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When the heart beats and forces blood out of the ventricles, it causes the arteries to widen and a pressure wave results causing what is known as a pulse Use the pads of your first 3 fingers to palpate: oCarotid: in the groove between the sternomastoid muscle and trachea oRadial pulse: found at the flexor aspect of the wrist and just above the radial bone oBrachial: in the antecubital fossa medial to the biceps tendon Normal rate for pulse is 60-100 bpmPulses are assessed through rate, rhythm, and force, equalityPulse Force Scale & Descriptors 3+ - full and bounding2+ - normal1+ - weak and thready 0 – absent Respiration Assessment Assess for: oRate – bpmoRhythm – regular or irregular oDepth – shallow or deep oPulse oximetry – O2 saturation Abnormal findings – should be documented and reported ASAP oTachypnea: refers to an increased resp. rateoBradypnea: to a decreased respiratory rateoOrthopnea:to labored breathing when lying flat that is relieved by sitting upoApnea: to long periods of no breathing, remember if the client has apnea longer than 3 min. if can result in brain damage/ deathoDyspnea: to difficult or labored breathingBlood Pressure Blood pressure is assessed to determine the current state of the heart and peripheral vascular systemoSBP is highest pressure during ventricular contractionoDBP is lowest pressure during ventricular relaxation
Pulse pressure = difference between SBP & DBP 5 factors that impact BP oCardiac output– if the heart pumps more blood, it increases the pressure on the vessel walls oPeripheral vascular resistance – the smaller the blood vessel, the higher the pressure needed to push the blood through Elasticity of blood vessels – less elasticity increases the pressure, more elasticity reduces the pressure oVolume of blood – increased blood volume increases the pressure on the blood vessels oViscosity of blood – thicker blood (more cells, less plasma) causes increased pressure on blood vessels Abnormal BP A healthy adult should have a BP of 120-139/80-89Hypertension: abnormally high blood pressureHypotension: abnormally low blood pressure Orthostatic hypotension: a drop in BP when person moves from lying to sittingoClient may feel weak or faint until their body adjusts and their BP returns to normal Contraindications for BP? There are times where we cannot use a specific extremity oIf the arm is injured, or just had surgery on the arm, if they had breast surgeryoIf a limb as a dressing, cast, IV, dialysis catheter Blood Pressure Equipment SphygmomanometerIf the cuff is the wrong size, you will get an inaccurate readingoPlace cuff 2.5 cm above brachial arteryoPlace stethoscope on brachial artery & slowly inflate cuffoSBP is the 1st“crisp” pulsatile soundoDBP is the last “crisp” pulsatile sound Pain Responses People can have different responses to pain. Typically, pain will have a physiologicalresponse on the body o