IUT for students
Topic 3.2.2. “Assessment of the functional state of the patient:
Measurement of blood pressure, pulse, respiratory rate.
Types of shortness of breath;
– types of breathing;
– characteristics of the pulse;
– Physiological norms of arterial pressure.
Be able to:
– assess the functional state of the patient;
– interpret and record the data obtained in the documentation for the implementation of the nursing process.
– monitoring of the patient’s condition (assessment of the functional state);
– organization of therapeutic communication.
– to work out the technique of determining the number of respiratory movements;
– work out the technique of studying the pulse;
– work out the technique of measuring blood pressure;
– to work out the technique of digital and graphic recording of indicators of the functional state of the patient.
– fill in the nursing process map in the column “Objective data”.
– to educate students in the ability to highlight the main thing in working with
patients to study the need to breathe, count and evaluate the pulse, measure blood pressure and teach the patients themselves and their relatives these manipulations.
– develop clinical thinking in the implementation of manipulations related to the examination of patients.
Nursing examination is not only about the physical, emotional needs of the patient. Its purpose is to obtain information about the patient, which is recorded in the nursing history of the disease.
The source of objective information can be: observations of a sister, observations of other medical specialists, medical records, medical literature, educational medical films, information presented on official medical websites.
In order to collect the necessary information and build further interaction, it is important for a sister to have communication skills. First of all, the patient’s trust in the medical staff is necessary. It is based on trust that he decides how much personal information can be provided.
The main method of examining a patient is a survey, examination, physical examination, observation of the physical and mental state.
The examination data are recorded in the “Nursing Assessment Sheet”.
Nursing examination is based on the doctrine of human needs. And the extent to which information about the satisfaction of these patient needs by the nurse will be collected will depend on the correctness of the nursing diagnosis, the formulation of the goal of nursing intervention, the planning of care in accordance with disturbed needs and identified problems, and as a result, the effectiveness and quality of nursing care. .
1. Mukhina S.A., Tarnovskaya I.I. Theoretical foundations of nursing: a textbook. – 2nd ed., corrected. and additional – M.: GEOTAR-Media, 2009 . – 368s.: Ill. Part 1, 128 – 132s., 333 – 338s. Part 2, 231 – 245s.
2. Educational and methodological guide on the basics of nursing, module No. 8, pp. 168-179.
3. “Theoretical foundations of nursing” S.A. Mukhina, I.I. Tarnovskaya, part 1, pp. 124-130.
4. Atlas of Manipulative Techniques of Nursing Care p.45, ch.4; pp.245-247 ch.13.
Independent extracurricular work.
1. Carefully study:
a. technique for counting the frequency of respiratory movements;
b. technique for examining the pulse;
in. technique for measuring blood pressure.
2. In the practical training diary, define the terms in writing:
Arterial pulse – ____________________________________.
· Tachycardia – ____________________________________________.
· Bradycardia – ___________________________________________.
Tachyphygmia – __________________________________________.
· Bradysphygmia – _________________________________________.
Pulse deficit – ____________________________________________.
NPV – __________________________________________________.
Tachypnea – ______________________________________________.
· Bradypnea – _____________________________________________.
Shortness of breath – _______________________________________________.
Apnea – ________________________________________________.
· Blood pressure – __________________________________.
· Arterial hypertension – _______________________________.
Arterial hypotension – ________________________________.
3. In the diary for practical training, write out the standard indicators:
Pulse, systolic blood pressure, diastolic blood pressure, respiratory rate.
Questions for self-control.
1. Content of the nursing examination.
2. Sources of information about the patient.
3. Patient examination methods.
4. The content of the objective method of examination.
5. Subjective and objective examination for each need.
6. Definition of anthropometry.
7. Places of probing the pulse.
8. Normal indicators of Ps, blood pressure, NPV.
9. Determination of water balance.
10.Documentation of the received data.
Observing breathing, it is necessary to determine the frequency, depth, rhythm of respiratory movements and assess the type of breathing.
Respiratory frequency (RR) – the number of respiratory movements in 1 min; One respiratory movement is considered a combination of inhalation and the exhalation following it. The respiratory rate in an adult at rest is 16-20 per minute, in women it is 2-4 breaths more than in men (in newborns, the respiratory rate is 40-45). In the vertical position, the respiratory rate increases (18-20), in the “lying” position it decreases (up to 14-16 per minute), in sleep it decreases to 12-14 per minute. In trained people and athletes, the frequency of respiratory movements can decrease and reach 6-8 per minute,
In terms of depth, breathing can be superficial, moderate depth and deep (depending on the volume of inhaled air). Factors leading to an increase in heart contractions can cause an increase in the depth and increase in breathing. This is physical activity, an increase in body temperature, a strong emotional experience, pain, blood loss, etc. The rhythm is determined by the intervals between breaths. Normal breathing movements are rhythmic. In pathological processes, breathing is non-rhythmic. Types of breathing: chest, abdominal (diaphragmatic) and mixed.
Breathing monitoring should be carried out imperceptibly for the patient, as he can arbitrarily change the frequency, depth, rhythm of breathing. You can tell the patient that you are examining his pulse.
Determination of the frequency, depth, rhythm of breathing (in a hospital). Equipment: clock or stopwatch, temperature sheet, hand, paper.
1. Warn the patient that a pulse test will be performed (do not inform the patient that the respiratory rate will be tested).
2. Wash your hands.
3. Ask the patient to sit (lie down) comfortably so that you can see the upper part of his chest and (or) abdomen.
4. Take the patient by the hand as for the study of the pulse, but observe the excursion of his chest and count the respiratory movements for 30 s. then multiply the result by 2.
5. If it is not possible to observe the excursion of the chest, then put your hands (your own and the patient’s) on the chest (in women) or the epigastric region (in men), simulating the study of the pulse (continuing to hold your hand by the wrist).
6. Record the results on the temperature sheet.
7. Wash your hands.
The frequency of respiratory movements is noted graphically in the temperature sheet in blue.
Shortness of breath is a feeling of difficulty in breathing.
Types of shortness of breath:
subjective (the patient feels a lack of air) and
objective (change in frequency, depth, rhythm, duration of inhalation and exhalation);
inspiratory (difficulty inhaling), expiratory (difficulty exhaling) and mixed (difficulty inhaling and exhaling),
physiological (with physical exertion) and pathological (with diseases, poisoning).
Choking – sudden onset of shortness of breath.
Apnea – stopping breathing.
Nursing staff should be able to identify abnormal breathing patterns.
With certain types of shortness of breath, the rhythm of respiratory movements may be disturbed. Violation of the function of the respiratory center causes a type of shortness of breath, in which, after a certain number of respiratory movements, a noticeable lengthening of the respiratory pause or a short-term cessation of breathing occurs. Such breathing is called periodic. Two types of shortness of breath with periodic breathing are known.
Biot ‘s breathing is characterized by rhythmic, deep respiratory movements that alternate at regular intervals with long (from several seconds to half a minute) respiratory pauses.
Cheyne-Stokes breathing is characterized by the fact that after a long (from several seconds to 1 minute) respiratory pause (apnea), silent shallow breathing first appears, which quickly increases in depth, becomes noisy and reaches a maximum at the 5-7th breath, and then, in the same sequence, it decreases and ends with the next regular short pause. Patients during a pause are sometimes poorly oriented in the environment or completely lose consciousness, which is restored when the respiratory movements are resumed.
Shallow breathing is often associated with an abnormal increase in breathing, in which inhalation and exhalation tend to become shorter.
Deep breathing, on the contrary, in most cases is associated with a pathological decrease in breathing.
Sometimes deep rare breathing with large respiratory movements is accompanied by a loud noise – large Kussmaul breathing, characteristic of coma.
There are venous, arterial and capillary pulses.
The arterial pulse is the rhythmic oscillation of the artery wall due to the ejection of blood into the arterial system during one cardiac cycle. The arterial pulse can be central (on the aorta, carotid arteries) or peripheral (on the temporal, radial, brachial, femoral, popliteal, posterior tibial artery, dorsal artery of the foot, etc.).
The nature of the pulse depends both on the size and speed of the ejection of blood by the heart, and on the state of the artery wall, primarily its elasticity. More often, the pulse is examined on the radial artery, which is located superficially between the styloid process of the radius and the tendon of the internal radial muscle.
Before examining the pulse, you need to make sure that the person is calm, not worried, not tense, his position is comfortable. If the patient has done some kind of physical activity (brisk walking), had a painful procedure, received bad news, the pulse examination should be postponed, since these factors can increase the frequency and change other properties of the pulse. Remember! Never examine the pulse with your thumb, as it has a pronounced pulsation and you can count your own pulse instead of the patient’s pulse.
Measurement of arterial pulse on the radial artery (in a hospital setting). Equipment: Clock or stopwatch, temperature sheet, pen, paper.
1. Explain to the patient the essence and course of the study. Obtain his consent to the procedure.
2. Wash your hands.
* During the procedure, the patient can sit or lie down. Offer to relax the arm, while the hand and forearm should not be “on weight”.
3. Press the radial arteries on both hands of the patient with fingers 2,3,4 and feel the pulsation (1 finger is from the back of the hand).
4. Determine the rhythm of the pulse for 30 seconds.
5. Take a watch or a stopwatch and examine the arterial pulsation rate for 30 seconds: if the pulse is rhythmic, multiply by two, if the pulse is non-rhythmic, count the frequency for 1 minute.
6. Report the result to the patient.
7. Press the artery harder than before against the radius and determine the tension.
8. Tell the patient the result of the study.
9. Record the result.
10. Help the patient to take a comfortable position or stand up. ] 1. Wash your hands.
12. Mark the results of the study in the temperature sheet.
The main properties of the pulse:
Frequency – the number of pulse fluctuations in 1 minute. At rest, in a healthy person, the pulse is 60-80 per minute. With an increase in heart rate (tachycardia) , the number of pulse waves increases (tachyphygmia), and with a slow heart rate (bradycardia), the pulse is rare (bradysphygmia).
Rhythm – determined by the intervals between pulse waves. If pulse fluctuations occur at regular intervals, then the pulse is rhythmic. When the rhythm is disturbed, an irregular alternation of pulse waves is observed – an arrhythmic pulse. In a healthy person, the contraction of the heart and the pulse wave follow each other at regular intervals.
Tension – is determined by the force with which the researcher must press the radial artery so that its pulse fluctuations completely stop. The voltage of the pulse depends on the blood pressure. With normal blood pressure, the artery is compressed with moderate effort, therefore, the pulse of moderate tension is normal. With high blood pressure, it is more difficult to compress the artery – such a pulse is called tense, or hard. In case of low pressure, the artery contracts easily – the pulse is soft.
· The pulse rate is graphically marked in the temperature sheet in red.
· Places of research of pulse are pressure points at arterial bleeding.
On the carotid arteries, the pulse is examined without strong pressure on the artery, since a sharp slowdown in cardiac activity is possible, up to cardiac arrest and a drop in blood pressure, dizziness, fainting, and convulsions may appear.
• Pulse deficit – the difference between heart rate and pulse rate (normally there is no difference).
Algorithm for determining the pulse on the radial artery.
1. With the fingers of the right hand, grasp the patient’s hand in the area of the wrist joint.
2. Place your first finger on the back of your forearm.
3. II-IV fingers feel for the pulsating radial artery and press it against the radial artery.
4. Characterize the pulse waves for 1 minute.
5. It is necessary to determine the pulse simultaneously on the right and left radial arteries, comparing their characteristics, which should normally be the same.
6. The data obtained during the study of the pulse on the radial artery is recorded in the medical history or outpatient card, marked daily with a red pencil in the temperature sheet. In the column “P” (pulse) values of the pulse rate from 50 to 160 per minute are presented.
For diagnostic purposes, you can determine the pulse on other arteries:
ON THE CAROTID ARTERY – with low blood pressure, it is most often very difficult to detect the pulse on the radial artery, therefore, the pulse on the carotid artery is counted. It is necessary to examine the pulse alternately from each side without strong pressure on the artery. With significant pressure on the arterial wall, the following are possible: a sharp slowdown in cardiac activity, up to cardiac arrest; fainting; dizziness; convulsions. The pulse is palpated on the lateral surface of the neck anterior to the sternocleidomastoid muscle between the upper and middle thirds.
ON THE FEMORAL ARTERY – the pulse is examined in the inguinal region with a straightened thigh with a slight outward turn.
ON THE POPULAR ARTERY – the pulse is examined in the popliteal fossa with the patient lying on his stomach.
ON THE POST-TIBIAL ARTERY – the pulse is examined behind the inner ankle, pressing the artery against it.
ON THE ARTERIES OF THE DORSAL OF THE FOOT – the pulse is examined on the dorsum of the foot in the proximal part of the first intermetatarsal space.