23. Vital Signs Blood Pressure Hypotensive or Hypertensive Heart Rate Bradycardia or Tachycardia Respiratory Rate Bradypneic or Tachypneic O 2 Saturation Hypoxia/Hypoxemia
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33. Ausculatory BP Measurement External pressure is applied to a superficial artery (most commonly the brachial). The stethoscope, or a Doppler device,is placed over the artery and the pressure is assessed by listening for the 5 phases of sounds a.k.a. Korotkoff’s sounds
35. Palpatory BP Measurement Used when Korotkoff’s sounds cannot be heard and electronic equipment to amplify the sound (i.e. doppler) is not available The pulses are palpated, instead of auscultated The first palpation is the SBP DBP is not able to be assessed
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39. Heart Rate Pulse is the term used to describe rate, rhythm, and volume of the heartbeat A pulse is produced by ventricular contraction which creates a wave of blood through the arteries The pulse reflects the heartbeat (Kozier et al, 2002, p. 23)
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41. Heart Rate & Blood Pressure Blood pressure is directly affected by the heart rate Heart rate is directly affected by blood pressure What does this mean…?
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44. Respiratory Rate Respiratory rate is calculated by counting the number of inspirations/respirations per minute Normal range is 15 – 20 bpm Depth & Rhythm (pattern) (Kozier et al, 2002)
45. Breathing Rates Eupnea – normal RR that is quiet, rhythmic, and effortless Tachypnea – rapid respirations, marked by shallow breaths (> 20 per minute) Bradypnea – abnormally slow breathing (< 8 per minute) Apnea – cessation of breathing (Kozier et al, 2002, p. 31)
46. Breathing Rates Cheyne-Stoke – Fast, deep respirations of 30 – 170 seconds punctuated by periods of apnea lasting 20 – 60 seconds Kussmaul’s – fast (over 20 per minute), deep (resembling sighs), labored respirations without a pause (Goldberg et al, 1997, p. 764)
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48. Oxygen Saturation Normal = 95% - 100% Below 70% is life threatening Pulse oximeter - measures arterial blood oxygen saturation Can detect hypoxemia before clinical signs & symptoms are apparent (Kozier et al, 2002)
62. Edema 4-Point Scale Greater than 1-inch Severe 4+ ½- to 1-inch Moderate 3+ ¼- to ½-inch Mild 2+ Up to ¼-inch Trace 1+ N/A None 0 Depth of Indentation Description Grade
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64. Pulse 4-Point Scale Increased pulse; moderate pressure for obliteration 3 + Full, bounding; cannot obliterate 4 + Normal, easily identified; not easily obliterated 2 + Palpable, but thready and weak; easily obliterated 1 + Absent 0 Description Grade
78. Grading Murmurs Murmur is exceptionally loud, with palpable thrill, and can be heard with the stethoscope just removed from contact with the chest. Grade 6 Murmur is extremely loud, with palpable thrill, and can be heard if only the edge of the stethoscope is in contact with the skin, but cannot be heard if the stethoscope is removed from the skin Grade 5 Murmur is very loud, with palpable thrill Grade 4 Moderately loud Grade 3 Quiet, but heard immediately after placing the stethoscope on the chest Grade 2 Very faint, heard only after listener has "tuned in"; may not be heard in all positions Grade 1 Description Gradation of Murmurs
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Editor's Notes
Thorough cardiac assessment Head – to – Toe Fashion
Blood pressure tells us about adequate perfusion B/P that is too low can cause poor perfusion SBP < 90 is considered unstable if symptomatic Elevated B/P can cause problems such as stroke Different factors cause elevations in B/P Pulse Too low or too high can cause poor perfusion Different factors cause elevations in pulse rates RR -elevated RR’s can indicate compensation for a cardiac problem 02 sat -low O2 sat’s may reflect poor perfusion or other cardiac disorders
Brief synopsis of a head – to – toe cardiac assessment tool Identifies key assessment findings that could indicate cardiac problems
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