Definition: The Nursing Process is a systematic, organized, rational

method of planning and providing individualized, humanistic nursing care

A scientific problem-solving approach Individualize dynamic continuing interpersonal

care Clients changing response & needs

To identify health statusActual health problemsPotential health problems

To establish plans

To deliver specific nursing care

Goal-oriented and client-centered

Cyclical (no absolute beginning and end), dynamic (moving) rather than static

Plan of care organized according to client problems rather than nursing goals

Basis of prioritizing nursing activities would be the problems and not the goals

Follows a logical sequence

Universally applicable (to any type of patient)

Interpersonal and collaborative Work with patients and relatives Work with colleagues and other

members of the health team

Adaptation of problem-solving techniques and principles

Problem-oriented, flexible, open to new information

Allows creativity of nurse and patient

CLIENTCENTERED

Evaluation

Implementat

ion

Plan

ning

Outcome Identifica

tion

Diagnosis

Assessment

Concepts:

Both the nurse and the patient benefit from the nursing process

Patient obtains greater benefit

Remember: Nursing process is CLIENT-CENTERED or

PATIENT-CENTERED and NOT NURSE-CENTERED

Improves quality of care

Ensures continuity and appropriate level of care

Facilitates client participation through planning with patient

Enables nurse to maximize resources

Feedback allows nurse to evaluate care

Serves as a framework for accountability through documentation

Promotes a positive working atmosphere through collaboration

Helps the nurse define roles to those outside the profession

For job satisfaction

Facilitates professional growth

Avoidance of legal action

Meeting standards of accredited hospitals

Assessment Phase

Diagnosing Phase

Planning Phase

Intervention Phase

Evaluation Phase

Assessment Phase Observation Interview/Interaction Examination / Measurement

S : “ Masakit Tiyan ko”

O: w/ facial grimace - febrile w/ temp 37.9’C, BP 130/90

mmHg, RR of 25 cpm, PR 86beats/min- pain scale of 6/10 which is moderate

- crushing pain every movement at RUQ

- w/ guarding behavior - irritable and uncooperative - w/ nausea & vomiting, non cylic, dry - w/ body weakness and fatigue

Systematic format Comprehensive/multifocal Used variety of sources Use appropriate methods Verify data Updated Recorded/comminicated

Diagnosis (Prioritize Problem) Analysis

Problem Identification

Acute Pain related to prostaglandin synthesis as manifested by verbal report, pain scale of 6/10 which moderate and guarding behavior.

Alternation in comfort related to pain as manifested by guarding behavior, facial grimacing, irritable & verbal reports

Data categorizedCues clustered to patternStandard compared with

patternHealth concerns &

strengths identifiedEtiological relationships

are proposedNursing Diagnosis stated

NANDA – dianostic system is organized around nine human responses patterns: exchanging, communicating, relating, valuing, choosing, moving, perceiving, knowing & feeling.

Based on clinical judgment of nurseActual Nursing Diagnosis – review of

validated dataRisk Nursing Diagnosis – client’s degree of

vulnerability to development of specific problem

Wellness Nursing Diagnosis – transitioning from a specific level to higher level of wellness

Syndrome Nursing Diagnosis – cluster of actual or high-risk diagnosis that are predicted to be present because of a certain situation

Planning Setting priorities Establishing goals Planning intervention

After end of the shift, the patient will be able to verbalize decrease of pain from 6 to 1 which is moderate to mild and verbalizes comfort.

Actual/imminent life threatening prioritized

Client involvedGoals are client focusedGoals are appropriate to diagnoseSMART objectivesOther member health team

involve

Implementation Validating Care plans Documenting care Continuing data collection

Nursing Care with Rationale Independent -positioning, Health teachings Dependent – medications, procedures Collaborative - diagnostic exam

Action consistent with plan

Skills performed competently

Performed in appropriate environment

Client safety protectedAction & responses

documented/communicated

Evaluation Re-assessment Comparison of client’s current status w/ expected outcome

The patient was able to :

a. Verbalize comfort by being calm and participative during conversation

b. Pain scale decreased from 6 to 1 which is moderate to mild

Planned & systematicClient’s current health status

compared with desired expected outcome

Recorded/communicated

S – Specific

M – Measurable

A – Attainable

R – Realistic

T – Time bound

Refers to the measurements of the client’s body Temperature (T), Pulse (P), Respiratory Rates (RR), and Blood Pressure (BP).

Are fundamentals to physical assessment (the first step in physical examination) to establish baseline values of the clients cardio respiratory activities.

The sequence of recording vital signs measurements in the nurses notes is T-P-R and BP.

On admission to health care agency to obtain baseline data

When a client has a change in health status or report symptoms such as chest pain or feeling of faint.

Before and after of surgery or an invasive procedure.

Before and after the admission of a medication the would affect the respiratory and cardiovascular.

Before and after any nursing intervention that could affect the vital sign (ambulation)

AGE In newborns thermoregulations and

the respiratory center are immature The newborns temperature fluctuates

with the environment, clothing must be adequate to maintain heat

In the elderly, the efficiency of thermoregulation is reduced by the physiological changes of aging, including loss of subcutaneous fat, decreased sweat gland activity, reduced metabolism, and poor vasomotor control.

The normal aging process causes changes in the elderly person’s respiratory functions.

Blood pressure varies throughout life. An adults blood pressure continues to increase with age

GENDER - Women usually experience greater temperature

fluctuations than men because of hormonal changes.

- Temperature variations occur during the menstrual cycle mainly in response to the progesterone level. As the progesterone level increases during ovulation, temperature gradually rises.

- Males in general have a higher blood pressure than do females of the same age.

RACE - Some ethic groups are more susceptible than

the others to hemodynamic alterations.- - According to the study, incidence of high

blood pressure is higher in African-American than Europeans Americans

LIFESTYLE - Lifestyle factors, such as cigarette smoking, can cause

chronic changes in the lungs as manifested by impaired ventilation.

- Stimulants such as caffeinated beverages and tobacco elevated heart rate.

MEDICATION - Some medication can directly or indirectly alter the pulse,

respiration, or blood pressure. - Digitalis preparation (cardiac glycosides) decrease the

pulse rate - Narcotic analgesics (pain medication) can depress the rate

and depth of respiration and lower the blood pressure

ENVIRONMENT

- Extremes in environment temp. Can affect a person’s body temp.

- Temperature and noise level can alter heart rate - Acid rain and industrialized areas are often associated

with a high occurrence of respiratory condition.

PAIN - With acute pain, sympathetic stimulation increases the

heart rate, which increases the cardiac output and vasoconstriction, causing an increased peripheral vascular resistance, these changes result in increased pulse and respiratory rates, depth of respiration and blood pressure.

- Chronic pain causes parasympathetic stimulation and decreases the pulse rate.

Reflects the balance between the heat produced and the heat lost from the body, measured in heat units called degrees.

Used to monitor for problems in thermoregulation.

Hypothalamic integrator is the center that controls the core temperature, is located in the preoptic area of the hypothalamus.

Simplified cartoon depicting thermoregulatory pathways. Peripheral thermoreceptors detect environmental and visceral temperatures and report these to the hypothalamus. Hypothalamic temperature receptors detect internal temperature. The thermoregulatory center initiates heat-loss or heat gain responses in peripheral organs

1. CORE TEMPERATURE Is the temperature of the deep tissues of

the body, such us the abdominal cavity and pelvic cavity.

2. SURFACE TEMPERATURE Is the temperature of the skin, the

subcutaneous tissue and fats.

Age Oral Rectal Axillary

Newborn - - 36.8OC

1 year old - - 36.8OC

5-8 years old 37OC - -

10 years old 37OC 37OC 36.5OC

Teen 37OC 37OC 36.5OC

Adult 37OC 37OC 36.5OC

Older adult (>70)

36OC - -

Glass thermometers

are called hallow cylinders with a liquid-filled (mercury) bulb at the base. The tube (the body or the stem) is calibrated in degrees, using the Celsius and Fahrenheit scale. Exposing the bulb to heat causes the mercury to expand and rise to a point on the scale. The mercury stabilizes at this point and does not fall unless is shaken vigorously.

a. oral thermometer- has a slender bulb

b. rectal thermometer- has a pear-shaped bulb

c. multi-use thermometer- has a blunt tip

Electronic Thermometers

Consists of a battery-powered display unit , a disposable plastic sheath covers the probe to prevent the transmission of infection. These thermometers provide reading in less than 60 seconds The electronic thermometer is ideally suited for use with the children because the sheath is unbreakable and the time necessary for accurate measurement is relatively short.

Tympanic Membrane Thermometer

is a portable, hand-held device resembling an otoscope that recharges using a battery pack. It records temperature through a sensor probe that is placed in the ear canal to detect infrared radiation from the eardrum. It is specially appropriate for infants over two months or very young children who may have difficulty remaining still while temperature is recorded using other methods. Recordings are obtained in seconds or less.

Disposable Paper Thermometerssingle-use thermometers are thin strips of chemically treated paper with raised dots that change color to reflect the temperature, usually in less than one minute. These thermometers are available in Celsius and Fahrenheit scales and are reported to be accurate.

Thermometer-Sensitive StripsCan be used to obtain general indication of body surface temperature. They are usually placed on the forehead or abdomen; the skin under the strip must be dry. After a specified length of time, the strip changes color. On one brand, a green ”N” indicates a normal temperature, a brown “N” indicates a transition phase, and a blue-green “F” indicates an elevated temperature

1. ORAL

Most common, accessible and convenient

The thermometer is placed in the right or left posterior sublingual pocket, bulb on either side of the frenulum.

The sublingual area has an abundant blood supply from the nearby carotid arteries and the central circulation of the heart

Contraindicated if client has been taking cold or hot fluids or smoking the nurse should wait for 30 minutes before taking the temperature orally to ensure that the temp of the mouth is not affected by the temp of the food fluid or warm smoke.

2. RECTAL SITES

Considered to be very accurate Contraindicated for client with myocardial infarction (can

produce vagal stimulation, which in turn can cause myocardial damage), for client who are undergoing rectal surgery, have a diarrhea of the rectum, a clothing disorder, or have significant hemorrhoids.

3. AXILLA

Preferred site for measuring temperature in newborns because it is accessible and offers no possibility of rectal perforation.

Commonly used site because it is the safest, even though least accurate method.

4. TYMPHANIC MEMBRANE

Readily accessible, very fast and reflects the core temperature

Has an abundant arterial blood supply

Temperature sensors applied directly to the tympanic membrane

can be uncomfortable and involve risk of membrane injury or perforation, thus non-invasive infrared thermometer in non-used.

Forehead Temperature Measurement- are most useful for infants and children where a more invasive measurement is not necessary.

The body temperature is measured in degrees on two scales; Celsius (centigrade) and Farenheit.

Farenheit scale (OF)- is a temperature scale with the freezing point @ 32 OF and boiling point of water @ 212 0F

Celsius/Centigrade scale (OC) is a temperature scale with the freezing point @ 0 OC and the boiling point of water @ 100 OC. (most widely used in the Phils.)

1. Celsius to FarenheitOF = {9/5 X OC} + 32Ex. 38 OC to OF

=38 X 9/5 + 32=342/5 + 32=68.4 + 32=100.4 OF

2. Farenheit to Celsius

OC = (OF – 32) X 5/9Ex. 100 OF to OC= ( 68 ) x 5\9=340/9= 37.77 or 37.8 OC

1. Pyrexia / Hyperthermia / Fever

Body temperature above normal range

A very high fever such as 40 OC which is called hyperpyrexia

Client who has a fever is referred to as febrile; the one who has not is afebrile

Intermittent Fever – the body temperature alternates at regular intervals between periods of fever and periods of normal or subnormal temperature.

Remittent Fever – a wide range of temperature fluctuation (>2 OF) occurs over the 24hours period, all of which are above normal.

Relapsing Fever – short periods of a few days are interspersed with periods of 1 day or days of normal temperature.

Constant Fever – body temperature fluctuates minimally but always remains above normal.

Temperature that rises to fever level rapidly following a normal temperature and then returns to normal within a few hours is called Fever Spike.

2. Hypothermias

Body temperature below normal range.

Two Classifications

Accident Hypothermia – can occur as a result of exposure to a cold environment, immersion to a cold water, and lack of adequate clothing, shelter or heat.

Induced Hypothermia – is the deliberate lowering of the body temperature to decrease the need for oxygen by the body tissues, involving the whole body or a body part. Indicated prior to cardiac or brain surgery.

Purpose:

To establish baseline data for subsequent evaluation.

To identify whether the core temperature is within normal range.

To determine changes in the core temperature in response to specific therapies (e.g antipyretic medication, immunosuppressive therapy, invasive procedure)

To monitor client at risk for imbalanced body temperature ( e.g client at risk for infection or diagnosis of infection; those who have been exposed to temperature extremes.)

Clinical signs of fever

Clinical signs of hypothermia

Site most appropriate for measurement

Factors that may alter body temperature

Thermometer

Thermometer sheath or cover

Water-soluble lubricant for rectal temperature

Disposable gloves

Towel for axillary temperature

Tissues / wipes

Preparation:

Check that the thermometer is functioning normally. If necessary, shake a glass thermometer down to below 35 OC.

Is the wave of blood created by contraction of the left ventricle of the heart.

Is the instrument of the pressure pulse created when the heart contracts and ejects blood into the aorta.

Commonly assessed by palpation (feeling) or auscultation (hearing).

The middle three fingertips are used for palpating all pulse sites except the apex of the heart.

A stethoscope is used for assessing apical pulses and fetal heart tones.

A Doppler ultrasound stethoscope is used for pulses that are difficult to assess.

AGE NORMAL RANGE AVERAGE RATE/MINUTES

Newborn 100-170 140

1 year old 80-170 120

3 years old 80-130 110

6 years old 75-120 100

10 years old 70-110 90

14 years old 60-110 90

Adult 60-100 80

PERIPHERAL PULSE is a pulse located away from the heart (e.g in the

foot, wrist or neck)

APICAL PULSE Is a central, pulse located at the apex of the heart.

PMI-point of maximal impulse-Left 5th intercostal space midclavicular line

1. Temporal - over temporal bone, superior (above) and lateral (away from the midline of the eye)

2. Carotid – bilateral, under lower jaw in neck along medial edge of sternocleidomastoid muscle.

3. Apical - at the apex of the heart.

in adult this is located on the left side of the chest , about 8 cm (3 inches) to the left of the sternum (breastbone) at the fourth, fifth or sixth intercostals space (area between the ribs)

for a child 7- 9 years of age, the apical pulse is located at the fourth or fifth intercostal spaces. Before 4 years of age it is left of the midclavicular line (MCL); between 4 and 6 years it is in the midclavicular line (MCL).

Used to auscultate heart sounds and assess apical-radial deficit

4. Brachial - at the inner aspect of the biceps muscles of the arm or medially in the antecubital space.

5. Radial - where the radial artery runs along the radial boon the thumb side of the inner aspect if the wrist.

- accessible, used routinely in adults to assess character of peripheral pulse.

6. Femoral - where the femoral artery passes along side in the inguinal ligaments.

- used to assess circulation to legs during cardiac arrest

7. Popliteal - where the popliteal artery passes behind the knee

- used to assess circulation to legs and to auscultate leg blood pressure.

8. Posterior Tibial - on the medial surface of the ankle where the posterior tibial artery passes behind the medial malleolus.

-used to assess

circulation to feet.

9. Pedal (Dorsalis Pedis) – where the dorsalis pedis artery passes over the bones on the foot, on an imaginary line drawn from the middle of the ankle to space between the big and second toes.

-Used to assess circulation to feet.

1. Pulse Quality – refers to the beat of the pulse, its rhythm and forcefulness

2. Pulse Rate – is an indirect measurement of cardiac output obtained by counting the number of apical or peripheral pulse waves over a pulse point.

a normal pulse rate for adults is between 60 to 100 beats per minute.

Bradycardia - is the heart rate less than 60 beats per minute

Tachycardia – is a heart rate in excess of 100 beats per minute in an adult.

3. Pulse rhythm – is the regularity of the heartbeat. It describes how evenly the heart is breathing.

Regular – the beats are evenly spaced

Irregular – the beats are not evenly spaced

Dysrhythmia ( Arrhythmia) – is an irregular rhythm caused by an early, late or missed heartbeat.

4. Pulse Volume – is a measurement of the strength or amplitude or force exerted by the ejected blood against the arterial wall with each contraction.

Normal – full, easily palpable

Weak – Thready and usually rapid

Strong – bounding

Pulse Deficit – difference between the apical and the peripheral pulse (2 nurses take this)

Pulse Pressure – difference between systolic and diastolic pressure in blood pressure

Equipment: Watch with a second hand

Purposes:

To establish baseline data for subsequent evaluation

To identify whether the pulse rate is within normal range

To determine whether the pulse rhythm is regular and the pulse volume is appropriate

To compare the equality of corresponding peripheral pulses on each side of the body

To monitor and assess changes in the client health status

To monitor clients at risk for pulse alteration (e.g for those with a history of heart diseases, hemorrhage, acute pain, fever infusion with large volume of fluids.)

Radial

1. Inform client of the site (s) at which you will measure pulse.

Rationale: Encourages participation and allays anxiety.

2. Flex client’s elbow and place lower part of arm across chest.

Rationale: Maintains wrist in full extension and exposes artery for palpation. Placing client’s hand over chest will facilitate later respiratory assessment without undue attention to your action. (It is difficult for any person to maintain normal breathing pattern when someone is observing and measuring)

3. Support client’s wrist by grasping outer aspect with thumb

Rationale: Stabilizes wrist and allows for pressures to be exerted.

4. Place your index and middle finger on inner aspect of client’s wrist over radial artery and apply light but firm pressure until pulse is palpated.

Rationale: Fingertips are sensitive, facilitating palpation of pulsating pulse. The nurse may feel own pulse if palpating with thumb. Apply light pressure prevents occlusion, of blood flow and pulsation.

5. Identify pulse rhythm.

Rationale: Palpate pulse until rhythm is determined. Describe as regular or irregular.

6. Determine pulse volumeRationale: Quality of pulse strength is an indication of stroke volume. Describe as normal, weak, strong or bounding.

7. Count pulse rate by using a second hand on watch for one full minute.

8. Records the rate, rhythm and applicable, number of regular beats.

Purpose:

To determine adequacy of peripheral circulation of presence of pulse deficit

Equipment:

Watch with second hand or indicator Stethoscope Antiseptic wipes

Is the act of breathing. It can be assessed by observing chest wall expansion and bilateral and symmetrical movement of the thorax. Another method the nurse can use the assess breathing is to place the back of the hand next to the client’s nose and nose to feel the expired air.

External Respiration - refers to the interchange of oxygen and carbon dioxide between the alveoli of the lungs and the pulmonary blood.

Internal respiration – takes place throughout the body, it is the interchange of the same gases between the circulating blood and the cells of the body tissue.

Inhalation/ Inspiration – refers to the intake of air into lungs.

Exhalation/ Expiration – refers to breathing out or the movement of gasses from the lungs to the atmosphere.

1. Costal (thoracic) Breathing – involves the intercostal muscles and other accessory muscle, such as the sternocleidomastoid muscle.

It can be observed by the movement of the chest upward and outward

2. Diaphragmatic (abdominal) Breathing – involves the contraction and relaxation of the diaphragm, and it is observed by the movement of the abdomen, which occur as result of the diaphragm’s contraction and downward movement.

Age Respiration (average and ranges)

Newborn 35(30-80)

1 year old 30 (20-40)

5-8 years old 20(15-25)

10 years old 19 (15-25)

Teen 18 (15-20)

Adult 16 (15-20)

Older adult (>70 ) 16 (15-20)

Contraction of the diaphragm

Increases in the vertical diameter of the thorax.

(The ribs move upward and outward)

Expansion of the lungs

INSPIRATION

Relaxation of the Diaphragm

Decrease in the size of the thorax

(The ribs moves downward and inward)

Decrease in the size of the lungs

EXPIRATION

NOTE: a normal adult inspiration is last to 1-1.5 seconds while the expiration lasts to 2-3 seconds.

it is normally describe in breath per minute ( bpm /cpm)

Eupnea – breathing that is normal in rate and in depth

Bradypnea – referred to as abnormal slow respiration

Tachypnea / Polypnea – referred to as normally fast respiration (quick, shallow Breath)

Apnea – absence of breathing

Depth of Respiration - can be established by watching the movement of the chest.

Deep Respiration – are those in which a large volume of air is inhaled and exhaled.

Shallow Respiration – involve the exchange of a small volume of air and often the minimal use of lung tissue.

Hyperventilation – refers to very deep, rapid respiration. (Overexpansion of lungs)

Hypoventilation – refers to very shallow respiration. (Under expansion of lungs)

Respiratory Rhythm – refers to the regularity of the expirations and the inspiration, it can be described as regular or irregular.

Cheyne-stroke Breathing – rhythmic waxing and warming of respiration, from very deep to very shallow breathing and temporary apnea.

Respiratory Quality or Character – refers to those aspects of breathing that are different from normal, effortless breathing.

1. Stridor - a thrill, harsh sound heard during inspiration with laryngeal obstruction.

2. Stertor – snoring or sonorous respiration, usually due to partial obstruction of the upper airway.

3. Wheeze – continous, high pitched musical squeak or whistling sound occurring on expiration and sometimes on inspiration when air moves through a narrowed or partially obstructed airway.

4. Bubbling – gurgling sounds heard as air passes through moist secretions in the respiratory tract.

Purposes: To acquire baseline data To monitor abnormal respiration and respiratory patterns

identify changes To assess the respiration before the administration of

general anesthetic or any medication that influences respiration

To monitor clients to risk for respiratory alterations

Assessment

Skin and mucous membrane color

Position assumed for breathing

Sign of cerebral anoxia

Chest movements

Activity Tolerance

Chest pain

Dyspnea

Medication Affecting Respiratory Rate

Is the measurement of pressure pulsation exerted against the blood vessels walls during systole and diastole

It is measured in terms of millimeters of mercury (mmhg)

The everage blood pressure of a healthy adulth is 120/80mmhg

is a measurement of the maximal pressure exerted against arterial walls during systole (when the myocardial fibers contact and tighten to eject blood from the ventricles) primary a reflection of cardiac output.

is a measurement of pressure remaining in the arterial system during diastole (period of relaxation that reflects the pressure remaining in the blood vessels after the heart has pumped), primary a reflection of peripheral vascular resistance.

Blood Volume

The volume of blood in the circulatory system. When the blood volume decreases, the blood pressure decreases because of decreased fluid in the arteries. Conversely, when the volume increases, the blood pressure increases because of the greater fluid volume within the circulatory system.

Cardiac Output

The major output that influence systolic pressure. When the pumping action of the heart is weak, less pumped into arteries (lower cardiac output), and the blood pressure decreases. When heart’s pumping action is strong and the volume of blood pumped into the circulation increases (higher cardiac output) the blood pressure increase

Peripheral Vascular Resistance

Peripheral resistance can increase blood pressure. Some factors that create resistance in the arterial system are the capacity of the arterioles and the capillaries, the compliance of the arteries, and the viscosity of the blood

Viscosity

The thickness of the blood based on the ratio of proteins and the cells to the liquid portion of blood, the greater the viscosity, the harder the heart must work to pumped blood, with a reluctant increases in the blood pressure.

Hypertension – a blood pressure that is persistently above normal. It is usually asymptomatic and is often a contributing factor to myocardial infarction (heart attack)

Hypotension – is a blood pressure that is below normal, that is a systolic reading consistently between 85 and 110mmHg in an adult whose normal pressure is higher than this.

Orthosthatic Hypotension – is a blood pressure that falls when the client sit or stand. It usually the result of peripheral vasodilatation in which the blood leaves the central body organs, especially the brain, and moves to the periphery, often causing the person to feel faint.

1. Direct (invasive Monitoring) Measurement- involves the insertion of a catheter into the brachial, radial, or femoral artery. Arterial pressure is represented as awavelike forms, displayed on an oscilloscope.

2. Indirect (noninvasive monitoring) – measurements

Auscultary method – is most commonly used. Required equipment is a sphygmomanometer, a cuff, and a stethoscope.

Palpatory method – when korotkoff’s sounds is not available, or to prevent misdirection from the presence of an auscultatory gap occurs.

Korotkoff’s sounds – series of sounds that correspond to changes in blood flow through an artery as pressure is released.

Phase1: Characterized by the first appearance of faint but clear tapping sounds that gradually increase in intensity; the first tapping sound is the systolic pressure.

Phase2: Characterized by muffled or swishing sounds; these sounds may temporarily disappear; especially in hypertensive people; the disappearance of the sound during the latter part of phase 1 and during phase 2 is called the auscultary gap and may cover a range of as much as 40mmHg failing to recognize this gap may cause serious errors of underestimating systolic pressure or overestimating diastolic pressure.

PHASE3: Characterized by distinct, loud sounds as the blood flows

relatively freely through an increasingly open artery.

PHASE4: Characterized by distinct, abrupt, muffling sound with a soft, blowing quality; in adults; the onset of this phase is considered to be first diastolic figure.

PHASE5: The last sound heard before a period of continuous silence; the pressure at which the last sound is heard is the second diastolic measurement.

1. Blood Pressure cuff - it is consist of an oblong rubber bag, or bladder, covered with a nonexpendable fabric called cuff

2. Hand bulb - is a device attached to the bladder by a rubber tube through which air is pumped. The hand bulb has a valve, regulated by a thumbscrew, that allows air to escape from the bladder at the desired rate.

3. Mercury Manometer- are manufactured in variety of models, including a floor model, a portable model and a wall model. The mercury rises in a calibrated glass tube registering the pressure as the cuff is inflated with air, then falls as the air released.

4. Aneroid Manometer- is an air pressure gauge that registers the blood pressure by a pointer on a dial. The dial is generally attaches to the cuff by hooks that fit into a small pocket.

5. Stethoscope- is an instrument used for listening to body sounds. The bell head of the Stethoscope is usually used for listening when blood pressure is measured.

Bladder cuff into narrow and wide

Armed unsupported

Insufficient rest before the assessment

Repeating assessment too quickly

Cuff wrapped too loosely or unevenly

Deflating cuff too quickly

Deflating cuff too slowly

Arm above level of the heart

Assessing immediately after a meal or while client smokes or has pain

Failure to use the same arm consistently

Purpose

To obtain baseline measure of arterial blood pressure for subsequent evaluation.

To determine the clients hemodynamic status

To identify and monitor changes in blood pressure resulting from disease process and medical therapy

Assess for sign and symptoms of hypertension

Assess for sign and symptoms of hypotension

Factors affecting blood pressure

Equipment

stethoscope

Blood pressure cuff

Sphygmomanometer

Pulse oximeters often show the pulsatile change in absorbance in a graphical form. This is called the "plethysmographic trace” or more conveniently, as "Pleth".

The measurements are obtained by simply shining two wavelengths of light (1 is a visible red beam, the other an invisible infrared beam) at e.g. the fingertip.

Desktop Finger/mobile

Desktop

Finger/mobile

Undergoing surgical procedure under general anesthesia

Undergoing surgical procedure under conscious sedation

Emergency situations like loss of consciousness, trauma etc.

After surgery during the recovery phase

In the ICU, Pulse Oximetry is used extensively on mechanically ventilated patients

Pulse Oximeters are routinely used in certain hospital wards and in casualty departments for immediate assessment of patients

Venous congestion (partial obstruction of the veins) of an arm or leg

Reduced peripheral pulsatile blood flow

Bright overhead lights, such as in an operating theatre

Shivering or significant, repeated movement of the sensor

Pulse oximetry struggles to distinguish between different forms of hemoglobin, such as carboxy-hemoglobin

Nail varnish may cause falsely low readings with most pulse Oximeters, especially those colored blue or black

Pulse oximetry struggles to distinguish between different forms of hemoglobin, such as carboxy-hemoglobin

Nail varnish may cause falsely low readings with most pulse Oximeters, especially those colored blue or black

Anemia

Jaundice

A fit, healthy person should have an oxygen saturation level between 95% & 99%. Results lower than this, and especially below 90% may be caused by problems including lung diseases, such as COPD, breathing difficulties, cigarette smoking or circulatory problems such as excessive bleeding or blood vessel problems.

A fit, healthy person should have an oxygen saturation level between 95% & 99%. Results lower than this, and especially below 90% may be caused by problems including lung diseases, such as COPD, breathing difficulties, cigarette smoking or circulatory problems such as excessive bleeding or blood vessel problems.

The pulse would be lost (causing the alarm to sound) and the saturations will decrease

Is non-invasive technique that measures the oxygen saturation (SpO2) of arterial blood.

It is useful for monitoring patients receiving oxygen therapy, those at risk for hypoxemia & post operative patients

hemoglo Normal Values: 95% - 100 %

MICHELLE E. FLORES,RN MAN

END

References:Fundamentals of Nursing, Kozier, Erb et alLippincott William and WilkinsFundamental of Nursing, UdanWorld wide web