When the heart beats and forces blood out of the ventricles it causes the

When the heart beats and forces blood out of the

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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: o Carotid : in the groove between the sternomastoid muscle and trachea o Radial pulse : found at the flexor aspect of the wrist and just above the radial bone o Brachial : in the antecubital fossa medial to the biceps tendon Normal rate for pulse is 60-100 bpm Pulses are assessed through rate, rhythm, and force, equality Pulse Force Scale & Descriptors 3+ - full and bounding 2+ - normal 1+ - weak and thready 0 – absent Respiration Assessment Assess for: o Rate – bpm o Rhythm – regular or irregular o Depth – shallow or deep o Pulse oximetry – O2 saturation Abnormal findings – should be documented and reported ASAP o Tachypnea: refers to an increased resp. rate o Bradypnea: to a decreased respiratory rate o Orthopnea: to labored breathing when lying flat that is relieved by sitting up o Apnea: to long periods of no breathing, remember if the client has apnea longer than 3 min. if can result in brain damage/ death o Dyspnea: to difficult or labored breathing Blood Pressure Blood pressure is assessed to determine the current state of the heart and peripheral vascular system o SBP is highest pressure during ventricular contraction o DBP is lowest pressure during ventricular relaxation
Pulse pressure = difference between SBP & DBP 5 factors that impact BP o Cardiac output – if the heart pumps more blood, it increases the pressure on the vessel walls o Peripheral 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 o Volume of blood – increased blood volume increases the pressure on the blood vessels o Viscosity of blood – thicker blood (more cells, less plasma) causes increased pressure on blood vessels Abnormal BP A healthy adult should have a BP of 120-139/80-89 Hypertension : abnormally high blood pressure Hypotension : abnormally low blood pressure Orthostatic hypotension : a drop in BP when person moves from lying to sitting o Client 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 o If the arm is injured, or just had surgery on the arm, if they had breast surgery o If a limb as a dressing, cast, IV, dialysis catheter Blood Pressure Equipment Sphygmomanometer If the cuff is the wrong size, you will get an inaccurate reading o Place cuff 2.5 cm above brachial artery o Place stethoscope on brachial artery & slowly inflate cuff o SBP is the 1 st “crisp” pulsatile sound o DBP is the last “crisp” pulsatile sound Pain Responses People can have different responses to pain. Typically, pain will have a physiological response on the body o

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