Vital signs - Blood pressure Monitoring

1. VITAL SIGNS
PREPARED BY:
USHA RANI KANDULA,
ASSISTANT PROFESSOR,
DEPARTMENT OF ADULT HEALTH NURSING,
ARSI UNIVERSITY,ASELLA,ETHIOPIA,
SOUTH EAST AFRICA.

2. INTRODUCTION
To provide appropriate nursing care to a
patient, the nurse must know how the
patient’s body is physiologically
responding.

3. One of the basic ways to determine
this is to assess the patient’s vital
signs.

4. We will learn not only how to assess vital
signs but how to relate them to vital
physiological functions of the body.

5. We will learn the implications of
abnormal readings and the
appropriate nursing care to provide.

6. THE SIX VITAL SIGNS

7. Vital signs, the fundamental
measurement of life signs, include
five objective measurements and
a sixth subjective measurement.

8.  The five objective measurements
include:
1. Blood pressure (BP)
2. Temperature (T)
3. Pulse (P)

9. 4. Respirations (R)
5. Oxygen saturation (SpO2)
The sixth vital sign is the subjective
measurement:
6. Pain

10. The five objective vital signs tell how
certain systems are
functioning,
provide data regarding the patient’s
overall condition,
and provide a baseline against which
you can measure even some changes in
vital signs.

11. Although subjective, the assessment of pain
is important because this feeling of distress
can have effects on
blood pressure,
pulse, and respirations,
and it serves as a warning that tissues are
actually being injured or about to be injured.

12. GENERAL GUIDELINES FOR
ASSESSMENT OF VITAL SIGNS
INCLUDE:

13. Using the appropriate equipment for
each patient, such as using a child’s BP
cuff for a child or a large adult cuff for an
obese patient.
 Being familiar with normal ranges for
different ages.

14. Always comparing vital signs with
previous vital sign ranges for that
specific patient.

15. Knowing the patient’s medical history,
medications, and therapies, because
sometimes they can have predictable
effects on vital signs.

16. Understanding and interpreting the vital
sign findings.
Recording and communicating significant
vital sign changes to the physician as
well as to the nurse on the next shift.

17. Minimizing environmental effects on vital
signs, such as waiting 15 to 30 minutes
after the patient has a cold drink to
assess oral temperature.

18. BLOOD PRESSURE

19. Blood pressure is the measurement of
the pressure or tension of the blood
pushing against the walls of the arteries
in the vascular system.

24. The amount of pressure is determined
by a combination of the following four
circulatory qualities:
1. Strength of the heart contraction, or
pumping action of the heart

25. 2. Blood viscosity, or thickness
3. Blood volume
4. Peripheral vascular resistance, or
elastic recoil ability of the blood vessel
walls

26. The stronger the contraction of the heart,
the greater the volume of blood pumped
out of the heart into the arteries.
The amount of blood ejected from the
heart in one contraction is known as the
stroke volume.

27. The volume of blood pumped from the
heart in a full minute is termed the
cardiac output.
The greater the cardiac output, the
higher the blood pressure will be.
Conversely, the lower the cardiac
output, the lower the pressure will be.

28. When the heart contraction is weaker or
the blood volume is decreased, such as
in cases of dehydration or hemorrhage,
the blood pressure will decrease.

29. Some conditions that decrease the
heart’s contraction strength include
congestive heart failure and myocardial
infarction ( heart attack), which damage
the heart muscle, rendering the
contraction of the muscle weaker.

30. Pregnancy, on the other hand,
increases the blood volume, and when
there is a higher fluid volume within the
vascular system, BP will naturally rise.

31. During exercise, the heart beats faster in
an effort to help meet the increased
demand for oxygen and as a result
raises BP.
When the arterial walls are non elastic
or constricted, the blood pressure will
increase.

32. An example of this is arteriosclerosis,
otherwise known as hardening of the
arteries, which is a gradual process that
happens to everyone as they progress
through the life span.

33. FACTORS AFFECTING
BLOOD PRESSURE

34. The patient with a family history of
hypertension (elevated blood pressure) or
other circulatory system problems is more
likely to develop hypertension than is the
patient who does not have a family history of
circulatory problems.
Diseases such as diabetes and kidney
disease also can affect BP.

35. Other factors that affect a person’s blood
pressure include:
• Age: The average systolic pressure in
newborns is around 40 mm Hg.
BP gradually increases throughout the
life span.

36. • Race: Hypertension tends to have a
higher incidence in African Americans,
especially males.
• Exertion or exercise: Both cause the
heart rate and cardiac output to go up,
which then raises the BP.

37. Rest: When a person is at rest, the
parasympathetic system is stimulated and lowers
the BP.
• Circadian rhythm: BP naturally lowers during
sleep, increases with waking until peak is reached
in the afternoon, and begins to lower during the
evening.

38. • Anxiety, stress, and emotions: These
factors stimulate the sympathetic
nervous system, raising BP.

39. Medications: These agents can directly
or indirectly lower or raise BP; includes
herbs and prescription, over-the counter,
drugs.
• Nicotine and caffeine: Nicotine can
raise BP long term, while caffeine only
raises BP for a short interval.

40. Obesity: BP is higher in some
overweight and obese individuals.
• Level of hydration: Dehydration, which
leads to volume loss, tends to lower BP;
overhydration, which leads to volume
increase, tends to raise BP.

41. • Hemorrhage: Loss of volume lowers
BP.
• Increased intracranial pressure: This
condition raises BP.

42. COMPONENTS OF A BLOOD
PRESSURE READING

43. The measurement of BP involves assessment
of two values:
1. Systolic pressure, which is the
measurement of the force exerted by the
blood against the walls of arteries during
contraction of the heart ventricles.

44. This time during which the ventricles
are contracted is known as systole
and is the time when the pressure is
the highest.

45. SPHYGMOMANOMETER

47. 2. Diastolic pressure, which is the
measurement of the pressure exerted by
the blood on the artery walls while the
heart ventricles are not contracting.

48. This is the lower of the two pressures.
The time during which the ventricles are
at rest is known as diastole.

49. Blood pressure is measured in
millimeters of mercury (mm Hg) and is
written as a fraction.
If the systolic pressure is 120 mm Hg
and the diastolic pressure is 72 mm Hg,
the blood pressure is written as 120/72
mm Hg, or just120/72.

50. The systolic pressure will always be the
highest reading and is documented as
the top number of the fraction, with the
diastolic pressure written as the bottom
number.

51. Pulse pressure is the measurement of
the difference between the systolic and
diastolic pressures (subtract the smaller
number, the diastolic, from the larger
number, the systolic) and normally is
between 30 and 50 points.


52. A pulse pressure less than 30 or greater
than 50 is considered abnormal.

53. An example of a normal pulse pressure
of 40 is seen in a blood pressure of
112/72 mm Hg.

54. The normal range for adult blood
pressure is between 90/60 and 120/80
mm Hg.
When the systolic pressure rises above
120, it is considered to be
prehypertension.

56. Hypertension is the term used to
describe a systolic reading consistently
above 140 or a diastolic reading
consistently over 90.

57. To make the medical diagnosis of
hypertension, the elevation must be
documented on at least two or more
separate occasions.

58. BLOOD PRESSURE EQUIPMENT

59. BLOOD PRESSURE EQUIPMENT
Blood pressure is assessed using a
stethoscope and a BP cuff, otherwise known
as a sphygmomanometer.

60. SPHYGMOMANOMETER
The aneroid sphygmomanometer consists of
an inflatable rubber bladder that holds air,
a cloth cuff that covers the bladder and is long
enough to wrap around the extremity,

61. RUBBER TUBING
Rubber tubing from the bladder to the gauge
to indicate the pressure, and rubber tubing
from the air bladder to a bulb that is used to
pump up the air bladder.

62. SCREW VALVE
A screw valve that is attached proximally to
the squeezable bulb allows you to fill and
empty the air from the bladder as you
observe the pressure manometer.

63. The aneroid gauge must be calibrated every
6 months to remain accurate, so make
certain the needle is on zero before using a
cuff.

64. An electronic sphygmomanometer has a
transducer that uses sound waves to
determine the pressure and a digital gauge
to provide the readout, and it automatically
inflates and deflates.

65. There is neither a squeezable bulb nor a
need for a stethoscope when using an
electronic cuff.

66. The sphygmomanometer may be mounted on
the wall above the patient’s bed or on an
automatic vital sign machine.

67. It also is available as a smaller, portable cuff
unit.
It provides additional information regarding
automatic vital sign machines.

68. The cuffs also come in different sizes, and the
correct size must be used to accurately
assess the blood pressure.

69. If the cuff is too large the reading will be
erroneously low, and if it is too small the
reading will be erroneously high.

70. The width of the blood pressure cuff should
cover approximately two thirds of the upper
arm.

71. STETHOSCOPE
A stethoscope has a sound-transmitting chest
piece consisting of a bell and a diaphragm,
which attaches to rubber tubing that leads to
two hollow metal tubes (binaurals) with
earpieces attached to the ends.

72. The earpieces are placed in the ears
corresponding to the angle of the ear canals
and should
point toward the face when the stethoscope is
in place.
 The chest piece is placed against the
patient’s skin.

73. The bell is used to auscultate the lower-
pitched sounds, such as the heart sounds,
and other low-frequency sounds ,

74. while the larger flat side, known as the
diaphragm, is used to auscultate higher-
pitched sounds, such as the lung sounds,
bowel sounds, and usually BP.

75. Sometimes heart sounds may be better heard
using the diaphragm. Note that some
stethoscopes

76. Do not have a bell, thus requiring that the
diaphragm be used, with lighter pressure for
lower-pitched sounds and more pressure for
higher-pitched sounds.

77. ASSESSMENT SITES

78. Blood pressure is normally assessed with
the cuff around the upper arm and the
stethoscope over the brachial artery at the
antecubital site, on the inner aspect of the
elbow.

79.  It also can be performed by wrapping the
cuff around the lower arm and placing the
stethoscope over the radial pulse.
However, certain conditions prevent you from
using these sites, including:
• Amputation of the arm

80. Mastectomy on the selected side
Presence of a shunt for renal dialysis on
the selected side.
Casts, braces, or dressings on the selected
side.

81. Recent vascular surgery or trauma on the
selected side.
 In some cases, the presence of an IV
infusion on the selected side.

82. When conditions prevent you from assessing
BP on either arm, it can be measured on the
leg by wrapping the correct-size cuff around
the midthigh ,

83. with the cuff bladder on the posterior aspect
of the thigh and the tubing exiting the cuff
distally (toward the knee), and placing the
stethoscope over the popliteal artery behind
the knee.

84. The systolic pressure may register 10 to 40
mm Hg higher in the leg than in the arm, but
the diastolic pressure should be about the
same.

85. KOROTKOFF’S SOUNDS

86. Upon inflation of the cuff and accompanying
compression of the artery, the flow of blood is
not audible with a stethoscope.

87. As you begin to deflate the cuff and allow
the return of blood flow, you will hear the
tapping sounds representing this blood
flow.

88. These are known as Korotkoff’s sounds,
named after the Russian physician who first
described the sounds heard over an artery
during cuff deflation.

89. There are five Korotkoff’s sounds:
• First sound: clear, rhythmic tapping sound
gradually increasing in intensity.
• Second sound: soft, swishing or murmuring
sound representing turbulent blood flow.

90. Third sound: sharper, crisper rhythmic sound
• Fourth sound: softening or muffling of
rhythmic sound
• Fifth sound: silence

91. You may or may not hear all five of the
sounds that represent different stages of
returning blood flow, but the first sound heard
is documented as the systolic pressure and
the point at which you last hear any sound is
documented as the diastolic pressure.

92. MEASUREMENT OF BLOOD PRESSURE

93. MEASUREMENT OF BLOOD PRESSURE
After selecting the site for assessment and
determining the correct size cuff, bare the arm,
and wrap the cuff around the extremity about 1
to 2 inches above the auscultation site for your
stethoscope.

94. While palpating the arterial pulse distal to the
cuff, close the screw valve and squeeze the
bulb to rapidly pump the inflatable cuff up to
70 mm Hg for an adult.

95. Now continue to slowly pump the pressure up
about 10 mm Hg at a time, until you can no
longer feel the pulse, noting the point at
which you lose the pulse.

96. Then deflate the cuff and wait 15 to 30
seconds.
Place your stethoscope over the arterial
pulse and keep the chest piece of the
stethoscope flat against the bare skin.

97. Pump the cuff up to approximately 30 mm Hg
above where you last felt the pulse.

98. For example, if you last felt the pulse at 116
mm Hg, pump the cuff up to 146 mm Hg.
It is uncomfortable for the patient and may
cause erroneous readings to pump the
pressure up to 180 or 200 mm Hg when
pressure is not that high.

99. Slowly unscrew the valve to release air from
the cuff bladder at 2 to 3 mm Hg per second,
while listening for Korotkoff’s sounds.

100. Record the number at which you hear the first
Korotkoff sound and the number at which you
hear the last sound.

101. Write it as a fraction, such as 118/76.
 If you hear the sounds all the way to zero on
the manometer, record the number at which
the sound decreased in amplitude as well as
the zero, such as 126/74/0.

102. AUSCULTATORY GAP

103. When assessing the blood pressure in some
patients with hypertension, you may hear a
20 to 30 mm Hg “gap” in the Korotkoff
sounds.

104. For example, you may hear the first Korotkoff
sound beginning at 162 mm Hg and then
hear nothing but silence as the needle drops
to 138 mm Hg, at which the Korotkoff sounds
return and continue until you lose them for
good at 74 mm Hg.

105. This silence and the return of sounds is
known as an auscultatory gap.
If you do not adequately inflate the cuff while
palpating, this gap can be missed and an
erroneously low blood pressure reading
recorded.

106. An error of this nature might result in failure
to identify an elevated blood pressure that
requires treatment.

107. Use caution to palpate carefully and then
inflate to 30 mm Hg above that point. If an
auscultatory gap is detected, record the
number at which it began and ended, for
example: BP – 162/74 with auscultatory gap
162 to 138.

108. THANKING YOU