Temperature and moistness coldmoist skinclammy shows

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Temperature and moistness;Cold/moist skin(clammy) – shows SLOW NSstimulation in shockEcchymosis (bruise)—a purplish-blue color fading to green, yellow, or brownover time—is associated with blood outside of the blood vessels and is usuallycaused by trauma
Blood pressureBP- Pressure exerted by blood on the walls of arteries.Affected by:Cardiac output,Distention of arteriesVolume and thickness of blood.Normal BP 100/60-140/90mmHg.NB – take BP bilaterally, record patients position and site and patient should not talkPostural (orthostatic)hypotension–is when BP drops significantly after the patient assumes anupright posture– patient feels dizzy, light headed and syncope.In cardiac patients, it is caused by;Reduced volume of fluid or blood in the circulatory systemInadequate vasoconstrictor mechanisms,Insufficient autonomic effect on vascularImplication of postural hypotensionWhen a person stands up or sits up from lying;A heart rate increases by 5 to 20 bpm above the resting rate to offset reduced stroke volume andmaintain cardiac output);Systolic pressure may decrease of up to 10 mm Hg;Diastolic pressure increases by 5 mm HgNBPostural change of increased HR and either reduced systolic pressure by 15 mmHg or diastolic pressureby 10 mmHg indicates volume depletion
Pulse pressureIs the difference between the systolic and thediastolic pressures.normally it is 30 to 40 mm HgIt indicates how well the patient maintains cardiacoutputIt is a reflection of stroke volume, ejection velocity,and systemic vascular resistance.Increases in conditionsthat elevate the stroke volume(anxiety, exercise, bradycardia), reduce systemicvascular resistance (fever), or reduce distensibility ofthe arteries (atherosclerosis, aging, hypertension).It decreases in shock, HF, hypovolemia, mitralregurgitation or obstruction to blood flow duringsystole
pulse-Pulse rate – normal – 60-90- varies with physicalactivity and anxiety.-Pulse rhythm/regularity – HR should be counted byauscultating the apical pulse while palpating theradial pulse simultaneously for a full minute.Adifference between the apical heart rate (heartcontractions at the apex) and peripheral pulse rateisreferred to as pulse deficit.Dysrhythmias (atrial fibrillation, atrial flutter,premature ventricular contractions, and varyingdegrees of heart block) often cause pulse deficit,
Pulse-Pulse strength/ amplitude/ quality: can bedescribed as absent, diminished/ weak, normal,or bounding –Weak – insufficient blood pumped from leftventricle e.g aortic valve stenosis. Bestappreciated from the carotid pulseNB – pulse points – temporal, carotid, brachial,radial, popliteal, femoral, posterior tibialarteries
Jugular vein pulsejugular vein pulse – reflects right atrium andright ventricle pressure before a contractionjugular vein distention – caused by increasedpressure on the right side of the heart(right sidedheart failure) (visible just above the clavicles,distention noted when patient lies supine)Do not palpate temporal or carotid arteriessimultaneously, because it is possible todecrease the blood flow to the brain.

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