fundamentals of nursing

1. 1
Fundamental of Nursing
Vital Signs
Respiratory rate & Blood Pressure
Dr. mosa alfageh

2. After completing this lecture, each student will be able to:
 Define respiration
 Describe the mechanics of breathing and the mechanisms that control respirations
 List the factors that influence the body respiration
 List the characteristics that should be included when assessing respiration
 Define blood pressure
 Understand the alteration in blood pressure
 List the factors that influence the blood pressure
 Identify the sites used to assess the blood pressure
2

3. 3

4.  Respiration is the act of breathing. (is the process by which the lungs bring oxygen
into the body and remove carbon dioxide)
Inhalation or inspiration refers to the intake of air into the lungs.
Exhalation or expiration refers to breathing out or the movement of gases from the
lungs to the atmosphere.
Ventilation is also used to refer to the movement of air in and out of the lungs.
4
There are basically two types of breathing:
 Costal (thoracic)breathing Costal breathing involves the external intercostal muscles
and other accessory muscles, such as the sternocleidomastoid muscles. It can be
observed by the movement of the chest upward and outward.
 Diaphragmatic (abdominal) breathing Diaphragmatic breathing involves the
contraction and relaxation of the diaphragm, and it is observed by the movement of
the abdomen, which occurs as a result of the diaphragm’s contraction and downward
movement.

5. Mechanics and regulation of
breathing
During inhalation, the
following processes normally
occur :
The diaphragm contracts
(flattens), the ribs move
upward and outward, and the
sternum moves outward, thus
enlarging the thorax and
permitting the lungs to
expand.
5

6. During exhalation: the
diaphragm relaxes, the ribs
move downward and inward,
and the sternum moves inward,
thus decreasing the size of the
thorax as the lungs are
compressed.
6
Mechanics and regulation of
breathing

7. Normal breath inspiration animation, awake
Diaghram contracts
Chest volume
Pleural pressure
Air moves down
pressure gradient
to fill lungs
-2cm H20
-7cm H20
Alveolar
pressure falls
Normal breath

8. Normal breath expiration animation, awake
Diaghram relaxes
Pleural /
Chest volume 
Pleural pressure
rises
Normal breath
Alveolar
pressure rises
Air moves down
pressure gradient
out of lungs

10. Time
volume
0
-1
-2
-5
Pressure
Expiration
Inspiration
+3
+2
+1
Normal breath

11.  Normal breathing is automatic and effortless. A normal adult inspiration lasts 1 to
1.5 seconds, and an expiration lasts 2 to 3 seconds.
 Respiration is controlled by Respiratory centers in the medulla oblongata and the
pons of the brain
 Chemoreceptors located centrally in the medulla and peripherally in the carotid and
aortic bodies. These centers and receptors respond to changes in the concentrations
of oxygen (O2), carbon dioxide (CO2), and hydrogen (H+) in the arterial blood
11
Mechanics and regulation of breathing

12. Assessing respirations
 Resting respirations should be assessed when the client is relaxed because exercise
affects respirations, increasing their rate and depth.
 Anxiety is likely to affect respiratory rate and depth as well.
12
Before assessing a client’s respirations, a nurse should be aware of the following :
• The client’s normal breathing pattern
• The influence of the client’s health problems on respirations
• Any medications or therapies that might affect respirations
• The relationship of the client’s respirations to cardiovascular function.

13. Assessing respirations
 The rate, depth, rhythm, quality, and effectiveness of respirations should be
assessed.
 The respiratory rate is normally described in breaths per minute.
 Breathing that is normal in rate and depth is called eupnea.
 Abnormally slow respirations are referred to as bradypnea
 Abnormally fast respirations are called tachypnea
 Apnea is the absence of breathing.
13
The depth
 The depth of a person’s respirations can be established by watching the movement
of the chest.
 Respiratory depth is generally described as normal, deep, or shallow.
Deep respirations are those in which a large volume of air is inhaled and exhaled,
inflating most of the lungs.
Shallow respirations involve the exchange of a small volume of air and often the
minimal use of lung tissue.
 During a normal inspiration and expiration, an adult takes in about 500 mL of air.
This volume is called the tidal volume.
 Hyperventilation refers to very deep, rapid respirations.
 Hypoventilation refers to very shallow respirations.

14. Assessing respirations
Respiratory rhythm
Respiratory rhythm refers to the regularity of the expirations and the inspirations.
Normally, respirations are evenly spaced.
 Respiratory rhythm can be described as regular or irregular.
 An infant’s respiratory rhythm may be less regular than an adult’s
14
Respiratory quality or character
refers to those aspects of breathing that are different from normal, effortless breathing.
 Two of these aspects are The amount of effort a client must exert to breathe
 The sound of breathing.
 Usually, breathing does not require noticeable effort.
 Sometimes, however, clients can breathe only with substantial effort—this is
referred to as labored breathing.
 The sound of breathing is also significant. Normal breathing is silent, but a number
of abnormal sounds such as a wheeze are obvious to the nurse’s ear.
 Many sounds occur as a result of the presence of fluid in the lungs and are most
clearly heard with a stethoscope.

15. Definitions
 Eupnea ; breathing normal in rate and depth (12-20 breath /min)
 Bradypnea ; rate of breathing is regular but abnormally slow (less than
10 breath/min)
 Apnea respirations cease for several seconds . Persistent cessation
results in cardiac arrest
 Kussmaul’s respirations ;respirations that are regular but abnormally
deep and increase in rate . It is associated with DKA(DIABETIC
KETOACIDOSIS)
 Dyspnea; the term for difficult or painful breathing
 Orthopnea ; when the difficulty is so marked that the client can
breathe only when in an upright position
 Cyanosis; (bluish tinge); especially in the lips (circumoral cyanosis)
and mucus membranes of the mouth . In severe conditions , cyanosis
spreads to the nails and extremities . An excess of carbon dioxide
causes the bluish tinge
15

16. 16

17. 17

18. Factors affecting respirations
 Exercise (increases metabolism),
Exercise increases rate and depth to meet the body's need for additional oxygen and to
rid the co2
 Acute pain
Pain alters rate and rhythm of respirations ; breathing becomes shallow
Patient inhibits or splints chest wall movement when pain is in area of chest or
abdomen
 Anxiety
Anxiety increases respiration rate and depth
18
 Smoking
Chronic smoking changes pulmonary airways, resulting in increased rate of respirations
at rest when not smoking
Body position
 A straight , erect posture promotes full chest expansion
 Lying flat prevents full chest expansion

19. Factors affecting respirations
19
 Medications
For example, narcotics such as morphine and large doses of barbiturates such as
pentobarbital depress the respiratory centers in the brain, thereby depressing the
respiratory rate and depth.
 Neurological injury
Injury to brainstem impairs respiratory center and inhibits respiratory rate and rhythm
 Hemoglobin functions
Decrease hemoglobin levels (anemia) reduce oxygen carrying capacity of the blood ,
which increase respiratory rate
Abnormal blood cell function (e.g sickle cell anemia) reduce ability of hemoglobin to
carry oxygen , which increase respiratory rate and depth

20. 20

21. Measurement of oxygen saturation (pulse oximetry)
 Assessment of Diffusion and Perfusion
 Evaluate the respiratory processes of diffusion and perfusion by measuring the
oxygen saturation of the blood.
 The percent of hemoglobin that is bound with oxygen in the arteries is the percent of
saturation of hemoglobin (or SaO2). It is usually between 95% and 100%.
21
 The saturation of venous blood (SVO2) is lower because the tissues have removed
some of the oxygen from the hemoglobin molecules. The usual value for Sv02,
which is 70%.
 Measurement of Arterial Oxygen Saturation.
 A pulse oximeter is a noninvasive device that estimates a client's arterial blood
oxygen saturation (SaO2) by means of a sensor attached to the client's finger, toe,
nose, earlobe, or forehead (or around the hand or foot of a neonate).
 The pulse oximeter can detect hypoxemia (low oxygen saturation) before clinical
signs and symptoms, such as a dusky color to skin and nail beds develop.
 Normal oxygen saturation is 95% to 100%, and below 70% is life threatening.

22. 22
(pulse oximetry)
(pulse oximetry)

23. 23

24. Blood pressure
Arterial blood pressure is a measure of the pressure exerted by the blood as it flows
through the arteries.
Because the blood moves in waves, there are two blood pressure measurements.
The systolic pressure is the pressure of the blood as a result of contraction of the
ventricles, that is, the pressure of the height of the blood wave.
The diastolic pressure is the pressure when the ventricles are at rest.
Diastolic pressure ;is the lower pressure, present at all times within the arteries.
 The difference between the diastolic and the systolic pressures is called the pulse
pressure.
 A normal pulse pressure is about 40 mmHg but can be as high as 100 mmHg
during exercise
24
 Blood pressure is measured in millimeters of mercury (mmHg) and recorded as a
fraction: systolic pressure over the diastolic pressure.
 A typical blood pressure for a healthy adult is 120/80 mmHg (pulse pressure of 40).
 Sometimes, it is useful to determine the mean arterial pressure (MAP) because this
represents the pressure actually delivered to the body’s organs.
 A normal MAP is 70 to 110 mmHg.

25. Determinants of blood pressure
Arterial blood pressure is the result of several factors:
1. The pumping action of the heart
2. The peripheral vascular resistance (the resistance supplied by the blood vessels through which the
blood flows)
3. The blood volume and viscosity.
PUMPING ACTION OF THE HEART
 When the pumping action of the heart is weak, less blood is pumped into arteries (lower cardiac
output), and the blood pressure decreases.
 When the heart’s pumping action is strong and the volume of blood pumped into the circulation
increases (higher cardiac output), the blood pressure increases.
25
PERIPHERAL VASCULAR RESISTANCE
 Peripheral resistance can increase blood pressure. The diastolic pressure especially is affected.
 Some factors that create resistance in the arterial system are the capacity of the arterioles and
capillaries, the compliance of the arteries, and the viscosity of the blood.
 The internal diameter or capacity of the arterioles and the capillaries determines in great part the
peripheral resistance to the blood in the body.
The smaller the space within a vessel, the greater the resistance.
Normally, the arterioles are in a state of partial constriction.
Increased vasoconstriction, such as occurs with smoking, raises the blood pressure, whereas
decreased vasoconstriction lowers the blood pressure.

26. Determinants of blood pressure
BLOOD VOLUME
When the blood volume decreases (for example, as a result of a hemorrhage or
dehydration), the blood pressure decreases because of decreased fluid in the arteries.
 Conversely, when the volume increases (for example, as a result of a rapid
intravenous infusion), the blood pressure increases because of the greater fluid
volume within the circulatory system.
BLOOD VISCOSITY
 Blood pressure is higher when the blood is highly viscous (thick), that is, when the
proportion of red blood cells to the blood plasma is high.
 This proportion is referred to as the hematocrit. The viscosity increases markedly
when the hematocrit is more than 60% to 65%.
26

27. Factors affecting blood pressure
1. Age
2. Exercise
3. Stress
4. Race
5. Gender
6. Medications
7. Obesity
8. Diurnal variations
9. Medical conditions
10. Temperature
27

28. 1.Age
Newborns have a systolic pressure of about 75 mmHg. The pressure rises with age,
2.Exercise.
Physical activity increases the cardiac output and hence the blood pressure. For reliable assessment of
resting blood pressure, wait 20 to 30 minutes following exercise.
3.Stress.
Stimulation of the sympathetic nervous system increases cardiac output and vasoconstriction of the
arterioles, thus increasing the blood pressure reading; however, severe pain can decrease blood
pressure greatly by inhibiting the vasomotor center and producing vasodilation.
4. Race.
African Americans older than 35 years tend to have higher blood pressures than European Americans
of the same age although the exact reasons for these differences are unclear
5.Sex.
After puberty, females usually have lower blood pressures than males of the same age; this difference
is thought to be due to hormonal variations. After menopause, women generally have higher blood
pressures than before. 28
Factors affecting blood pressure

29. 6.Medications.
Many medications, including caffeine, may increase or decrease the blood pressure.
7.Obesity.
Both childhood and adult obesity predispose to hypertension.
8.Diurnal variations.
Pressure is usually lowest early in the morning, when the metabolic rate is lowest, then rises
throughout the day and peaks in the late afternoon or early evening.
9.Medical conditions.
Any condition affecting the cardiac output, blood volume, blood viscosity, and/or compliance of
the arteries has a direct effect on the blood pressure.
10.Temperature.
Because of increased metabolic rate, fever can increase blood pressure. However, external heat
causes vasodilation and decreased blood pressure. Cold causes vasoconstriction and elevates
blood pressure.
29
Factors affecting blood pressure

30. Hypertension
A blood pressure that is persistently above normal is called hypertension.
 A single elevated blood pressure reading indicates the need for reassessment.
 Hypertension cannot be diagnosed unless an elevated blood pressure is found when
measured twice at different times.
 An elevated blood pressure of unknown cause is called primary hypertension.
 An elevated blood pressure of known cause is called secondary hypertension
Individuals with diastolic blood pressures of 80 to 89 mmHg or systolic blood pressures
of 120 to 139 mmHg should be considered prehypertensive and, without intervention,
may develop cardiac disease.
 Hypertension is when either the systolic BP is higher than 140 mmHg or when the
diastolic blood pressure (BP) is 90 mmHg or higher.
30

31. 31

32. hypotension
 Hypotension is a blood pressure that is below normal
 Orthostatic hypotension is a blood pressure that decreases
when the client sits or stands.
 Hypotension can also be caused by analgesics ,bleeding, severe
burns, and dehydration.
32

33. Method of measure B.P
Blood pressure can be assessed directly or indirectly..
 Direct (invasive monitoring) measurement involves the insertion of a catheter into the
brachial, radial, or femoral artery. Arterial pressure is represented as wavelike forms
displayed on a monitor. With correct placement, this pressure reading is highly accurate.
 Noninvasive indirect methods of measuring blood pressure are the auscultatory and
palpatory methods)
33
Noninvasive indirect
Manual sphygmomanometers :
- Mercury and aneroid sphygmomanometer
need to listen for the sounds of the client’s systolic and diastolic blood pressures through a
stethoscope.
Automated sphygmomanometers : Electronic blood pressure devices should be calibrated
periodically to check accuracy.
- Use in hospitals
- Self measurement
- AMBP (ambulatory blood pressure)measurement
- Measurement in community settings

34. THE PROPER NAME FOR A BLOOD PRESSURE CUFF IS
SPHYGMOMANOMETER
MERCURY
ANEROID

36. The ambulatory blood pressure monitoring
(ABPM)

37. Assessing B.P
BLOOD PRESSURE ASSESSMENT
SITES
 The blood pressure is usually assessed in
the client’s upper arm using the brachial
artery and a standard stethoscope.
 Assessing the blood pressure on a client’s
thigh is indicated in these situations :
The blood pressure cannot be measured on
either arm (e.g., because of burns or other
trauma).
37
 Brachial – taken on the upper arm; most common site.
 Radial – taken on the lower arm; possible site for infants or
clients who have very large upper arms.
 Popliteal – taken on the thigh.
 Dorsalis pedis and posterior tibial – taken on the lower leg.

38. BLOOD PRESSURE ASSESSMENT SITES
 Systolic pressure in the legs is usually higher by 10 to 40 mm Hg (20mmhg) than in the brachial artery, but the
diastolic pressure is the same.
Contraindications to assesse in the client’s upper arm using the brachial artery
1. The brachial artery should not be used to measure blood pressure in those with
arteriovenous fistulas (e.g., for renal dialysis).,
2. Patients who have had trauma to the upper arm, previous mastectomy or a
forearm amputation should not have blood pressure measured on the affected side
at the brachial artery.
3. Blood pressure should not be measured on an arm that has had brachial artery
surgery or is at risk of lymphoedema or burn.
4. The client has an intravenous infusion or blood transfusion in that limb.
38

39. Accurate blood pressure measurement
I. Patient
II. Equipment
III. Technique

40. I. Patient - Posture
¤ Patient seated , back
supported, arm bared
at heart level
¤ Five minutes rest
Blood pressure measurement
• Sitting position
• Arm and back are supported.
• Feet should be resting firmly on the
floor
• Feet not dangling.
Position of the arm
• Raise patient arm so that the brachial artery
is roughly at the same height as the heart. If
the arm is held too high, the reading will be
artifactually lowered, and vice versa.

41. I. Patient - Posture

43. I. Patient - Posture

44. I. Patient - Arm

45. I. Patient - Arm

46. Popliteal BP +20 mmHg

47. I. Patient - Circumstances
¤ Quiet , warm room
¤ No caffeine, smoking, 30 minutes.
¤ No talking
Blood pressure measurement

48. II. Equipment
Blood pressure measurement
Blood pressure is measured with
• a blood pressure cuff,
• a sphygmomanometer, and
• a stethoscope.
The blood pressure cuff consists of
bag, called a bladder, that can be
inflated with air

49.  Blood pressure cuffs come in various
sizes because the bladder must be the
correct width and length for the client’s
arm
 The arm circumference, not the age of
the client, should always be used to
determine bladder size.
 If the bladder is too narrow, the blood
pressure reading will be erroneously
elevated; if it is too wide, the reading
will be erroneously low
49
II. Equipment

50.  The width should be 40% of the circumference,
or 20% wider than the diameter of the midpoint,
of the limb on which it is used.
 The length of the bladder also affects the
accuracy of measurement.
 The bladder should be sufficiently long to cover
at least two-thirds of the limb’s circumference.
50

53. • Non - invasive

54. • Cuff size
• Cuff size

55. II. Equipment
Blood pressure measurement
Calibration
Calibration

56. III. Technique
• Korotkoff Sound no 5 (disappear of sound=DBP)
• Both arms: (if peripheral arterial disease)
• Standing BP: in elderly & diabetic(orthostatic HTN.)
• Cuff at heart level (whatever patient’s position)
Blood pressure measurement

57.  When taking a blood pressure using a stethoscope,
the nurse identifies phases in the series of sounds
called Korotkoff’s sounds
 Five phases occur but may not always be audible .
The systolic pressure is the point where the first tapping
sound is heard (phase 1).
the diastolic pressure is the point where the sounds
become inaudible (phase 5).
57
Assessing B.P

58. 200
180
160
140
120
100
80
60
40
20
0
No sound
Clear sound
Clear sound
Muffled sound
No sound
Phase 1
Phase 3
Phase 4
Phase 5
Muffling Phase 2
Auscultatory
gap
No sound
mmHg
Korotkoff sounds
Systolic BP
Phase 3
Phase 4
Diastolic BP

60. BP Measurement Definitions
BP Measurement Definition
SBP First Korotkoff sound*
DBP Fifth Korotkoff sound*
Pulse pressure SBP minus DBP
Mean arterial pressure
BP (blood pressure)
DBP, (diastolic blood pressure)
SBP,( systolic blood pressure).

61. What is
auscultatory
gap?
61

62. 62

63. Recording vital signs
 Special electronic and paper graphic flow sheets exist for recording vital
signs.
 Record vital sign and site assessed on vital sign.
 Record in the nurses' notes any accompanying or precipitating symptoms
such as chest pain and dizziness with abnormal BP, shortness of breath with
abnormal respirations, cyanosis with hypoxemia, or flushing and diaphoresis
with elevated temperature.
 Document any interventions initiated as a result of vital sign measurement
such as administration of oxygen therapy, hydration, or an antihypertensive
63

64. V.S chart
64