Vital Signs: Chapter 32
TABLE 32-3 Acceptable Ranges of Heart Rates
TABLE 32-4 Factors Influencing Pulse Rate
Vital Signs: Chapter 32
TABLE 32-5 Acceptable Ranges of Respiratory Rate
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TABLE 32-6 Alterations in Breathing Pattern
TABLE 32-7 Average Optimal Blood Pressure for Age
TABLE 32-8 Classification of Blood Pressure for Adults Ages 18 and
Older
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TABLE 32-9 Antihypertensive Medications
Vital Signs: Chapter 32
Vital Signs: Chapter 32
Figure 32-14 The sounds auscultated during blood pressure
measurement can be differentiated into five Korotkoff phases. In this
example blood pressure is 140/90 mm Hg.
TABLE 32-10 Common Errors in Blood Pressure Assessment
Indirect measurement of blood pressure by palpation is useful for
clients whose arterial pulsations are too weak to create Korotkoff sounds.
Severe blood loss and decreased heart contractility are examples of
conditions that result in blood pressures too low to auscultate accurately. In
these cases, you can assess the systolic blood pressure by palpation. The
diastolic blood pressure is difficult to determine by palpation (Box 32-14).
When using the palpation technique, record the systolic value and how you
measured it (e.g., RA 90/2, palpated, supine).
You can use the palpation technique along with auscultation. In some
hypertensive clients the sounds usually heard over the brachial artery when
Vital Signs: Chapter 32
the cuff pressure is high disappear as pressure is reduced and then reappear
at a lower level. This temporary disappearance of sound is the auscultatory
gap. It typically occurs between the first and second Korotkoff sounds. The
gap in sound covers a range of 40 mm Hg and thus causes an
underestimation of systolic pressure or overestimation of diastolic pressure.
The examiner needs to be certain to inflate the cuff high enough to hear the
true systolic pressure before the auscultatory gap. Palpation of the radial
artery helps to determine how high to inflate the cuff. The examiner inflates
the cuff 30 mm Hg above the pressure at which the radial pulse was
palpated. Record the range of pressures in which the auscultatory gap occurs
(e.g., BP RA 180/94 mm Hg with an auscultatory gap from 180 to 160 mm
Hg, sitting).
Orthostatic hypotension, also referred to as postural hypotension,
occurs when a normotensive person develops symptoms and low blood
pressure when rising to an upright position. When a healthy individual
changes from a lying, to sitting, to standing position, the peripheral blood
vessels in the legs constrict. Constriction of the lower extremity vessels when
standing prevents the pooling of blood in the legs due to gravity. Thus an
individual normally does not feel any symptoms when standing. In contrast,
when clients have a decreased blood volume, their blood vessels are already
constricted. When a volume-depleted client stands, there is a significant drop
in blood pressure with an increase in heart rate to compensate for the drop in
cardiac output. Clients who are dehydrated, anemic, or have experienced
prolonged bed rest or recent blood loss are at risk for orthostatic hypotension.
Some medications cause orthostatic hypotension if misused, especially in
older adults or young clients. Always measure blood pressure before
administering such medications.
Assess for orthostatic hypotension during vital sign measurements by
obtaining blood pressure and pulse with the client supine, sitting, and
standing. Obtain blood pressure readings 1 to 3 minutes after the client
changes position. In most cases, orthostatic hypotension is detected within a
minute of standing. If orthostatic hypotension occurs, assist the client to a
lying position and notify the health care provider or nurse in charge. While
obtaining orthostatic measurements, observe for other symptoms of
hypotension such as fainting, weakness, or light-headedness. When recording
orthostatic blood pressure measurements, record the client's position in
addition to the blood pressure measurement; for example: 140/80 mm Hg
supine, 132/72 mm Hg sitting, 108/60 mm Hg standing. Because the skill of
orthostatic measurements requires critical thinking and ongoing nursing
judgment, do not delegate this procedure.