Stressors that Affect Circulation

1
Stressors that Affect Circulation

• NUR101 LECTURE 9
• FALL 2010
• K. BURGER, MSEd, MSN, RN, CNE
• PPP by Sharon Niggemeier RN BSN MSN

2
Circulatory Needs

• Blood circulation affects all aspects of well
  being.
• Circulation is monitored through assessment of
  Vital Signs along with other collected data.
• The patients physiological status is reflected
  by their vital signs.

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Vital Signs

• Signs of Vitality and Life
• Deviations from normal ranges can indicate chg in
  health status.
• TPR BP VS
• T-temperature
• P-pulse
• R-respirations
• BP- blood pressure
• VS-vital signs

4
CNS Regulates VS

• Hypothalamus Controls temperature
• Anterior Hypothalamus -Dissipation of heat
  
• Posterior Hypothalamus-conservation of heat
  
  

• Medulla
• Vasomotor center controls BP through
  vasoconstriction or vasodilation
• Cardiac center controls pulse
• Respiratory center controls respirations(rate
  and depth)

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Relationship Between VS

• R 1/4 P
• R 20 P 80
• P diastolic BP
• P 80 120/80

• T increases an increase in P R and BP

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Factors Influencing VS

• Age
• Gender
• Race
• Diet
• Weight
• Heredity
• Medications
• Activity

7
More Factors Influencing VS

• Pain
• Hormones
• Stress
• Emotions
• Circadian Rhythms

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Guidelines for Assessing VS

• Systematic
• Normal Range
• Baseline
• Recheck
• Client Norm
• Dx
• Treatments
• Monitor prn

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Temperature Regulation

• Thermal Balance
• Heat Production
• Heat Loss
• Core vs Surface

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Heat Production

• By product of metabolism
• B.M.R.- Basal Metabolic Rate
• Muscle activity
• Exposure to increased temperature
• Hormones Thyroxine, Epinephrine

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Heat Loss (Transfer)

• Conduction - direct transfer of heat by contact

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Heat Loss-Convection

• Heat dissemination via motion. A fan blows warm
  air across a warm body.

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Heat Loss-Radiation

• Heat given off by rays from the body. Heat loss
  from an uncovered head.
• Main form of heat loss.

14
Heat Loss-Evaporation

• Conversion of a liquid to a vapor. Perspiration
  vaporizes from the skin.
• Diaphoresis

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????What are some other ways heat is lost from
body???
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Fever

• Pyrexia100.4 104.0 F
• HyperpyrexiaAbove 104.0 F

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Fever Patterns

• Intermittent
• Remittent
• Constant
• Relapsing

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?? Fever Terminology ??Which term can be used
to describe a fever that

• Is constantly elevated with little fluctuation
• Fluctuates but does not come down to normal
• Returns to normal for a day or two, but then goes
  up again
• Alternates between normal and fever

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Resolutions of Pyrexia

• Crisis- sudden return to normal body
  temp.
• Lysis- gradual return to normal body temp.

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S/S of Fever

• Loss of appetite Delirium
• Headache Seizures
• Dehydration Thirst
• Flushed face ?????
• Rapid pulse
• Decreased urinary output(OLIGURIA)

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Temperature ranges

• Oral- 96.8 100.4 F
• 98.6 average norm
• Axillary- approximately 1 degree lower
• Rectal- approximately 1 degree higher

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Fever

• Onset- (Chill)
• Course ( Flush)
• Abatement (fever subsides)

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Assessing Temperature

• Glass
• Electronic
• Tympanic
• Tape/Patch
• Disposable (ie Clinidot)

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Oral Temperature

• Most common site
• Place against sublingual artery
• Contraindicated in oral surgery/infection
• Wait 15 min. if pt. ate/drank
  or smoked
• Electronic- blue probe

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Axillary Temperature

• Preferred for children under 6 yrs. routinely
  used on infants.
• Place in center of axilla against artery off the
  subclavian.
• Blue probe -electronic thermometer
• Document 102.4 A

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Rectal Temperature

• Last resort for assessing temperature
• Place against inferior rectal artery
• Contraindicated rectal surgery/cardiac pt.
• Lubricate thermometers
• REMEMBER PPE

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(Continued) Rectal Temperature

• Electronic thermometers
• Red Probe only
• Insert ½ - 1 inch adult
  ¼ - 1/2 inch child
• Left position is best
• Document 102.8 R

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Electronic Thermometers

• Check for baseline number- specific number after
  being turned on.
• Error indicators- low battery
• completeness- digital display clearly shows
  entire numbers
• If probe cover breaks- discard, check
  pt.mouth/axilla/rectum for broken pieces.
• Do not use bent probes.

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??? Nursing Diagnoses ???
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Nursing Interventions Temperature

• Check VS frequently
• Assess skin
• Note change in LOC
• Seizure precautions ?
• Monitor I O
• REDUCE COVERINGS

• Encourage fluids
• Tepid baths
• Administer antipyretics
• Promote comfort REST
• Hypothermia blanket

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Heat Stroke

• Hot, dry skin
• Dizziness
• Abdominal pain
• Delirium
• Eventual LOC

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Hypothermia

• Mild (93.2 96.8 F)
• Moderate (86.0-93.2 F)
• Severe ( below 86.0 F)

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Evaluations-Temperature

• Is patient afebrile?
• Are interventions working? i.e cool compresses,
  tepid bath, antipyretics?
• S/S of infection present?

34
Nurses Notes 5/31/02 415pm Reports headache,
feeling on fire, face flushed, skin warm,
T-104.6 A P-100 R- 20 BP- 150/80. Dr. Arrid
notified. Tylenol 650mg po administered as per
telephone order. Fluids encouraged, tepid bath
given. S.Niggemeier RN----------------------------
- 445pm T-102.2 A P- 88 R-18 BP 130/78 taking
fluids, feels better than before. S.Niggemeier
RN-----------------------------
35
Pulse-Physiology

• SA node- creates electrical impulses causing
  contraction of Left ventricle.
• A wave of blood is pumped into the arteries.
• Throbbing sensation is felt - Pulse
• Pulse rate should the heart rate
• Pulse rate is the number of pulsations felt in a
  minute.
• Pulse usually diastolic pressure

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Pulse Rates

• Newborn 120-150
• Infant 80-140
• Child 75-110
• Adult 60-100
• Pulse rates ????? as age increases

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Cardiac Output COSV x HR

• Cardiac output (CO) is the amount of blood
  pumped/min by the heart and approximately
  5000ml or 5L/min
• Stroke Volume (SV) is the amount of blood ejected
  from the L ventricle with each contraction.

• Heart rate (HR) is the number of times the heart
  contracts.
• Inversely related- when SV goes up the HR goes
  down.

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?? CARDIAC OUTPUT ??CV (5000) SV(70) X HR

• In the above equation, what would the clients
  heart rate be?
• If a client had a weak heart (ieCHF) that was
  only able to eject a SV of 50, what would happen
  to the clients HR?
• If a client had a well-conditioned heart muscle
  (ie athlete) that was able to eject a SV of 100,
  what would their HR be?

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Pulse Sites

• Temporal
• Carotid
• Apical
• Brachial
• Radial
• Femoral
• Popliteal
• Dorsalis Pedis
• Posterior Tibia

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Pulse assessment

• Rate -number of beats /min
• Rhythm- pattern of the rate. Regular or
  Irregular. Count irregular rhythm for 1 min.
• Quality- strength of the pulse 0-4

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Pulse - Quality Scale

• 4 bounding very strong, does not disappear with
  moderate pressure
• 3 normal, easily felt,
• 2 weak, light pressure causes it to disappear
• 1 thready, not easily felt, disappears with
  slight pressure
• 0- no pulse

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??? NURSING DIAGNOSES
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Nursing Interventions-Pulse

• Monitor for symmetry
• Note pulse deficit
• Promote circulation i.e. massage, TEDS,
• Teaching i.e dont cross legs

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Evaluations

• Is pulse with normal range?
• All pulses present
• Equally Bilateral?
• Are interventions to promote circulation working?
  i.e. massage, TEDS etc.

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Terminology

• Bradycardia- HR below 60/min
• Tachycardia- HR above 100/min
• Sinus Arrhythmia- HR increases on inspiration and
  decreases on exhalation common in children and
  young adults
• Dysrhythmia- abnormal rhythm
• Palpitation-aware of your HR without feeling for
  itusually rapid
• Pulse deficit- difference between apical and
  radial pulses Apical-100 Radial-80 then the Pulse
  deficit is 20

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Pulse Documentation

• 5/23/02 120am c/o palpitations. P-96 reg 3. No
  pulse deficit.-------------------
  S.Niggemeier RN

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Respirations Physiology

• Process whereby CO2 and O2 are exchanged in the
  tissues.
• Oxygenation of the body
• CO2 is the stimulus for breathing
• Inspiration - breathing inDiaphragm contracts
  pulls down
• Expiration- breathing outDiaphragm relaxes
  moves up
• Normal Tidal Volume 500 ml

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Respiration Rates

• Newborn 40-60/min
• Child 20-30
• School age 18-26
• Adult 16-20
• Respirations decrease as age increases

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Assessing Respiratory Status

• Oxygenation status
• Neurological state
• Musculoskeletal status

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Oxygenation status

• Note S/S of hypoxia (oxygen deprivation
• Cyanosis - bluish tinge caused by decrease in O2
  in RBC.
• Cyanosis is assessed by checking the mucous
  membranes of the conjunctiva (lower eyelids),
  under the tongue and inside the mouth..should be
  pink not pale or bluish

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??Other signs of dyspnea??
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Neurological state

• Hypoxia results in neurological changes
• alert
• becomes anxious
• then irritable
• progresses to drowsiness
• eventually a coma

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Musculoskeletal Status

• Abnormalities that prevent the thorax from
  expanding result in hindered respirations
• Scoliosis
• Lordosis
• Pectus excavatum
• Kyphosis
• Pectus carinatum

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Respiratory Assessment

• Rate- number of breaths/min
• Rhythm - even, labored
• Quality- deep, shallow

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Pulse Oximetry

• Indirect measurement of arterial oxygen
  saturation of hemoglobin
• 95 - 100 normal range
• Below 90 hypoxia
• Factors that interfere with accurate measurement
  dark nail polish, anemia,vasoconstriction (PVD,
  hypothermia), carbon monoxide poisoning,
  movement, excessive background light, tight probe

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?? NURSING DIAGNOSES??
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Nursing Interventions- Respirations

• Elevate HOB (head of the bed)
• Promote calm atmosphere
• Administer oxygen as needed
• Relaxation techniques

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Evaluation- Respiratory

• Rate within normal range?
• SOB?
• Dyspnea?
• Breathing less labored?
• Less cyanotic?

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Terminology

• Apnea
• Adventitious sounds
• Rales/crackles
• Gurgles /rhonchi
• Stertor
• Wheeze
• Cheyne-Stokes

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Terminology

• Bradypnea
• Dyspnea
• Hyperinflation
• Hypoxia
• Orthopnea
• Tachypnea

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Documentation 5/30/02 Reports dyspnea. R 24,
labored , shallow. HOB elevated. Dry crackles
auscultated bilaterally. Dr. C. Stokes notified.
O2 2L via NC applied. S. Niggemeier
RN------------------------
62
Blood Pressure -Physiology

• Blood pressure is the force against the arterial
  walls.
• Maximum BP is achieved when the Left ventricle
  contracts - Systolic pressure
• Lowest BP is when the heart rests - Diastolic
  pressure
• Pulse pressure is the difference between the
  Systolic and Diastolic pressures BP 140/90 PP
  (pulse pressure) 50

63
Maintaining and Regulating Blood
Pressure Peripheral Resistance Pumping Action of
heart (Cardiac Output) Blood volume Viscosity of
blood Elasticity of vessel walls Hormonal
factors renin, aldosterone
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Hypertension

• Elevated BP above normal for sustained time
• Unknown cause - primary or essential hypertension
• Known cause- secondary hypertension
• 3 or more elevated readings to confirm DX

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Hypertension

• Stage 1
• Systolic 140-159
• Diastolic 90-99
• Stage 2
• Systolic gt160
• Diastolic gt100

• Normal Blood Pressure lt 120/80
• Prehypertension
• Systolic 120-139
• Diastolic 80-89

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Hypotension

• Low BP - systolic of 90-115 with no ill effects
• Can be drug induced or illness related (MI,
  burns, blood loss)
• Orthostatic Hypotension or Postural Hypotension
  low BP when rising to an erect position, common
  after periods of bed rest

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Terminology

• Auscultatory Gap
• Diastolic
• Korotkoff sounds
• Pulse Pressure
• Systolic

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Direct BP Measurement

• Measure BP by means of inserting a catheter
  (arterial line) into an artery and measure by
  machine
• Used in critical care

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Indirect BP Measurement

• Auscultating with stethoscope and
  sphygmomanometer
• Palpating- feeling for an estimated systolic
• Doppler amplifies Korotkoff sounds
• Electronic meters- monitor BP with no need for
  stethoscope

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Sphygmomanometers

• Aneroid-measures mmHg on calibrated dial
• Mercury - measures mmHg via mercury filled
  cylinder (no longer used due to mercury hazardous
  material)

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Cuff Sizes Stethoscope Use

• Vary in size
• Must use appropriate size for pt.
• Pedi cuff, small, medium, large etc..
• Thigh cuffs

• Use either bell or diaphragm to auscultate sounds
• Make sure ear tips block out noise
• Clean after each use with alcohol pads

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Augment Korotkoff Sounds

• Raise arm over head for 15 sec prior to retaking
  BP
• Have pt. open/close hands - empties veins
• Pump bulb up quickly
• Wait 30-60 sec between readings
• Dont reinflate cuff once air is being released
  it muffles sounds

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Brachial Popliteal

• Use either arm
• Preferred site
• Easy access

• Use either thigh
• Less preferred
• Difficult to access
• Systolic pressure will be 10-40 mmHg higher than
  brachial

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Palpating BP

• Cuff is inflated 30mmHg above the point where
  pulse is no longer palpated.
• Release cuff and as air is releasing feel for
  return of pulse that is the systolic
• No stethoscope is used.
• No diastolic pressure can be assessed

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Nursing Interventions- Blood Pressure

• Monitor BP
• Administer antihypertensives as ordered
• Teaching - i.e. diet, exercise, stress, etc.

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Evaluation Blood pressure

• B/P within normal range?
• C/O headaches or other s/s
• Teachings regarding diet, weight, exercise,
  stress etc being followed?

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Terminology

• A/R- apical radial
• FUO - fever unknown origin
• PP -pulse pressure
• SOB - short of breath
• VS- vital signs

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?? Documentation of VS ??

• On what type of chart form are vital signs
  usually documented?