VITAL SIGNS: Temperature, Pulse, Respiratory Assessment, Blood Pressure Taking

vital signs are body temperature, the pulse, respiration and blood
pressure
Body temperature – T
Pulse or heart rate – PR / HR
Respiratory rate – RR
Blood Pressure – BP

WHEN TO ASSESS VITAL SIGNS

 admission to a health care agency or to a hospital to obtain the baseline data 

 when a client has a change in health status (ex. Chest pain, skin warm to touch)

 before during and after a surgery or an invasive procedure 

 before and after administration of medication that could affect the respiratory or cardiovascular
system

 before and after any nursing intervention that could affect vital signs

 VS can be monitored q 15 mins, q 30 mins, 1hr, q 2 hrs, q 4 hrs or depending on the doctor’s
order

Temperature
- reflects the balance between the heat that is produced in your body and the heat that is lost from the
body

- measured in heat units called degrees

- refers to the warmth of a human body

- heat is produced from exercise and metabolism of food

- heat is lost thru the skin, the lungs and the body’s waste products
2 kinds
1. Core temperature – the temp of the deep tissues of the body,
such as the abdominal cavity and pelvic cavity
- it remains relatively constant and is a range of temp
2. Surface temperature – the temp of the skin, the subcutaneous
tissue and fat
- it rises and falls in response to the environment
* The body continually produces heat as a by-product of
metabolism
* When the amount of heat produced by the body is equals the
amount of heat lost, the person is in heat balance
* As long as heat production and heat loss are properly balanced,
body temp remains constant
Factors that affect the body’s heat production:
1. Basal metabolic rate (BMR)
- the rate of energy utilization in the body required to maintain activities such
as breathing
- metabolic rate decreases with age, the younger the person the higher the
BMR
2. Muscle Activity
- muscle activity, including shivering, increase metabolic rate
3. Thyroxine output
- Increased thyroxine output increases the rath of cellular metabolism
throughout the body
Thyroxine - it is the one that controls how much energy your body uses on
like your metabolic rate. it also is involved in digestion how your heart and
muscles work, how your brain develops.
4. Epinephrine, norepinephrine and sympathetic stimulation/stress response
 - these hormones immediately increase the rate of cellular metabolism in
many body tissues
5. Fever
- increases the cellular metabolic rate and thus increases body temp

Factors that affect the body’s heat loss:

1. Radiation – loss of heat to the surrounding air (heat lost from the body to a cold
room)
2. Conduction – movement of air across the surface to cause heat to move away from
body (when the body is immersed in cold water)
3. Convection – loss of body heat by means of transfer to the surrounding cooler air
(wind blowing across exposed skin)
4. Evaporation – loss of heat due to liquid turning to a gas (sweat, alcohol swab)
Factors affecting Body Temperature:
1. Age – infants / older adults
- less or loss of subcutaneous fats
- due to extreme changes in temp
- due to decreased thermoregulatory controls (older adult)
2. Diurnal Variations/Circadian Rhythms – body temp normally changes throughout the
day
- the point of highest body temp is usually reached between 4-6 pm, and the
lowest point is reached during sleep between 4-6 am
3. Exercise – hard work or strenuous exercise can increase body temp to as high as
38.9 degree Celsius
4. Hormones – women experience more hormone fluctuations than men
5. Stress – stimulation of the sympathetic nervous system can increase the production
of epinephrine and norepinephrine, thereby increasing metabolic activity and
heat production
6. Environment – extremes in environmental temp can affect a person’s temp regulatory
system

2 Primary Alterations in Body Temperature:

1. Hyperthermia, Pyrexia or fever
- a body temp above the usual range
- a very high fever such as 41 degree Celsius is called HYPERPYRXIA
- client who has fever is referred to as Febrile
- client who does not have fever is referred to as Afebrile
4 Common types of fever:
a. Intermittent – the body temp alternates at regular intervals between periods of fever
and periods of normal or subnormal temperature
b. Remittent - wide range of temperature fluctuations which occurs over a 24-hour
period all of which are above normal
c. Relapsing - short febrile periods of a few days are intermix with periods of 1 or 2 days
of normal temp
d. Constant – the body temp fluctuates minimally but always remain above normal
NURSING INTERVENTIONS FOR CLIENTS WITH FEVER
* monitor the vital signs
* assess the skin color and the temp
* check for the five cardinal signs of infection/inflammation (pain, heat. Redness,
swelling, loss of function)
* remove excess blanket when the client feels warm, but provide extra warmth when the
client feels chilled
* provide adequate nutrition and fluids at 2.5 to 3 liters to prevent dehydration
* measure the intake and output
* reduce physical activity to limit heat production
*administer antipyretic medications to reduce fever as ordered by doctor
* provide oral hygiene to keep the mucous membranes moist
* provide a tepid sponge bath to increase heat loss through conduction
* provide dry clothing and be linens

ANTIPYRETICS
Tylenol (acetaminophen) – also an analgesic
Dose: 325 – 650 P.O. q 4 hrs
Can be taken every 4-6 hrs
Aspirin (ASA) – Lowers temp. Is classified as analgesic, anti-inflammatory and anti-
platelet
Dose: 325 – 650 P.O. q 4 hrs
Ibuprofen (Advil, Motrin) is an analgesic, antipyretic
Dose: 200 – 600 mg q 6 hrs, not q 4 hrs
* over the counter antipyretic medications like Biogesic, Bioflu etc.

In some conditions an elevated temperature is not a true fever. . .

Heat Exhaustion - is a result of excessive heat and dehydration, 38.3-38.9 degree
Celsius
Heat Stroke – person is experiencing exposure to very hot weather, have warm flushed
skin, and often do not sweat, 41.1 degree Celsius or higher
hypothermia - it is the core body temperature is below the lower limit of normal
- range again was 36.5 to 37.5 which is the normal

three physiological mechanisms:

a. excessive heat loss
b. is inadequate heat production
c. impaired hypothalamic regulate thermoregulation

are two types of your hypothermia

1. induced hypothermia - the deliberate lowering of the body temperature to decrease
the need for oxygen by the body tissues

2. accidental hypothermia - this can occur as a result of exposure to a cold environment

so very common so exposure to a cold environment or immersion in very cold water or
lack of adequate clothing, shelter or heat
- if skin and underlying tissues are damaged by freezing cold this results in
frostbite commonly seen in hands, feet, nose and ears.

Nursing interventions for clients with hypothermia

* provide a warm environment
* provide dry clothing
* provide or apply warm blankets or comforters
* keep the limbs close to the body
* cover the patients or the covered up the patient's scalp with a cup or turban
* supply warm oral fluids or intravenous fluids for the patients
* apply warming pads

how is the temperature measured?

temperature is measured in:
1. degrees Fahrenheit average is 98.6 degrees F
2. degree centigrade or the Celsius average is 37 degree Celsius

normal temperature range

for fahrenheit is 96.6 299.6
for Celsius 36.5 to 37.5 degrees celsius

thermometer placement
oral - place the tip on either side of the frenulum
you place the tip of the thermometer or the probe of the thermometer
Axillary – Pat axilla dry if very moist

- The tip of the thermometer is placed in the center of the axilla

Rectal – apply clean gloves

- instruct the client to take a slow deep breath during insertion

 - never force thermometer if resistance is felt

- insert 1.5 inches in adults

Tympanic – pull the pinna slightly upward and backward for an adult

- pull the pinna straight back and upward for children over 3 years old

- pull the pinna slightly downward and backward for children below 3 years of age

- point the probe slightly anteriorly, toward the eardrum

- insert the probe slowly using a circular motion until snug

Temporal Artery – brush hair aside if covering the temporal area

- with the probe flush on the center of the forehead depress the red button keep depressed

- slowly slide the probe midline across the forehead to the hairline, not down the side of the face

- lift the probe from the forehead and touch on the neck just behind the earlobe. Release the
button.

Advantages Disadvantages
ORAL - accessible - thermometers can break if
- convenient bitten
- inaccurate if client has just
ingested hot or cold food or
fluid or smoked
- could injure the mouth
following oral surgery
AXILLARY - safe and non-invasive - the thermometer may need
to be left in place a long time
to obtain an accurate
measurement
RECTAL - reliable measurement - inconvenient and more
unpleasant for clients
specially those who cannot
turn to sides
- could injure the rectum
- presence of stool may
interfere with thermometer
placement
TYMPANIC MEMBRANE - readily available - can be uncomfortable and
- reflects the core involves risk of injuring the
temperature membrane if the probe is
- very fast inserted too far
- repeated measurements
may vary. Right and left
measurements can differ
- presence of cerumen can
affect the reading
TEMPORAL ARTERY - safe and non-invasive - requires electronic
- very fast equipment that may be
expensive or unavailable
- variation in technique
needed if client has
perspiration on the forehead
RESPIRATORY ASSESSMENT
Respiration – is the act of breathing
Ventilation – is also used to refer to the movement of air in and out of the lungs.
Inhalation or Inspiration – refers to the intake of air into the lungs. Diaphragm contracts (moves
down).
Exhalation or Expiration – refers to breathing out or the movement of gases from the lungs to
the atmosphere. Diaphragm relaxes (moves up).

Respiratory Center of the brain

Medulla Oblongata – controls rhythm and depth of breathing
Pons – controls the rate of breathing

TWO TYPES OF BREATHING

Costal or Thoracic Breathing
- involves the external intercostal muscles and other accessory muscles such as
sternocleidomastoid muscles.
- it can be observed by the movement of the chest upward and outward.
Diaphragmatic or Abdominal 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 diaphragms contraction and
downward movement.

ASSESSING RESPIRATIONS
- resting respirations should be assessed when the client is relaxed because exercise
affects respirations, increasing their rate and depth
- respiration is also assessed after exercise to identify the client’s tolerance to activity
- anxiety is likely to affect respiratory rate and depth as well

Before assessing client’s respiration:

* nurses should be aware of the following:
- the client’s normal breathing pattern
- client’s health problems on respiration
 - any medication or therapies that might affect respirations
EUPNEA – breathing that is normal in rate and depth

The normal respiratory rate changes with age. The normal rates are as given below for specific
ages:
Newborns: 30-40 breaths per minute
Less than 1 yr: 30-40 breaths per minute
1-3 years: 23-35 breaths per minute
3-6 years: 20-30 breaths per minute
6-12 years: 18-26 breaths per minute
12-17 years: 12-20 breaths per minute
Adults over 18: 12-20 breaths per minute.

Rates:
Tachypnea – quick, shallow breaths
Bradypnea – abnormally slow breathing
Apnea – cessation of breathing

Volumes:
Hyperventilation – overexpansion of the lungs characterized by rapid and deep breaths
Hypoventilation – under expansion of the lungs, characterized by shallow respirations

Rhythm:
Cheyne-strokes breathing – rhythmic waxing and waning of respirations, from very deep to very
shallow breathing and temporary apnea.

Ease or Effort:
Dyspnea – difficult and labored breathing during which the individual has a persistent,
unsatisfied need of air and feels distressed.
Orthopnea – ability to breathe only in upright sitting or standing positions.
AUDIBLE WITHOUT AMPLIFICATION
Stridor – a shrill, harsh sound heard during inspiration with laryngeal obstruction
Stertor – snoring or sonorous respiration, usually due to a partial obstruction of the upper airway
Wheeze – continuous, high-pitched musical squeak or whistling sound occurring on expiration
and sometimes on inspiration when air moves through a narrowed or partially
obstructed airway.
Bubbling – gurgling sounds heard as air passes through moist secretions in the respiratory tract

CHEST MOVEMENTS
Intercostal retraction – indrawing between the ribs
Substernal Retraction – indrawing beneath the breastbone
Suprasternal retraction – indrawing above the clavicles

SECRETIONS AND COUGHING

Hemoptysis – the presence of blood in the sputum
Productive cough – a cough accompanied by expectorated secretions
Non-productive cough – a dry, harsh cough without secretions

Infants / Children – crying needs to be quieted before assessing respirations for there could be
abnormal respiratory rate and rhythm
- they use their diaphragms for inhalation and exhalation, if necessary, place
your hand gently on infant’s abdomen to feel the rapid rise and fall during
respirations.
Older Adults – ask client to remain quiet, or count respirations after taking the pulse
- Any changes in rate or type of breathing should be reported immediately

PULSE ASSESSMENT
Pulse Rate and Heart Rate
* your pulse is your heart rate, or the number of times your heart beats in one minute.
* the pulse is a wave of blood created by contraction of the left ventricle of the heart
* the pulse wave represents the stroke volume output or the amount of blood that enters the
arteries with each ventricular contraction
* compliance of the arteries is their ability to contract and expand
* When a person’s arteries lose their distensibility as can happen with age, greater pressure is
required to pump blood into the arteries.

CARDIAC OUTPUT
* Is the volume of blood pumped into the arteries by the heart and equals the result of the stroke
volume times the heart rate per minute
* SV x HR/min = CO
* ex. 75 ml. x 60 beats/min = 4,500 ml/min or 4.5 L/min
*When an adult is resting the heart pumps about 5 liters of blood each minute

* In a healthy person, the pulse reflects the heartbeat

* in some types of cardiovascular disease, the heartbeat and pulse rates may differ
* ex. A client’s heart rate may produce very weak or small pulse waves that are not detectable in
a peripheral pulse far from the heart
- in these instances, the nurses should assess the heartbeat and the peripheral
pulse

 Peripheral Pulse – is a pulse located away from the heart, example in the foot or wrist
 Apical Pulse – is a central pulse, located in the apex of the heart, also referred to as the
point of maximal impulse (PMI)

Factors Affecting the Pulse:

Age – as age increases the pulse rate gradually decreases overall
Sex – after puberty, the average males pulse rate is slightly lower than the females
Exercise – the pulse rate normally increases with activity
Fever – the pulse rate increases due to peripheral vasodilation associated with elevated body
temperature
Medications – some medications increase or decrease the pulse rate
Ex. Digitalis preparations decrease heart rate, whereas epinephrine increase it
Hypovolemia – loss of blood from the vascular system increases the pulse rate
Stress – increases the rate as well as the force of the heartbeat, also in fear, anxiety and pain, it
stimulates the sympathetic nervous system
Position – when a person is sitting or standing blood usually pools in dependent vessels of the
venous system
Pathology – certain disease or heart conditions alter pulse rate

PULSE SITES:
Temporal – where the temporal artery passes over the temporal bone of the head
Carotid – at the side of the head where the carotid artery runs between the trachea and the
sternocleidomastoid muscle
Apical – at the apex of the heart
Adults – left side of the chest, about 3 inches to the left of the sternum at the 5th
intercostal space (area between the ribs)
Older Adult – the apex may be further left if conditions are present that have led to an
enlarged heart
Before 4 yrs of age – the apex is left to the midclavicular line
Between 4 and 6 yrs – it is at the midclavicular line
For 7 to 9 yrs – the apical pulse is located at the 4th or 5th intercostal space
Brachial – at the inner aspect of the biceps muscle of the arm or medially in the antecubital
space
Radial – where the radial artery runs along the radial bone, on the thumb side of the inner aspect
of the wrist
Femoral – where the femoral artery passes alongside the inguinal ligament
Popliteal – where the popliteal artery passes behind the knee
Posterior Tibial – on the medial surface of the ankle where the posterior tibial artery passes by
the medial malleolus
Dorsalis Pedis/Pedal – where the dorsalis pedis artery passes over the bones of the foot on an
imaginary line drawn from the middle of the ankle to the space between the bid and
second toes.

Radial - readily available

Temporal - used when radial pulse is not accessible
Carotid - used during cardiac arrest / shock in
adults
- used to determine circulation to the brain
Apical - routinely used for infants and children up
to 3 yrs of age
- used to determine discrepancies with
radial pulse
- used in conjunction with some
medications
Brachial - used to measure blood pressure
- used to measure cardiac arrest for
infants
Femoral - used in cases of cardiac arrest / shock
- used to determine circulation to a leg
Popliteal - used to determine circulation to a lower
leg
Posterior Tibial - used to determine circulation of the foot
Dorsalis Pedis/Pedal - used to determine circulation to the foot

Palpation – feeling, applying moderate pressure

- the middle three fingertips are used for palpating all pulse sites except the apex of the
heart
- excessive pressure alters a pulse
- too little pressure may not be able to detect it
Auscultation – hearing
- a stethoscope is used for assessing apical pulses
DUS – is used for pulses that are difficult to assess
- the DUs headset has earpieces similar to standard stethoscope ear unit

BLOOD PRESSURE
- is the measurement of force applied to artery walls
Arterial Blood Pressure – is a measure of the pressure exerted by the blood as it
flows through the arteries.
- Blood moves in waves
- measured in millimeters of mercury (mm Hg)
- recorded as a fraction Systolic pressure/Diastolic Pressure
- A typical blood pressure for a healthy adult is 120/80 mm Hg

2 BP Measurements
Systolic Pressure – Pressure of the blood as a result of contraction of the ventricles, the
pressure of the height of blood wave. Pumping.
Diastolic Pressure – Pressure when the ventricles are at rest, it is the lower pressure
present at all times in the arteries. Filling.

Normal Blood Flow – no occlusion of blood flow

Blood Occlusion – cuff pressure blocks blood flow
Systolic Pressure – Systolic pressure > cuff pressure.
- can hear pulse and it is the first audible sound
Diastolic Pressure – Diastolic pressure > cuff pressure
- cannot hear pulse and it is the last audible sound
Pulse Pressure – is the diff between the diastolic and the systolic pressure
- a normal pulse pressure is about 40 mmHg but can be as high as 100 mmHg
during exercise
Formula: PP = SP – DP

Mean Arterial Pressure – it is useful also to determine the mean arterial pressure (MAP)
because this represents the pressure actually delivered to the body’s organs
- MAP greater than 65 will keep all organs perfused
Formula: MAP = SBP + (2 x DBP)
3

4 Determinants of Blood Pressure

1. 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
2.Peripheral Vascular Resistance
- increase blood pressure
- diastolic pressure is affected
- the smaller the space within a vessel, the greater the resistance
- increase vasoconstriction (smoking) raises blood pressure, whereas decrease
vasoconstriction lowers the blood pressure
- if elastic and muscular tissues of the arteries are replaced with fibrous tissues,
the arteries lose its ability to constrict and dilate thus is known as
ARTERIOSCLEROSIS (blood is thick and stiff)
3. Blood Volume
- when the blood volume decreases (hemorrhage or dehydration), the blood
pressure decreases because of decrease fluid in the arteries.
- when the blood volume increases (rapid intravenous infusion), the blood
pressure increases because of greater fluid volume within the circulatory system
4. 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 when the hematocrit is more than 60%-65%

Factors Affecting Blood Pressure

1. Age – newborns have a systolic BP of 75 mmHg, the pressure rises with age
- on the onset of Puberty BP tends to decline
- in older adults, elasticity of the arteries is decrease, this increases the systolic
BP, due to the walls no longer retracting as flexibly the diastolic BP may also be
high.
2. Exercise – physical activity increases the cardiac output and blood pressure
- for reliable assessment of resting blood pressure, wait 20 to 30 minutes ff
exercise.
3. Stress – stimulation of the sympathetic nervous system increases cardiac output and
vasoconstriction of the arterioles, increasing the blood pressure reading.
4. Race – African American older that 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 pressure than before
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 – fever can increase blood pressure due to increase metabolic rate
- external heat causes vasodilation and decreased blood pressure
- cold causes vasoconstriction and elevates blood pressure

Classifications of Blood Pressure

Blood Pressure SYSTOLIC DIASTOLIC
Category mmHg mmHg
Normal less than 120 and Less than 80
Elevated 120 – 129 and Less than 80
High Blood 130 – 139 or 80 – 89
Pressure Stage 1
High Blood 140 or higher or 90 or higher
Pressure Stage 2
Hypertensive Higher than and/ or Higher than
crisis 180 120

Hypertension – a blood pressure that is persistently above normal

- a single elevated blood pressure reading indicates the need for reassessment
- hypertension cannot be diagnosed unless an elevated BP is found when
measured twice at different times
- the stage of hypertension is determined by the higher of the two values
Ex. If either the systolic or diastolic values falls in the stage 2 range, stage 2
hypertension is assigned

2 Types of Hypertension
Primary Hypertension – is an elevated blood pressure of unknown cause
Secondary Hypertension – is an elevated blood pressure of known cause

Factors Associated with Hypertension

- thickening of the arterial wall, which reduces the size of the arterial lumen
- inelasticity of the arteries
- lifestyle factors as cigarette smoking, obesity, heavy alcohol consumption
- lack of physical exercise
 - high blood cholesterol levels
- continued exposure to stress

Hypotension – is blood pressure that is below normal

- a systolic reading consistently between 85 and 100 mmHg in an adult whose
normal pressure is higher than this
- ORTHOSTATIC HYPOTENSION is a blood pressure that decreases when the
client sits or stands
- it is a result of peripheral vasodilation in which blood leaves the central body
organs, especially the brain and moves up to the periphery causing a person to
faint
- it can also be caused by:
*Analgesics (Demerol/Meperidine Hydrochloride)
*Bleeding
*Severe burns
*Dehydration
- it is important to monitor hypotensive clients carefully to prevent falls
- when assessing for Orthostatic Hypotension:
*Place client in a supine position for 10 mins
*Record the client’s blood pressure
*Assist the client to slowly sit or stand. Support the client in case of faintness
*Immediately recheck the blood pressure in the same sites
* Repeat the pulse and blood pressure after 3 mins
* Record the results, a drop in blood pressure of 20 mmHg systolic or 10
mmHg diastolic indicates orthostatic hypotension

Assessing Blood Pressure

- Blood Pressure is measured with a blood pressure cuff, a sphygmomanometer
and a stethoscope
- BP cuff consists of a bag called a bladder, that can be inflated with air
- 2 tubes * one connects to a bulb that inflates the bladder
* the other tube is attached to a sphygmomanometer
- Sphygmomanometer – indicates the pressure of air within the bladder
- Valve – traps and releases the air in the bladder

2 Types of Sphygmomanometer
*Aneroid
*Digital/Electronic – eliminates the need to listen for the clients systolic and diastolic BP
through a stethoscope
- should be calibrated periodically to check accuracy

Doppler Ultrasound Stethoscope

 - Used to assess when BP sounds are difficult to hear, such as infants, obese
clients, and clients in shock
- Systolic BP may be only BP obtainable with some ultrasound models

Blood Pressure Assessment Sites

- Upper arm using the brachial artery and stethoscope
- BP is assess on client’s thigh in this situation: BP cannot be measured on either
arm (due to burns or trauma, etc.)

BP is not measured on client’s limbs

* the shoulder, arm, hand (hip, knee, or ankle) is injured or diseased
* a cast or bulky bandage is on any part of the limb
* the client has had surgical removal of breast or axillary (inguinal) lymph nodes on that
side
* the client has an intravenous infusion or blood transfusion in that limb
* the client has an arteriovenous fistula (renal dialysis) in that limb

2 Methods in Assessing BP
1. Direct (Invasive Monitoring)
- involves insertion of a catheter into the brachial, radial, femoral artery
- arterial pressure is represented by a wavelike form displayed on a monitor
- pressure reading is highly accurate
2. Indirect (Non-invasive Monitoring)
A. Auscultatory
- commonly used in hospitals, clinics and homes
- external pressure is applied on the artery, then pressure is read from the
sphygmomanometer, while listening for sounds with a stethoscope

KOROTKOFF’S SOUNDS PHASES

Phase 1: A sharp tapping
- this is the first sound heard as the cuff pressure is released. This sound
provides the systolic pressure reading.

Phase 2: A swishing/whooshing sound

- swishing sounds as the blood flows through blood vessels as the cuff is
deflated

Phase 3: A thump (softer than phase 1)

- intense thumping sounds that are softer than phase 1 as the blood flows
through the artery but the cuff pressure is still inflated to occlude flow during
diastole.

Phase 4: A softer, blowing, muffled sound that fades

 - softer and muffled sounds as the cuff pressure is released. The change
from the thump of phase 3 to the muffled sound of phase 4 is known as the first
diastolic reading.

Phase 5: Silence
- silence that occurs when the cuff pressure is released enough to allow
normal blood flow. This is known as the second diastolic reading.

B. Palpatory
- used when Korotkoff’s sounds cannot be heard
- or used when electronic devices to amplify the sounds are not available
- or during auscultatory gap – temporary disappearance of a sound and
reappearance of the sound at a lower level
- nurse uses light to moderate pressure to palpate the pulsations of the
artery as the pressure in the cuff is released
- first pulsations of the artery are felt, the systolic pressure as the pressure
in the cuff is released and pressure is read in the sphygmomanometer
- a single whiplike vibration is felt in addition, to the pulsations identifies
the point nearing the diastolic pressure

Common Errors in Assessing Blood Pressure

* Bladder cuff too narrow
* Bladder cuff too wide
* Arm unsupported
* Insufficient rest before the assessment
* Repeating assessment too quickly
* Cuff wrapped too loosely or unevenly
* Deflating cuff too quickly
* Deflating cuff too slowly
* Failure to use the same arm consistently
* Arm above level of the heart
* Assessing immediately after a meal or while client smokes or in pain
* Failure to identify auscultatory gap

Pain Assessment
- 5th vital signs
- it is an unpleasant and highly personal experience that may be imperceptible to
others, while consuming all parts of an individual’s life
- according to Margo McCaffery, a nurse expert on pain, “pain is whatever the
person says it is and exists whenever he says it does”.
- an unpleasant sensory and emotional experience associated with actual or
potential tissue damage, or described in terms of such damage

Types of Pain (Location/Duration/Intensity/Etiology)

Location: Radiating Pain – some pain radiates (spread or extend) to other areas
Ex. Low back to legs
Referred Pain – appear to arise in different areas or parts of the body
Ex. Cardiac pain may be felt in the shoulder or left arm with /
without chest pain
Visceral Pain – pain arising from organs or hollow viscera
- often received in an area remote from the organ causing
the pain
Duration: Acute – a pain which lasts only the expected recovery period
- has a sudden or slow onset, regardless of intensity
Chronic – persistent pain
- prolonged, usually recurring or lasting 3 months or longer
Intensity – standard scale is used in classifying intensity of pain: 0 as no pain to 10 as
worst possible pain scale
Mild pain – 1-3 rating
Moderate pain – 4-6 rating
Severe pain – 7-10 rating
Etiology: Nociceptive – pain experienced when an intact, nervous system send
signals that tissues are damaged
Somatic Pain – originates in the skin, muscles, bone or connective
tissue. Ex. Paper cut
 Visceral Pain – results from activation of pain receptors in the
organs or hollow viscera. Ex. Labor Pain
Neuropathic – pain associated with damaged or malfunctioning nerves
due to an illness, injury, or undetermined reasons
- it is chronic, and as described as “burning”, electric-shock
or tingling, dull and aching
Peripheral Neuropathic Pain – pain ff damage or sensitization of
PNS. Ex. Phantom limb, Carpal tunnel syndrome
Central Neuropathic Pain – results from malfunctioning nerves in
the CNS. Ex. Spinal cord injury pain, post stroke pain

Pain Intensity or Rating Scales

- the single most important indicator of the existence and intensity of pain is the client’s
report of pain
* there are several well-designed pain scales that are used to help asses the extent of
one’s pain, all of which help improve communication between healthcare
providers and patients.
* some of these tools are most suited for people of certain ages, while others are more
useful for people who are highly involved in their own health care.

4 Most Common Types of Pain Scaling

1. Numeric Rating Pain Scale
* one of the most commonly used pain scales in healthcare
*numerical rating scale is designed to be used by those over age 9.
*if you use the numerical scale, you have the option to verbally rate your pain
form 0-10 or place a mark on a line indicating your level of pain.
2. Wong-Baker Faces Pain Scale
* combines pictures and numbers for pain ratings.
*it can be used in children over the age of 3 and in adults.
* six faces depict different expressions, ranging from happy to extremely upset.
Each is assigned a numerical rating between 0 (smiling) and 10 (crying). If you
have pain, you can point to the picture that best represents the degree and
intensity of your pain.
3. FLACC Scale
* face, legs, activity, crying and consolability. It was developed to help medical
observers assess the level of pain in children who are too young to cooperate
verbally. Also used in adults who are unable to communicate.
*0-2 points assigned for each of the five areas.
0: Relaxed and comfortable
1 to 3: Mild discomfort
4 to 6: Moderate pain
7 to 10: Severe discomfort/pain
4. Color Analog Scale
*this uses colors, with red representing severe pain, yellow representing
moderate pain, and green representing comfort.
* colors are usually positioned in a linear format with corresponding numbers of
words that describe your pain. Used for children and is considered reliable.