the appropriate members of the health-care team need to be notified.
3. How do you interpret her temperature, pulse, and respiratory rate?
• Similar to the blood pressure assessment discussed above, it would be important to assess the
temperature measurement in light of previous values and, most important, what her temperature
was in the operating room and PACU. The fact that her skin is warm does not support the low
reading. Verify that the thermometer was inserted in the correct location and that the equipment (if
using an electronic device) is functioning properly. Ask the client if she had anything cold to
drink. Ask her if she feels cold. Inadvertent hypothermia is a possible intraoperative complication
that could quickly be validated by checking the operative and PACU record. A repeat temperature
measurement would be recommended.
• Her pulse is within the normal range; however, it may not reflect her norm. It is a strength that her
heart rate is regular and that the volume is adequate. Checking the vital sign record would provide
information about the pattern of her heart rate (and other vital signs). She is at risk of bleeding,
pain, and strong emotions following such major surgery. Tachycardia may indicate that she is
experiencing one or more of these; she has also likely received a range of anaesthetic agents, many
of which have cardiac implications (bradycardia or tachycardia or both).
• She is experiencing tachypnea and possible hypoventilation; however, she is not experiencing
hypoxemia as her oxygen saturation is normal. It would be important to check the O.R. record to
see whether she was intubated during the procedure (hip replacements can be performed under
spinal anaesthesia to avoid the pulmonary complications of general anaesthesia). The PACU
record should be checked for the pattern of her respirations in the immediate postoperative period.
Is she in pain (incisional or possibly tracheal, if she was intubated) and is this why she is breathing
more rapidly and guardedly in her depth of respiration? Was moving from the stretcher to her bed
difficult? She is at risk for respiratory acidosis with hypoventilation, so it would be important to
encourage her to deep breath. Auscultation of her lungs would indicate if both lung fields are
expanding and to what extent. As with the other vital signs, the pattern must be monitored and
clinical judgment used to interpret the situation.

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