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  • Clinical Support Worker Skills HandbookTo be used in conjunction with the Trust Interventions Course
  • Name:………………………………..Course Date:……………………….© Trust Interventions 2012 2
  • This handbook has been designed to support delegates who attend a‘Clinical Support Workers Skills Workshop’ offered by TrustInterventions Limited.The purpose of this handbook is to help enhance the learningacquired on the course and can be used as a future reference.Trust Interventions has developed a range of training courses thatcan be flexibly delivered to suit organisational and individual needs.For further information about these training courses and otherservices please ask the trainer or contact:© Trust Interventions 2012 3
  • Taking TemperatureTemperature Recording SitesTraditionally, the oral, axillae or rectum have been the preferred sitesfor obtaining temperature readings. This is due to their accessibility.With the development of new technology, the use of tympanicmembrane is increasingly becoming popular, as it is less invasive andprovides rapid results (Burke 1996)OralTo measure the temperature orally, the thermometer is placed in thesublingual pocket of tissue at the base of the tongue. This area is inclose proximity to the thermoreceptors, which respond rapidly tochanges in the core temperature; hence changes in coretemperatures are reflected quickly here (Marini & Wheeler 1997)Oral temperatures are affected by the temperatures of ingested foodsand fluids and by the muscular activity of chewing. A respiratory ratethat exceeds 18 breaths per minute, together with a patient whosmokes, will also reduce the core temperature values (Marieb 1998).It is important that the thermometer is placed in the sublingual pocketand not the area in front of the tongue, as there may be atemperature difference of up to 1.7°C between these areas. Thistemperature difference is due to the sublingual pockets being moreprotected from the air currents which cool the frontal areas (Neff et al1989). Oxygen therapy has been shown not to affect the oraltemperature reading (hasler &Cohen 1982; Lim-Levy 1982).RectalThe rectal temperature is often higher than the oral temperaturebecause this site is more sheltered from the external environment.Rectal thermometry has been demonstrated in clinical trails to bemore accurate than oral thermometry. The researchers (Jenson et al© Trust Interventions 2012 4
  • 1994) conclude that rectal thermometry is more accurate route fordaily measurements, but is more invasive, often unacceptable for thepatient and time consuming. Although this method is more precise,fever can still be detected by oral screening. If greeter accuracy isrequired the rectal method offers greater precision. The presence ofsoft stool may separate the thermometer from the bowel wall and givea false reading, especially if the central temperature is changingrapidly. In infants this method is not recommended as it provides arisk of rectal ulceration or perforation.A rectal thermometer should be inserted at least 4cm in an adult toobtain the most accurate reading.AxillaThe axilla is considered less desirable than the other sites because ofthe difficulty to achieve accurate and reliable readings as it is not tooclose to major vessels and skin surface temperatures vary more withchanges in temperature of environment (Woollens 1996). It is usuallyonly used for patient who are unsuitable for, or who cannot tolerateoral thermometers, e.g. after general anaesthetic or those patient withmouth injuries.To take an axillary temperature reading the thermometer should beplaced in the centre of the armpit, with the patient’s arm firmly againstthe side of the chest. It is important that the same arm is used foreach measurement as there is often variation in temperature betweenleft and right (Howell 1972).Whichever route is used for temperature measurement, it is importantthat this is then used consistently, as switching between sites canproduce a record that is misleading or difficult to interpret.Time for recording temperaturesThe average person experiences circadian rhythm, which makes theirhighest body temperature occur in the late afternoon or earlyevening, i.e. between 4pm and 8pm. The most sensitive time for© Trust Interventions 2012 5
  • detecting pyrexias appears to be between 7pm and 8pm (Angerami1980). This should be considered when interpretating variations in 4or 6 hourly observations, and when taking once daily temperatures.Types of thermometerA variety of thermometers are now available, from clinical glassthermometers with oral or rectal bulbs to the electronic sensorthermometer to the tympanic thermometer. Mercury thermomertershave been used extensively in the past, but it has been shown thatthey are unable to detect temperatures lower than 34.5°C (94°F) orhigher than 40.5°C (105°F). they are also slow to respond totemperature changes (Marini & Wheeler 1997). The use of electronicdevices is therefore preferable where there are extremes oftemperature or where there are temperature fluctuations. Infrared-sensing ear canel probes (tympanic membrane thermometers) havethe advantages of providing rapid results, are easy to use and areconvenient for both the nurse and the patient (Burke 1996). However,inconsistent study results have highlighted problems with their use(Yeo & Scarbough 1996; Thomas et al 1997). The practitioner mustunderstand the principals of use and the correct technique in order toobtain an accurate recording (White et al 1994; Burke 1996).Ideally, all variables such as site, technique and instrument shouldremain unchanged, but this is not always practical. Nurses are oftenpressurised as they are busy and this could be on of the reasons forthe inconsistency in data. With the emergence of electronic devicesto measure temperature, this has gone some way to addressingthese problems (Woollens 1996).© Trust Interventions 2012 6
  • Conditions that may need monitoring 1. Patient with conditions that affect basal metabolic rate, such as disorders of the thyroid gland, require monitoring of body temperature. Hypothyroidism is a condition where an inadequate secretion of hormones from the thyroid gland results in a slowing of physical and metabolic activity; thus the individual has a decrease in body temperature. Hyperthyroidism is excessive activity of the thyroid gland: a hypermetabolic condition results, with an increase in all metabolic processes. The patient complains of a low heat tolerance. Thyrotoxic crisis is a sudden increase in thyroid hormones and can cause hyperpyrexia (Mize et al 1993). 2. Postoperative and critically ill patients require monitoring of temperature. The patient’s temperature should be observed pre-operatively in order to make any significant comparisons. In the postoperative period the nurse should observe the patient for hyperthermia or hypothermia as a reaction to the surgical procedures (Mize et al 1993). 3. Patients with a susceptibility to infection, for example those with a low white blood cell count (less than 1000 cells/mm3), or those undergoing radiotherapy, chemotherapy or steroid treatment, will require a more frequent observation of temperature. The fluctuation in temperature is influenced by the body’s response to pyrogens. Immunocompromised patients are less able to respond to infection. Bacteraemia means a bacterial invasion of the blood stream. Septic shock is a circulatory collapse as a result of severe infection. Pyrexia may be absent in those who are immunosuppressed or in the elderly. 4. Patients with a systemic or local infection require monitoring of temperature to assess development or regression of infection© Trust Interventions 2012 7
  • 5. Patients receiving a blood transfusion require careful monitoring of temperature for incompatible blood reactions. Reaction to a blood transfusion is most likely to occur in the early stages and a rise in the patient temperature in indicative of a reaction. Cluroe (1989) suggests frequent recordings of temperature in the first 15 minutes of a blood transfusion as well as general observation of the patient. Pyrexia can occur throughout a blood transfusion, and results from a reaction by recipients antibodies. It may occur as soon as 60-90 minutes after the start of blood transfusion (Cluroe 1989).ReferencesAngerami E.L.S (1980) Epidemiological study of body temperature inpatients in a teaching hospital. Int J Jurs Stud, 17, 91-9Brown, S (1990) Temperature taking – getting it right. Nurs Stand.5(12), 4-5.Burke, K (1996) The tympanic membrane thermometer inpaediatrics: a review of the literature. Accid Emergency Nurse, 4(4),190-193.Cluroe, S (1989) Blood transfusions. Nursing; 3(40), 8-11Connell, F (1997) the causes and treatment of fever: a literaturereview. Nurs Stand, 12 (11), 40-43.Damanhouri, Z & Tayeb, O.S (1992) Animal models for heat strokestudies. J Pharmacol Toxicol Meth, 28, 119-27.Hasler, M & Cohen, J (1982) The affect of oxygen administration onoral temperature assessment. Nurs Res, 31, 265-8Howell, T (1972) Axillary temperature in aged women. Age aging, 1,250-254Jenson, B.N et al (1994) The superiority of rectal thermometry tooral thermometry with regard to accuracy. J Adv Nurs, 20, 660-65.Kirkler,S (1990) Pyrexia: what to do about temperatures. Nurs Stand,4(25), 37-8.Lim-Levy,F (1982) The affect of oxygen inhalation on oraltemperature. Nurs Res, 31, 150-152.Marieb, E.M (1998) Human Anatomy and Physiology.4th edn. Pp 908-964 Benjamin Cummings, California.© Trust Interventions 2012 8
  • Marini, J & Wheeler, A (1997) Medical Care Medicine, 2nd edn. Pp456-64. Williams and Wilkins, London.Minor, D.G & Waterhouse, J.M (1981) Circadian Rhythms and theHuman. Wright, Bristol.Mize, J, Koziol-McLain, J & Lowenstein, S.R (1993) The forgottonvital sign: temperature patterns and associations in 642 traumapatients at an urban level 1 trauma centre. J Emergency Nurs, 19(4),303-305.Nakamura, K et al (1997) Oral temperatures in the elderly in nursinghomes in summer and winter in relation to activities of daily living. IntJ Biometeorol, 40(2),, 103-106.Neff, J et al (1989) Effect of respiratory rate, respiratory depth, andopen versus closed mouth breathing on sublingual temperature. ResNurs Health, 12, 195-202.Sharber, J (1997) The efficacy of tepid sponge bathing to reducefever in young children. Am J Emergency Med, 15(2), 188-92.Thomas, K.A et al (1997) Effect of facial cooling on tympanictemperature. Am J Crit Care, 6(1), 46-51.Vane, J.R (1978) in: Cox et al. Pharmacology of the Hypothalmus.Macmillan, London.White, N, Baird, S & Anderson, D.L (1994) A comparison oftympanic thermometer readings to pulmonary artery catheter coretemperature recordings. Appl Nurs Res 7(4), 165-9.Woollens, S (1996) Temperature measurements devices. ProfNurse, 11(8), 541-7.Yeo, S & Scarbough, M (1996) Exercise induced hypothermia mayprevent core temperature measurement by tympanic membranethermometer. J Nurs meas, 4(2), 143-51.© Trust Interventions 2012 9
  • PulseDefinitionThe pulse is an impulse transmitted to arteries by contraction of theleft ventricle, and customarily palpated where an artery crosses abone, for example, the radial artery at the wrist (Roper 1995).IndicationsThe pulse is taken for the following reasons: 1. To gather information on the heart rate, pattern of beats (rhythm) and amplitude (strength) of pulse 2. To determine the individuals pulse on admission as a base for comparing future measurements 3. To monitor changes in pulseReference MaterialThe arterial pulse rate varies in different client groups as age-relatedchanges affect the pulse rate (Timby 1989)The pulse may vary depending on the posture of an individual. Forexample, the pulse of a healthy man may be around 66 beats perminute when he is lying down; this increases to 70 when sitting upand 80 when he standard suddenly (Marieb 1998)The rate of a pulse of an individual with a healthy heart tends to berelatively constant. However, when blood volume drops suddenly orwhen the heart has been weakened by disease, the stroke volumedeclines and cardiac output is maintained only by increasing the rateof the heart beat.© Trust Interventions 2012 10
  • Cardiac output is the amount of blood pumped out by each heartventricle in 1 minute, while the stroke volume is the amount of bloodpumped out by a ventricle with each contraction. The relationshipbetween these and the heart is expressed in the following equation:Cardiac output = heart rate x stroke volumeThe heart rate and hence pulse rate are influenced by various factorsacting through neutral, chemical and physically induced homeostaticmechanisms. 1. neural changes in heart rate are caused by the activation of the sympathetic nervous system which increases heart rate, while parasympathetic activation decreases heart rate (Ganong 1995). 2. Chemical regulation of the heart is affected by hormones (adrenaline and thyoxine) and electrolytes (sodium, potassium and calcium) (Ganong 1995). High or low levels of electrolytes particularly potassium, magnesium and calcium can cause al alteration in the heart’s rhythm and rate. 3. Physical factors that influence the heart rate are age, sex, exercise and body temperature (Marieb 1998).Tachycardia is defined as an abnormally fast heart rate, over100 beats per minute in adults, which may result from a raised bodytemperature, increased sympathetic response due tophysical/emotional stress, certain drugs or heart disease (Marieb1998).Bradycardia is a heart rate slower than 60 beats per minute. Itmay be the result of a low body temperature, certain drugs orparasympathetic nervous system activation. It is also found in fitathletes where physical and cardiovascular conditioning occurs. Thisresults in hypertrophy of the heart with an increase in its strokevolume. These heart changes result in a lower heart rate but with thesame cardiac output (Marieb 1998). If persistent bradcardia occurs inan individual as a result of ill health, this may result in inadequateblood circulation to body tissues. A slowing of the heart rate© Trust Interventions 2012 11
  • accompanied by a rise in blood pressure is one of the indications ofraised intracranial pressure.RhythmThe pulse rhythm is the sequence of beats. In health, these areregular. The coordinated action of the muscles of the heart inproducing a regular heart rhythm is due to the ability of the cardiacmuscles to contract inherently without nervous control (Marieb 1998).The coordinated action of the muscles in the heart results from twophysiological factors: 1. Gap junctions in the cardiac muscles, which form inter- connections between adjacent muscles and allow transmission of nervous impulses from cell to cell (Marieb 1998). 2. Specialised nerve-like cardiac cells that form the nodal system. These initiate and distribute impulses throughout the heart, so that the heart beats as one unit (Marieb 1998). These are the sinoatrial node, atrioventricular node, atrioventricular bundle and the purkinje fibres.The sinoatrial node is the pacemaker, initiating each wave ofconcentration. This sets the rhythm for the heart as a whole (seediagram). Its characteristic rhythm is called sinus rhythm.Defects in the conduction system of the heart can cause irregularheart rhythms, or arrhythmias, resulting in uncoordinated contractionsof the heart.Fibrillation is a condition of rapid and irregular contractions. Afibrillating heart is ineffective as a pump (Marieb 1998). Atrialfibrillation is a disruption of rhythm in the atrial areas of the heartoccurring at extremely rapid and uncoordinated intervals. The rapidimpulses result in the ventricles not being able to respond to everyatrial beat and, therefore the ventricles contract irregularly. These aremany causes of this condition but the following are the mostcommon: 1. Ischaemic heart disease 2. Acute illness 3. Electrolyte abnormality© Trust Interventions 2012 12
  • 4. ThyrotoxicosisVentricular fibrillation is an irregular heart rhythmcharacterised by chaotic contraction of the ventricles at very rapidrates. Ventricular fibrillation results in cardiac arrest and death if notreversed with defibrillation and the injection of epinephrine. Thecause of the condition is often myocardial infarction andhypovolaemia.Because body fluids are good conductors of electricity it is possiblethrough electrocardiography to observe how the currents generatedare transmitted through the heart. The electrocardiogram provides agraphic representation and record (electrocardiogram) of electralactivity as the heart beats. The electrocardiogram (ECG) makes itpossible to identify abnormalities in electral conduction within theheart. The normal ECG consists of a series of three distinct areascalled deflection waves. The first of these is a P wave, which resultsfrom an electrol impulse in the sinoatrail node. The large QRScomplex results from ventricular depolarisation and takes place priorto contraction of the heart muscles. The T wave is caused byventricular repolarisation. In a healthy heart, the size and rhythm ofthe deflection waves tend to remain consent. Changes in patter ortiming of the deflection of the ECG may indicate problems with theheart’s conduction system, such as those caused by myocardialinfarcation (Marieb 1998), see diagram.Amplitude is a reflection of pulse strength and the elasticity ofthe arterial wall. The flexibility of the artery of the young adult feelsvery different to the hard artery of the patient sufferening fromarteriosclerosis. It takes some clinical experience to appreciate thedifference in amplitude. However, it is important to be able torecognise major changes such as the faint flickering pulse of theseverely hypovalaemic patient.© Trust Interventions 2012 13
  • Guidelines – Pulse – ProcedureAction Rationale1. Explain and discuss the To ensure that the patientprocedure with the patient understands the procedure and gives his/her consent2. Measure where possible the To ensure continuity andpulse under the same condition consistency in recording. Toeach time. Ensure that the ensure that the patient ispatient is comfortable. comfortable.3. Place the second or third The fingers are sensitive tofingers along the appropriate touch. The thumb and forefingerartery and press gently. have pulses of their own that may be mistaken for the patients pulse.4. Press gently against the The radial artery is usually usedperipheral artery being used to as it is often the most readilyrecord the pulse accessible.5. The pulse should be counted Sufficient time is required tofor 60 sec. detect irregularities or other defects.6. Record the pulse rate. To monitor differences and detect trends; any irregularities should be bought to the attention of the appropriate personnel.Note: in children under 2 years of age, the pulse should not be takenin this way; the rapid pulse rate and small area for palpation can leadto inaccurate data. The heart rate should be assessed by using astethoscope and listening to the apical heartbeat.© Trust Interventions 2012 14
  • Resting Heart Rate Age or fitness level Beats per minute (bpm)Babies to age 1: 100–160Children ages 1 to 10: 60–140Children age 10+ and adults: 60–100Well-conditioned athletes: 40–60ReferencesBirdsall, C (1985) How do you interpret pulses? Am J Nurs, 85(7),785-6.Cluroe, S (1989) Blood transfusions. Nursing, 3(40), 8-11/Ganong, W.F (1995) Review of Medical Physiology, 17th edn.Appelton & Lange, Norfolk, Connecticut.Jarvis, C.M (1980) Vital signs: a preview of problems. In assessingVital Functions Accurately. Intermed Communication.Hickey, J.V (1986) The Clinical Practice of Neurological Nursing, 2ndedn. J.B. Lippincott, Philadelphia.Marieb, E.M (1998) Human Anatomy and Physiologgy, 4th edn.Benjamin Cummings, California.Roper, N (ed) (1995) Pocket Medical Dictionary, p.223. ChurchillLivingstone, Edinborough.Timby, B (1989) Clinical Nursing Procedure, J.B. Lippincott,Philadelphia.Wieck, L et al (1986) Illustrated Manual of Nursing Techniques, 3rdedn. J.B Lippincott, Philadelphia.© Trust Interventions 2012 15
  • RespirationsOxygen is carried in the blood in two ways, bound to the haemoglobinwithin the red blood cells and dissolved in plasma. Haemoglobincarries 98.5% of the oxygen from the lungs and the tissues. Theamount of oxygen bound to haemoglobin depends in several factors.Diseases that reduce the oxygen-carrying ability of the bloodwhatever the cause are termed anaemia. This characterised byoxygen blood levels that are inadequate to support normalmetabolism (Marieb 1998). Common causes of anaemia include: 1. Insufficient number of red cells, including destruction of red cells, haemorrhage and bone marrow failure. 2. Decreases in haemoglobin content, including iron deficiency anaemia and pernicious anaemia. 3. Abnormal haemoglobin, including thalassaemia and sickle cell anaemia.Internal respirationInternal respiration is the exchange of gases that occurs within thetissues between the capillaries and the cells. Carbon dioxide entersthe blood and oxygen moves into the cells.Hypoxia is the result of an inadequate amount of oxygen delivered tobody tissues. The blue coloration of tissues and mucosal membranesis termed cyanosis.Lung defence mechanisms© Trust Interventions 2012 16
  • The upper airway is designed to warm, humidify and filter the inspiredair. The nasal passage absorbs noxious gases and trap inhaledparticles. Smaller particles are removed by a cough reflex.Observation of respirationRespirations of an individual should be observed for rate, depth andpattern of breathing.Rate and depth determine the type of respiration. The normal rate atrest is approximately 14-18 breaths per minute in adults and is fasterin infants and children (see table). The ratio of pulse rate torespiration rate is approximately 5:1.Changes in the rate of ventilation may be defined as follows.Tachpnoea is an increased respiratory rate, seen in fever forexample, as the body tries to rid itself of excess heat. Respirationsincrease by about 7 breaths per minute for every 1°C rise intemperature above normal. They also increase with pneumonia, theother obstructive airway diseases, respiratory insufficiency andlesions in the pons of the brainstorm (Brunner & Suddarth 1989).Bradypnoea is a decreased but regular respiratory rate, suchas that caused by depression of the respiratory centre in the medullaby opiate narcotics, or by brain tumour.Respiratory Rates – Timby 1989Age Average range/minuteNewborn 30 – 80Early childhood 20 – 40Late children 15 – 25Adulthood – male 14 – 18Adulthood – female 16 – 20© Trust Interventions 2012 17
  • DepthThe depth of respiration is the volume of air moving in and out witheach respiration. This tidal volume is normally about 500ml in anadult and should be constant with each breath. A spirometer is usedto measure the precise amount (see Respiratory capacities). Normal,relaxed breathing is effortless, automatic, regular and almost silent.Dyspnoea is undue breathlessness and an awareness ofdiscomfort with breathing. There are several types of dyspnoea. 1. Exertional dyspnoea is shortness of breath on exercise and is seen with heart failure. 2. Orthopnoea is a shortness of breath lying down which is relieved by the patient sitting upright. This is often caused by the left ventricular failure of the heart. 3. Paroxysmal, nocturnal dyspnoea is a sudden breathlessness that occurs at night when the patient is lying down and is often caused by pulmonary oedema and left ventricular failure (Brunner & Suddarth 1989).PatternChanges in the pattern of respiration are often found in disorders ofthe respiratory control centre (Brunner & Suddarth 1989). Examplesof changes in respiratory follow:Hyperventilation is an increase in both the rate and depth ofrespiration. This follows extreme exertion, fear and anxiety, fever,hepatic coma, midbrain lesions of the brain stem and acid-baseimbalance such as diabetic ketoacidosis (Kussmaul’s respiration) orsalicylate overdose (in both of these situations the body compensatesfor the metabolic acidosis by increased respiration), as well as an© Trust Interventions 2012 18
  • alteration in blood gas concentration (either increased carbon dioxideor decreased oxygen). The breathing pattern is normally regular andconsists of inspirations, pause, longer expiration and another pause.However, this may be altered by some defects and diseases. Inadults, more than 20 breaths per minute is considered moderate,more than 30 is severe.Apnoeustic respiration is a pattern of prolonged, gaspinginspiration, followed by extremely short, inefficient, expiration seen inlesions of the pons in the midbrain.Cheyne-Stokes respiration is periodic breathing characterisedby a gradual increase in depth respiration followed by a decrease inrespiration, resulting in apnoea (Brunner & Suddarth 1989)Biot’s respiration is an interrupted breathing pattern, like Cheyne-Stokes respiration, except that each breath is the same depth. It maybe seen with spinal meningitis or other central nervous systemconditions.Conditions where a patient’s respirations may need carefulmonitoring are described below: 1. Patients with conditions that affect respiration, such as those described in the text, require monitoring of respiration to evaluate their condition and the effectiveness medication. 2. Postoperative and critically ill patients require monitoring of respiration. The patient’s respiration should be recorded pre- operatively in order to make significant comparisons. The breathing is observed to assess for the return to normal respiratory function. 3. Patients receiving oxygen inhalation therapy or receiving artificial respiration require monitoring of breathing to assess respiratory function.© Trust Interventions 2012 19
  • ReferencesBell, G.H et al (1980) Textbook of Physiology and Biochemistry, 10th edn.Churchill Livingstone, Edinburgh.Boylan, A & Brown, P (1985) Respirations. Nurs Times, 81, 35-8.Brunner, L.S & Suddarth, D.S (1989) The Lippincott Manual of medical-Surgical Nursing, Vol 2. Harper & Row, London.Ganpng, W.F (1995) Review of Medical Physiology, 17th edn. Appelton &Lange, New York.Glennister, T.W.A & Ross, R.W (1980) Anatomy & Physiology forNurses, 3rd edn. William Heineman Medical Books, London.Jarvis, C.M (1980) Vital Signs: a preview of problems. In: Assessing VitalFunction Accurately. Intermed Communication.Kertson, L.D (1989) Comprehensive Respiratory Nursing: A DecisionMaking Approach. W.B Saunders, Philadelphia.Marieb, E.M (1998) Human Anatomy and Physiology, 4th edn. BenjaminCummings, Californa.Roberts, A (1980) Systems and Signs. Respiration 1,2. Nurse Times, 76,Systems of Life, Nos 71,72 p.8.Rokosky, J.S (1981) Assessment of the individual with altered respiratoryfunction. Nurse Clin North Am. 16(2), 195-9.Timby, B (1989) Clinical Nursing Procedure. J.B. Lippincott, Philadelphia.© Trust Interventions 2012 20
  • Blood Pressure MeasurementDefinitionBlood pressure may be defined as the force exerted by blood againstthe walls of the vessels in which it is contained. Differences in bloodpressure between different areas of the circulation provide the drivingforce that keeps the blood moving through the body (Marieb 1998).Blood pressure is usually expressed in terms of millimetres ofmercury (mm Hg)IndicationsBlood pressure is measured for one of two reasons: 1. to determine the patient’s blood pressure on admission as a baseline for comparison with future measurements 2. to monitor fluctuations in blood pressure.Normal blood pressureNormal blood pressure generally ranges from 100/60 to 140/90mm/Hg. Blood pressure can fluctuate within a wide range and still beconsidered normal.Systolic pressureThe systolic pressure is the maximum pressure of the blood againstthe wall of the vessel following ventricular contraction and is taken asan indication of the integrity of the heart, arteries and arterioles(Marieb 1998).© Trust Interventions 2012 21
  • Diastolic pressureThe diastolic pressure is the minimum pressure of the blood againstthe wall of the vessel following closure of the aortic valve and is takenas a direct indication of blood vessel resistance (Marieb 1998).Hypotension or low blood pressure is generally defined in adults as asystolic blood pressure below 100mm/Hg (Marieb 1998). In manycases, hypotension simply reflects individual variations; however itmay indicate orthostatic hypotension, i.e. postural changes that resultin a lack of normal reflex response leading to a low blood pressure, orit may be the first indicator of a shock condition. E.g. septic shock,cardiogenic, hypovolaemic or toxic shock syndrome.Hypertension is defined as a elevation of systolic blood pressure.This may be a temporary response to fever, physical exertion orstress. Persistent hypertension is a common disease andapproximately 30% of people over the age of 50 years arehypersensitive (Marieb 1998). Persistent hypertension is diagnosed inan individual when the average of three or more blood pressurereadings taken at rest, several days apart, exceeds the upper limits ofwhat is considered normal for the patient.Methods of recording and equipmentThere are two main methods for recording the blood pressure: directand indirect. Direct methods are more accurate than indirectmethods. The most accurate method of measuring blood pressureinvolves the insertion of a minute pressure transducer unit into anartery for transmission of a waveform or digital display on a monitor.The most commonly used techniques involve placing a cannula in anartery and attaching a pressure-sensitive device to the external end.Patients who need to be constantly monitored, e.g. in theatres, high-dependency and intensive care units, may require such devices to beused. In such patients it is essential to have an early knowledge ofany change in the blood pressure, as this may indicate deteriorationin condition and require prompt treatment.© Trust Interventions 2012 22
  • The indirect method is the auscultatory method. This procedure isused to measure the blood pressure in the brachial artery of the arm.A blood pressure reading can either be taken by the traditionalmethod of a sphygmomanometer or electronically, using a devicesuch as a dynamap. With any piece of equipment, adequate trainingshould be provided, to ensure accuracy.The sphygmomanometerThe sphygmomanometer consists of a compression bag enclosed inan unyielding cuff, and inflating bulb, pump or other device by whichthe pressure is-increased, a manometer from which the appliedpressure is read, and a control valve to deflate the system.ManometerMercury sphygmomanometers are reliable, on the whole and areeasy to maintain. Any damaged equipment should either be repairedor disposed of. Correct disposal is important due to the risk ofmercury contamination (HSE 1998). While in use, the manometermust be kept in vertical position, otherwise substantial errors canoccur (Campbell et al. 1990).CuffThe cuff is made of washable material that encircles the arm andencloses the inflatable rubber bladder. It is secured round the arm orleg by wrapping its tapering end to the encircling material, usually byVelcro.Inflatable bladderA bladder that is too short and/or too narrow will give falsely highpressures. The British Hypertension Society recommended in 1986that the centre of the bladder should cover the brachial artery and© Trust Interventions 2012 23
  • that the bladder length should be 80% of the arm circumference andthe width at least 40% (Gillespie and Curzo 1998).Control valve, pump and rubber tubingThe control valve is a common source of error. It should allow thepassage of air without excessive pressure needing to be applied onthe pump. When the valve is closed, it should hold the mercury at aconstant level abd when released, it should allow a controlled fall inthe level of mercury. The rubber tubing should be long (approximately80cm) and with airtight connections that can be easily separated.Campbell et al (1990), in reviewing the methods forsphygmomanometer inaccuracies, found that errors in technique andequipment malfunction accounted for difference in readings of morethan 15mmHg. Problems with equipment malfunction were furthersupported in a study by Carney et al (1995), who evaluated 463sphygmomanometers and found that only 58% were in working order.The stethoscopeUsing the stethoscope it is possible to identify a series of five phasesas blood pressure falls from the systolic to the diastolic. Thesephases are known as Korotkoff’s sounds (see diagram)When the cuff pressure has fallen to just below the systolic pressure,a clear but often faint tapping sound suddenly appears in phase witheach cardiac contraction. The sound is produced by the transient andturbulent blood flowing through the brachial artery during the peak ofeach systole.As the pressure in the cuff is reduced further the sound becomeslouder, but when the artery is no longer constricted and the bloodflows freely, the sound become muffled and then can no longer beheard. The diastolic pressure is usually defined as the cuff pressureat which the sounds disappear (Marieb 1998).The stethoscope diaphragm should be placed lightly over the point ofmaximal pulsation or the brachial artery (Petrie et al 1997). The© Trust Interventions 2012 24
  • diaphragm is designed to amplify low frequency sounds such asKorotkoff’s sounds (Hill and Grim 1991). Excessive pressure on thestethoscope’s diaphragm may partially occlude the brachial arteryand delay the occurrence of Korotkoff’s sounds. For this reason thediaphragm should not be tucked under the edge of the cuff.Korotkoff’s sounds form five phases: 1. The appearance of faint, clear tapping sounds, which gradually increase in intensity. 2. The softening of sounds, which may become swishing. 3. The return of sharper sounds which become crisper but never fully regain the intensity of the phase 1 sounds. 4. The distinct muffling sound which becomes soft and blowing. 5. The point at which all sounds ceases.Additional informationMuch recent research has focussed on the faulty techniquesemployed when blood pressures are taken (Campbell et al 1990;Bogan et al 1993; Kemp et al 1994; Torrance & Serginson 1996;Gillespie & Curzio 1998). Blood pressure readings are altered byvarious factors that influence the patient, the techniques used and theaccuracy of the sphygmomanometer. The variability of any readingscan be reduced by an improved technique and by taking severalreadings (Campbell et all 1990). In 1981 Thompson discussed themethodology of blood pressure recording and identified poortechnique and observer bias as possible sources of error. Theconcluded that many nurses were inadequately trained in bloodpressure and that more attention needed to be paid to this area. In1996 Beevers and Beevers found that observer error could bereduced if techniques for measuring blood pressure were taughtrepeatedly during medical and nursing training. Furthermore, thetechniques should be reinforced regularly.Similar conclusions were found in studies by Mancia et al (1987),Feher and St John (1992) and Torrance and Serginson (1996). Poortechnique due to inadequate education can caused marked variationin the accuracy of measurements and can lead to inappropriatetreatment decisions (kemp et al 1994).© Trust Interventions 2012 25
  • Ambulatory blood pressure is increasingly regarding as superior toindividual blood pressure readings (National High Blood PressureEducation Programme Coordinating Committee 1990; perloff et al1993). Ambulatory blood pressure monitoring is expensive, time-consuming and has some risks as it can cause phlebitis (Creery et al1985). Although ambulatory blood pressure monitoring is consideredmore accurate, manual measurement remains the most commonmethod (Veerman & Van Monfrans 1993).Variations in the procedure and frequency of taking blood pressuremay be required in different patient groups with differing conditions.With a child it is important that the correctly sized cuff is used andthat the average of repeated measurements is recorded. Lowdiastolic pressures are common in elderly patients who may haveatherosclerosis and in patients with an increased cardiac output, i.e.as a result of pregnancy, exercise or hypothyroidism.In pregnancy, changes in blood pressure may indicate pregnancy-induced hypertension. An increase of 30mmHg or more systolicpressure and 15mmHg diastolic pressure over the previous readingsmay be indicative of this condition (Ferris 1990).Patients with lines or shunts for dialysis in their arms or superior venacava obstruction may be unsuitable for upper arm measurements ofblood pressure; however, the blood pressure may be measured in theleg of forearm. For this procedure, the patient lies prone and a thighcuff or large cuff is applied to the lower third of the thigh. The cuff iswrapped securely with its lower edge above the knee and its bladdercentred over the posterior popliteal artery. The stethoscopediaphragm should be applied on the artery below the cuff. Systolicblood pressure is normally 20-30 mmHg higher in the leg than thearm. The right sized cuff should be used for obtaining the bloodpressure from the forearm, and the bladder should be centred overthe radial artery about 2.5cm above the wrist. Forearm bloodpressure measurements may vary significantly from an upper armmeasurement, and therefore it is important to document cuff size andlocation (Hill and Grim 1991).Patients who have just had breast surgery with lymph nodedissections and/or radiotherapy, or have lymphoedema should not© Trust Interventions 2012 26
  • have their blood pressure recorded on the affected side. This is dueto the increased sensitivity of the area and the risk of developinglymphoedema. Patient should be told to have their blood pressuretaken using the unaffected arms or legs. Conditions that may need monitoring 1. Hypertension is never diagnosed on a single blood pressure reading. Blood pressures are monitored to evaluate the condition of a patient and the effectiveness of medication (Marieb 1998). 2. Postoperative and critically ill patients do not require monitoring of blood pressure for cardiovascular stability. The patient’s blood pressure should be recorded preoperatively in order to make significant comparisons. The reduction is cardiac diastole after surgery may result in a decreased coronary perfusion and therefore reduced cardiac output and vasoconstriction. Report immediately a falling systolic pressure as this may be an indication of hypovolaemic shock (Marini & Wheeler 1997). Haemorrhage may be primary at the time of the operation or intermediary in the first few hours after surgery. The blood pressure returns to the patient’s normal levels and causes loosening of poorly tied vessels and the flushing out of clots. The resulting blood loss causes a decrease in cardiac output and hypotension. Secondary haemorrhage can occur some time after surgery and can be due to infection. This also results in a fall in blood pressure. 3. Blood transfusions require careful monitoring of the blood presuure for several reasons. An incompatible blood transfusion may lead to agglutination and a resulting fall in blood pressure. Circulatory overload may lead to a rise in blood pressure, while the infusion of large quantities of blood may alter clotting factors and result in bleeding, causing a fall in blood pressure (Cluroe 1989). 4. Patients receiving intravenous infusions require blood pressure monitoring to observe for circulatory overload. Certain chemotherapy protocols diuretics are frequently used to reduce the increase in blood volume, which results in a rise in blood pressure. Careful monitoring of blood pressure, weight, kidney© Trust Interventions 2012 27
  • function and electrolytes is imperative to prevent fluid overload and electrolyte imbalance (Marini & Wheeler 1997). 5. Patients with local of systemic infections or neutropenia require monitoring of their blood pressure in order to detect septicaemia shock. This is characterised by a change in the capillary epithelium and vasodilatation due to circulating cell mediation (Bone 1996), which permits loss of blood and plasma through capillary walls into surrounding tissues. The decrease in the circulating volume of blood results in impaired tissue perfusion, culminating in cellular hypoxia (Ganong 1995).Things to ask  Previous blood pressure problems  Current/previous BP medication  When BP last checked and what was reading  Contributing lifestyle, e.g. stress, exercise, diet, smoking, alcohol  Dizziness  Pins and needles  Tingling  Photophobia  Slurring of words  Headaches  Weakness© Trust Interventions 2012 28
  • Blood Pressure Measurement Blood Pressure Measurement Action BP is normal. No action should beLess than 120/75 takenBetween 120/75 and 130/85 BP is in so called normal range, but should be reviewed in a year.Between 130/85 and 140/89 BP is in upper range of normal. Recheck in a few months. Individuals could consider adopting a healthier lifestyle i.e. healthy diet, lose weight, take more exercise, etcBetween 140/90 and 199/109 BP is raised. It is important to try and retake the measurement after a period of rest. If it is the same, the individual may have high BP. Advise to make appointment with Practice Nurse or GP within the next week to have it rechecked.Between 200/110 and 239/119 Recheck the BP after five minutes. If it remains at these levels, consult a WIC Nurse for advice. These readings should not be ignored.Over 240/120 Recheck the BP. If it remains at this level, it is very important the BP is checked by eg GP or A&E.© Trust Interventions 2012 29
  • ReferencesBeevers, M & Beevers G,B (1996). Blood pressure measurement inthe next century, a plea for stability. Blood Press Monit, 1(2), 117-20.Bogan, B, Kritzer, S & Deane, D (1993) Nursing Student complianceto standards for blood pressure measurement. J Nurse Educ, 32(2),90-92.Bone, R.C (1996). The pathogenesis of sepsis and rationale for newtreatments. Proceedings of the International Intensive CareConference, Barcelona.Campbell, N.R et al (1990). Accurate, reproducible measurement ofblood pressure. Can Med Assoc J, 143(1), 19-24.Carney, S.L et al (1995) Hospital sphygmomanometers use an audit.J Qual Clinical Pract, 15, (1), 17-22.Cluroe, S (1989) Blood Transfusion. Nursing, 3(40), 8-11.Conceicao, S et al (1976) Defect in Sphygmomanometers. Br Med J.2, 886-8.Creery, T.C et al (1985) Phlebitis Associated with non invasive 24hour ambulatory blood pressure monitor. JAMA, 254, 2411.Feher, M & Harris St. John, K. (1992) Blood Pressure Measurementby junior hospital doctors: a gap in Medical Education? HealthTrends, 24(2), 59-61.Ferris, T.F (1990) Hypertension in Pregnancy. The kidney, 23(1), 1-5.Ganong, W.F (1995) Review of Medical Physiology, 17th Edn.Appleton and Lange. Norwalk, Connecticut.Gillespie, A and Curzio, J (1998) Blood pressure measurementassessing staff knowledge. Nurs Stand, 12(23), 35-7.Hill, M.N & Grim, C.M (1991) How to take a precise blood pressure.Am J Nurs, 91(2), 38-42.HSE (1989) Control of Substances Hazardous to Health Regulations.Health and Safety Executive, London.© Trust Interventions 2012 30
  • Kemp, F et al (1994) How effective is training for blood pressuremeasurement? Prof Nurs, 9(8), 521-4.Londe, S & Klitzner, T (1984) Auscultatory blood pressuremeasurement: effect of blood pressure on the head-on stethoscope.West J Med, 141(2), 193-5.Mancia, G et al (1987) Alerting reaction and rise in blood pressureduring measurement by physician and nurse. Hypertension, 9, 209-215.Marieb, E.M (1998) Human Anatomy and Physiology, 4th edn pp.690-718. Benjamin Cummings, California.Marini, J & Wheeler, A (1997) Critical Care Medicine: TheEssentials, 2nd edn. Pp. 19-43. Williams and Wilkins, Baltimore.Maxwell, M.H (1982) Error in blood pressure measurement due toincorrect cuff size in obese patients. Lancet, 2, 33-6.National High Blood Pressure Education ProgrammeCoordinating Committee (1990) Report on Ambulatory bloodpressure monitoring. Arch Intern Med, 150, 2270-80.North, L.W (1979) Accuracy of sphygmomanometers. AssocOperating Room Nurses J. 30, 996-1000.Perloff, D et al (1993) The prognostic value of ambulatory bloodpressures JAMA, 249, 2792-8.Petrie, J.C, O’Brian, E.T, Litler, W.A & DeSweit, M (1997) BritishHypertension Society: Recommendations on Blood PressureMeasurement, 2nd edn. British Hypertension Society, London.Thompson, D.R (1981) Recording patient’s blood pressure: Areview. J adv Nurs, 6(4), 23-90.Torrance, C & Serginson, E (1996) Student nurses knowledge inrelation to blood pressure measurement by sphygmomanometry andauscultation. Nurs Educ. Today, 16(6), 297-402.Veerman, D.P & Van Monfrans, G.A (1993) Nurse measured orambulatory blood pressure in routine hypertension care? JHypertens, 11, 287-92.Webster, J et al (1984) Influence of arm position on measurement ofblood pressure. Br Med J, 288, 1574-5.© Trust Interventions 2012 31
  • Systolic Pressure Estimation 1. Palpate brachial artery pulsation 2.Inflate cuff until pulsation vanishes 1. Deflate cuff 2. Take reading SYSTOLIC AND DIASTOLIC PRESSURE MEASUREMENTS 3. Place stethoscope gently over point of maximal pulsation of brachial artery 4. Inflate cuff to 30mm Hg above estimated systolic pressure. 5. Reduce pressure at rate of 2-3mm Hg per second or per pulse beat. 6. Take reading of systolic pressure when repetitive, clear tapping sounds appear for two consecutive beats.© Trust Interventions 2012 32
  • 7. Take readings of diastolic pressure when repetitive sounds disappear. Weight Management 1) The preferred method for assessing whether underweight or overweight exists is the body mass index. 2) There has been an increase in the prevalence of overweight and obesity during the last decade. This has led to a shift in emphasis towards prevention of overweight, especially among young adults, rather than only treating existing overweight and obesity. 3) Excess body weight carries health risks, which increase with the degree of obesity. 4) The risk to health is greater if the excess fat is mainly distributed around central part of the body. This indicates an excess of internal fat and is associated with a prediposition towards coronary heart disease, stroke, diabetes, breast cancer and gallstones. 5) The practice team can play a key role in efforts to stop the increase and reduce the prevalence of overweight, but it is important to target endeavours. 6) Specialist knowledge is needed when advising overweight children and their parents about diet in relation to body weight. 7) Current research does not support a marked difference in eating behaviour between overweight and normal weight people. 8) The recommended type of slimming programme combines regular moderate physical activity with a reduced energy diet comprising a wide range of foods. 9) Very low calorie diets (VLCD) are designed to produce rapid weight loss. They should be used only if conventional methods have failed and they are not suitable for people with a relatively small amount of weight to be lost. 10) The plight of those trying to gain weight if often overlooked. Again, advice should be based on choices from the four main food groups. Inclusion of nutritious snacks can be helpful. 11) Specialist knowledge is required when advising parents suspected of having anorexia or bulimia nervosa.© Trust Interventions 2012 33
  • Assessment of Body WeightAlthough relative height for weight is still often used to assesswhether a patient is overweight, the preferred method is the bodymass index (or Quetelet index). This is the ratio of weight (kilograms)over the square of height (meters): Weight (Height)For example, the body mass index for a 70kg man, 1.7 metres tallwould be: 70 = 24.2 1.7 X 1.7Table 12.1 gives the recommended classification of body weightaccording to the body mass index.This method is applicable to adult men and women. However, it doesnot take body composition into consideration. Therefore, it may beinappropriate for certain people: • Children or adolescents (males and females under 18 years of age) as growth is still occurring. Tables of reference standard weights for children can be found in the report on dietary reference values (DH 1991) and new centile charts for children have been developed. • Elderly people, owing to the changes, which occur in body composition as part of the natural ageing process. • Pregnant women, owing to the growth of the developing baby and maternal stores. • Individuals with a high proportion of muscle; those who take part in many sporting activities may appear to be in the overweight category when body mass index is calculated.For convenience, the graph shown in figure 12.1 can be used withpatients in the age range 20-65 years. Suitable BMI ranges forchildren are being considered.© Trust Interventions 2012 34
  • Blood GlucoseThe blood sugar level is the amount of glucose (sugar) in the blood. Itis also known as serum glucose level. It is expressed as millimolesper litre (mmol/l).Normally, blood glucose levels stay within narrow limits throughoutthe day: 4 to 8mmol/l. But they are higher after meals and usuallylowest in the morning.In diabetes the blood sugar level moves outside these limits untiltreated. Even with good control of diabetes, the blood sugar level willstill at times drift outside this normal range.Why control blood sugar levels?For reasons that are not well understood, when very high levels ofblood glucose are present for years, it leads to damage of the smallblood vessels.This in turn increases your risk of developing late-stage diabetescomplications such as: • retinopathy (eye disease) • nephropathy (kidney disease) • neuropathy (nerve disease) • cardiovascular disease, such as heart attack, hypertension, heart failure, stroke and problems caused by poor circulation, eg gangrene in the worst cases.With Type 1 diabetes, these complications may start to appear 10 to15 years after diagnosis.Its often less than 10 years after diagnosis of Type 2 diabetes,because this type of diabetes is often present for years before it is© Trust Interventions 2012 35
  • recognised.By keeping the blood sugar level stable, you significantly reduce yourrisk of these complications.How can I measure blood sugar levels?You can learn to measure blood sugar levels simply and quickly witha home blood glucose level testing kit. All kits have at least twothings: a measuring device and a strip.To check your blood sugar level, put a small amount of blood on thestrip. Now place the strip into the device. After about 30 seconds itwill display the blood glucose level.The best way to take a blood sample is by pricking your finger with asharp lancet thats designed to penetrate the skin only as far asneeded to draw a drop of blood.What should glucose levels be?The ideal values are: • 4 to 7mmol/l before meals. • less than 10mmol/l 90 minutes after a mealaround 8mmol/l at bedtime© Trust Interventions 2012 36