Chapter 5 Vital Signs



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Equality


The nurse should assess both radial pulses to compare the characteristics of each. A pulse in one extremity may be unequal in strength or absent in many diseases, such as thrombosis, aberrant blood vessels, or aortic dissection. The carotid pulse should not be measured simultaneously because excessive pressure may stop blood supply to the brain.
Nursing process and Pulse Determination

Assessment


When assessing the pulse, the nurse should collect the following data: the client’s general condition, such as age, sex, status of an illness and treatment; the pulse rate, rhythm, strength, equality, factors influencing pulse and arterial wall elasticity.

A healthy, normal artery feels straight, smooth, and soft. Older people often have inelastic that feel twisted and irregular upon palpation. Pulse assessment is helpful to determine the general state of cardiovascular health and the response to other system imbalances.


Nursing Diagnosis


Tachycardia,bradycardia,and dysrhythmias are defining characteristics of many nursing diagnosis and are considered along with other assessment data, such as activity intolerance, anxiety, fear, fluid volume deficit, gas exchange impaired, hyperthermia, and hypothermia.

Nursing Plan


The nursing care plan includes interventions based on the nursing diagnosis identified and the related factors; the expected outcomes generally are that the clients can tell the normal range and physiological changes of the pulse; and the clients can cooperate with the treatment and care.

Implementation


·Instruct the clients to rest to decrease heart energy consuming. Oxygen administration can be provided according to the client’s condition.

·Observe the clients’ condition closely. Instruct the clients to take medicine on time and observe the reactions of the medicine. Tell the clients to keep first-aid medicines along with them.

·Provide mental support. Let the clients to keep steady mood.

·Health education: Stop smoking and drinking alcohol, take light and digestible diet, keep bowels smooth. Teach the clients to monitor the pulse prior to taking medicines that affect the heart rate. Tell the clients to report any notable changes of heart rate or rhythm to health care provider. Teach the clients and family members the basic first-aid skills.


Evaluation


The nurse evaluates the therapeutic effect by assessing the pulse rate, rhythm, strength, and equality; the clients’ mental status, cooperation with treatment and nursing; and the clients’ knowledge about health.
Section Blood Pressure
Blood pressure is the lateral pressure on the walls of an artery by the flowing blood under pressure from the heart.Systemic or arterial blood pressure,the blood pressure in the system of arteries in the body, is a good indicator of cardiovascular health.Blood flows throughout the circulatory system because of pressure changes.It moves from an area of high pressure to an area of low pressure.

The heart’s contraction forces blood under high pressure into the aorta.The peak of maximum pressure when ejection occurs is the systolic pressure. When the ventricles relax, the blood remaining in the arteries exerts a minimum or diastolic pressure.Diastolic pressure is the minimal pressure exerted against the arterial walls at all times.

The standard unit for measuring blood pressure is millimeters of mercury (mmHg). The measurement indicates the height to which the blood pressure can raise a column of mercury. Blood pressure is recorded with the systolic reading before the diastolic (e.g, 120/80mmHg ).The difference between systolic and diastolic pressure is the pulse pressure.For a blood pressure of 120/80mmHg, the pulse pressure is 40mmHg.

Physiology of Arterial Blood Pressure

Blood pressure reflects the interrelationship among cardiac output,peripheral vascular resistance,blood volume,blood viscosity, and artery elasticity.

Cardiac Output


Cardiac output is the volume of blood pumped into the arteries by the heart during 1 minute.

The blood pressure depends on the cardiac output and peripheral vascular resistance. When volume increases in an enclosed space such as a blood vessel,the pressure in that space rises.Thus as cardiac output increases,more blood is pumped against arterial walls,causing the blood pressure to rise.Cardiac output can increase as a result of greater heart muscle contractility, an increase in heart rate, or an increase in blood volume.


Peripheral Resistance


Blood circulates through a network of arteries, arterioles, capillaries, venules, and veins.Arteries and arterioles are surrounded by smooth muscle that contracts or relaxes to change the size of the lumen.The size of arteries and arterioles changes to adjust blood flow to the needs of 1ocal tissues.For example, when more blood is needed by a major organ, the peripheral arteries constrict, decreasing their supply of blood. More blood becomes available to the major organ because of the resistance change in the periphery. Normally, arteries and arterioles remain partially constricted to maintain a constant flow of blood. Peripheral vascular resistance is the resistance to blood flow determined by the tone of vascular musculature and diameter of blood vessels.The smaller the lumen of a vessel, the greater peripheral vascular resistance to blood flow. As resistance rises, arterial blood pressure rises. As vessels dilate and resistance falls, blood pressure drops.

Blood Volume


The volume of blood circulating within the vascular system affects blood pressure.Most adults have a circulating blood volume of 5000 ml.Normally the blood volume remains constant.However, if volume increases, more pressure is exerted against arterial walls.For example, the rapid, uncontrolled infusion of intravenous fluids elevates blood pressure. When circulating blood volume falls, as in the case of hemorrhage or dehydration, blood pressure falls.
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