Vital Signs (Blood Pressure)

Jacqueline M. Calaycay, RN, MSN

Blood Pressure
Force exerted by the bld against vessel walls. Pressure of
bld within the arteries of the body lt. ventricle contracts
bld is forced out into the aorta to the lg arteries, smaller
arteries & capillaries
Systolic- force exerted against the arterial wall as lt.
ventricle contracts & pumps bld into the aorta
max. pressure exerted on vessel wall.
Diastolic arterial pressure during ventricular
relaxation, when the heart is filling, minimum
pressure in arteries.

Blood Pressure

Factors affecting B/P

lower during sleep
Lower with bld loss
Position changes B/P
Anything causing vessels to dilate or constrict medications

B/P (cont.) P&P p. 240 see table 9-3

Measured in mmHg millimeters of mercury
Normal range
syst 110-140 dias 60-90
Hypertensive - >160, >90
Hypotensive <90

B/P (cont.) P&P p. 240 see table 9-3

Non invasive method of B/P measurement
Sphygmomanometer, stethoscope
3 types of sphygmomanometers
Aneroid glass enclosed circular gauge with
needle that registers the B/P as it descends
the calibrations on the dial.
Mercury mercury in glass tube - more
reliable read at eye level.
Electronic cuff with built in pressure
transducer reads systolic & diastolic B/P

B/P (cont.)
Cuff inflatable rubber bladder, tube connects to the
manometer, another to the bulb, important to have correct
cuff size (judge by circumference of the arm not age)
Support arm at heart level, palm turned upward - above
heart causes false low reading
Cuff too wide false low reading
Cuff too narrow false high reading
Cuff too loose false high reading

B/P (cont.)
Listen for Korotkoff sounds series of sounds created as
bld flows through an artery after it has been occluded with
a cuff then cuff pressure is gradually released. P&P p. 240.
Do not take B/P in
Arm with cast
Arm with arteriovenous (AV) fistula
Arm on the side of a mastectomy i.e. rt mastectomy,
rt arm

Procedure B/P
Assessment

Determine best site & baseline B/P

Nursing Diagnosis

Decreased cardiac output

Fluid volume excess
Fluid volume deficit

Planning

Expected outcome
Have pt rest 5 min before taking B/Pa
Wash hands

Implementation

Palpate brachial pulse

Position cuff 1inch above pulse - Arm at level of
heart, wrap snugly around arm
Manometer at eye level

Procedure (cont.)
Implementation

Inflate cuff while palpating brachial Artery. Note

reading at which pulse disappears continue to
Inflate cuff 30 mmHg above this point. Deflate
cuff slowly and note when reading when pulse is
felt. Deflate cuff completely and wait 30 sec.
With stethoscope in ears locate the brachial artery
place diaphragm over site
Close valve of pressure bulb. Inflate cuff 30 mm
hg above palpated systolic pressure
Slowly release valve
Note point on manometer when first clear sound is
heard (1st phase Korotkoff) systolic pressure
Continue to deflate noting point @ which sound
disappears 5th phase Korotkoff (4th korotkoff in
children
Deflate & remove cuff

B/P Lower Extremity

Best position prone if not supine with knee slightly
flexed, locate popliteal artery (back of knee).
Large cuff 1 inch above artery, same procedure as arm.
Systolic pressure in legs maybe 10-40 mm hg higher
If unable to palpate a pulse you may use a doppler
stethoscope

Oxygen Saturation (Pulse Oximetry)

Non-invasive measurement of oxygen saturation
Calculates SpO2 (pulse oxygen saturation) reliable estimate of arterial oxygen
saturation
Probes finger, ear, nose, toe
Patient with PVD or Raynauds syndrome difficult to obtain.
Normal 90-100%
Remove nail polish
Wait until oximeter readout reaches constant value & pulse display
reaches full strength
During continuous pulse oximetry monitoring inspect skin under
the probe routinely for skin integrity rotate probe.

Procedure Vital Signs

Assessment

Route of temperature po, tympanic, axilla, rectal

Determines if client has had anything hot/cold to drink or
smoked (20 min)

Planning

Obtain equipment thermometer, watch, stethosope, B/P

cuff & graphic sheet
Wash hands

Implementation

Explains procedure to client

Temperature tympanic - thermometer
Pulse - Position clients arm @ side or across chest, palpate
radial artery
Resp Keeps fingers on wrist count respirations
Documents TPR on graphic sheet
B/P correct position, clients arm supported @ heart level
Document

Vital Signs (cont.)

Evaluation

V/S within normal range

Critical Thinking

You are assessing a clients pulse and the

rate is irregular. How would you
proceed?