VITAL SIGNS / CARDINAL SIGNS

baseline information determined to monitor changes in body functions

WHEN TO ASSESS 1. 2. 3. 4. Upon or on admission As ordered Before and after pre-op meds (invasive procedure/surgery) Before and after administration of blood (to monitor change) stop infusion!!! chilling, allergic reaction

5. Before and after any nursing intervention 6. When (+) for chest pain or any ABN sensation occurs 7. Before and after administration of medication that affects the Cardiovascular or Respiratory systems 4 RULES IN TAKING VITAL SIGNS 1. Place patient in a comfortable position 2. Inform the patient about the procedure 2 important protocols in institutions - check dr.s orders - verify your patient 3. Report any ABN reading to your baseline data 4. Frequency depends on the Dr.s order and the institution

BODY TEMPERATURE
Body Temperature - reflects the balance between the heat produced and the heat lost from the body, and is measured in heat units called degrees 2 kind of BT 1. Core Temperature 2. Surface Temperature is the temperature of the deep tissues of the body, Such as the cranium, thorax, abdominal and the pelvic cavity. remains relatively constant at 37C - skin, subcutaneous tissues, fats - 20C to 40C or 68F to 104F

Hypothalamus - center for thermoregulation a. Anterior H controls heat loss and vasodilation b. Posterior H controls heat production and vasoconstriction 1

Alterations / ABN Fever / Pyrexia / Hyperthermia - BT normal 36.5 to 37.5C - > 37.8C (oral) - > 38C (rectal)

Hyperpyrexia BT 41C - convulsions, seizures - possible brain damage Hypothermia - normal = < 35.5C in adults * normal BT in infants = 35.5C to 36.5C = underdeveloped hypothalamus, small body surface

Mechanisms of Heat Loss

1. Evaporation/Vaporization continuous evaporation of moisture from the respiratory tract and from the mucosa of the mouth and from the skin a. insensible heat loss b. insensible water loss continuous and unnoticed heat loss - accounts for 10% of basal heat loss continuous and unnoticed water loss

2. Conduction transfer of heat from one molecule to a molecule of lower temperature, e.g. TSB and ice pack 3. Radiation Transfer of heat from the surface of one object to the surface of another without contact between the 2 objects, e.g. infrared rays 4. Convection dispersion of heat by air currents

FACTORS THAT AFFECT HEAT PRODUCTION

1. BMR rate of energy utilization in the body required to maintain essential activities such as breathing 2. Muscle Activity increases metabolic rate 3. Thyroxine output increased thyroxine output increases the cellular metabolism chemical thermogenesis-the stimulation of heat production in the body through increased cellular metabolism 4. Epinephrine, norepinephrine and sympathetic stress response 5. Fever

Clinical signs of fever (Healthcare Lecture)

1. PR 2. RR 3. Shivering 2

4. 5. 6. 7. 8. 9.

Cold skin Body malaise Cyanotic nail beds Herpetic lips prone to severe dehydration cessation of sweating

NURSING INTERVENTION / MANAGEMENT /CARE OF Px WITH FEVER 1. Tepid Sponge Bath running, lukewarm water w/o alcohol (dry skin, skin darkening, can be an irritant) never rub (friction) 2. Vital signs 3. Skin Color (+) cyanosis 4. Remove excessive clothing / blanket for heat loss 5. Provide adequate nutrition monitor Intake-output 6. IVF as ordered by physician 7. Promote good hygiene good nursing care Good oral hygiene enhances appetite - prevents spread of infection - promotes salivation 8. Promote Rest 9. Provide full circulation of air through electric fan (convection) 10. Administer anti-pyretic drugs as ordered 2 TYPES OF NURSING INTERVENTION 1. Independent nursing intervention 2. Dependent nursing intervention with Dr.s orders

Clinical signs of fever (Kozier)

Onset (Cold or chill phase) Increased heart rate Increased respiratory rate and depth Shivering Pallid, cold skin Complaints of feeling cold Cyanotic nail beds Gooseflesh appearance of the skin Cessation of sweating Absence of chills Skin that feels warm Photosensitivity Glassy-eyed appearance Increased pulse and respiratory rates Increased thirst Mild to severe dehydration Drowsiness, restlessness, delirium or convulsions Herpetic lesions of the mouth 3

Course (Plateau Phase)

Defervescence (Fever abatement/Flush Stage

Loss of appetite (if the fever is prolonged) Malaise, weakness and aching mucsles Skin that appears flushed and feels warm Sweating Decreased shivering Possible dehydration

CLINICAL MANIFESTATIONS OF HYPOTHERMIA 1. Decreased body temperature, pulse and respirations 2. Severe chilling (initially) 3. Feelings of cold and chills 4. Pale, cold, waxy skin 5. Frostbite (nose, fingers, toes) 6. Hypotension 7. Decreased urinary output 8. Lack of muscle coordination 9. Disorientation 10. Drowsiness progressing to coma FACTORS AFFECTING BODY TEMPERATURE AGE Infant greatly influenced by temp of the environment - low BT - underdeveloped Hypothalamus Children more variable than adults before puberty Older people at risk for hypothermia due to - inadequate diet, - loss of subcutaneous fat, - lack of activity and - reduced thermoregulatory efficiency - they are also sensitive to extremes in the environmental temp.

DIURNAL VARIATIONS 1600 to 1800 hours 0400 to 0600 hours (by as much as 1 C or 1.8 F EXERCISE HORMONES Can increase BT up to 38.3C to 40C (101F to 104F) - rectal Women > hormone fluctuations than men. Progesterone secretion at the time of ovulation raises the BT by about 0.3C to 0.6C (0.5 to 1F) May increase production of epi-, norepi, Extremes in environmental temp may affect a persons BT 4

STRESS ENVIRONMENT

FEVER
FEBRILE - 37.6C AFEBRILE 36.5 to 37.5C Common types of Fever 1. Intermittent the BT alternates at regular intervals between periods of fever and periods of normal or subnormal temp. 2. Remittent wide range of temp. fluctuations more than 2C (3.6F) occurs over a 24hour period, all above normal 3. Relapsing short, febrile periods of a few days are interspersed with periods of 1 or 2 days of normal temp. 4. Constant/Sustained the BT fluctuates minimally but always remains above normal. 5. Fever spike temp that rises to fever level rapidly following a normal temp and then returns to normal within a few hours Heat stroke generally have been exercising under hot weather - have warm, flushed skin - do not sweat Heat exhaustion - result of excessive heat and dehydration - signs include paleness, dizziness, nausea, vomiting, fainting, and a moderately increased temp. (101F to 102F) Types of thermometers Mercury in glass used for oral and axillla Blue colored / Red colored rectal Disposable single use Electronic 2 to 60 secs Temperature sensitive tape surface temp. only; forehead and abdomen Infrared sense body heat in the form of infrared energy given by a heat source, w/c is in the ear canal 7. Temporal artery thermometers uses a scanning infrared thermometer that compares the arterial temp in the temporal artery of the forehead to the temp in the room and alculates the heat balance to approximate the core temp of the blood in the pulmonary artery * 2 types of oral thermometer that can be glass or elctronic 1. Basal thermometer calibrated with 0.1 F intervals and is for fertility purposes 2. Hypothermia thermometers have a greater low range 81 to 108 F 1. 2. 3. 4. 5. 6. CONVERSION Celsius = (F -32) 5/9 Fahrenheit = (1.8 C) +32 5

As Per RLE Lecture Factors Affecting BT - Condition of client - Envronment - Circadian Rhythm - Food - Gender Female higher BT than males after puberty; ovulation raises BT by 1 C Hormones 1. Hypothyroid low T4 and T3 low BT endomorphic 2. Hyperthyroid high T4 and T3 high BT - ectomorphic Cleaning Thermometer cleanest to dirtiest For Rectal, use water based lubricant (KY Jelly) oil based may irritate mucous membranes

Equipment: 1. 2. 3. 4. 5. 6. Thermometer Thermometer sheath or cover Water soluble lubricant for rectal temperature Disposable gloves Antiseptic wipes Towel for axillary temperature

ASSESING A PERIPHERAL PULSE

CLINICAL SIGNS OF CARDIOVASCULAR ALTERATIONS 1. 2. 3. 4. 5. 6. 7. Dyspnea difficulty in breathing Fatigue Pallor Cyanosis bluish discoloration of skin and mucous membranes Palpitations Syncope (fainting) Impaired peripheral tissue perfusion (as evidenced by skin discoloration and cool temp.)

FACTORS THAT MIGHT ALTER THE PULSE emotional status activity level medications that affect heart rate such as digoxin, beta blockers, or calcium channel blockers

FACTORS AFFECTING THE PULSE AGE GENDER EXERCISE FEVER MEDICATIONS Age Increase Pulse rate decrease < females PR

After puberty, average males PR is

PR *rate of increase in athletes is lesser than average person because of greater cardiac size, strength and efficiency PR PR/HR PR/HR 1. in response to the lower BP that results from peripheral vasodilation associated with elevated BT 2. due to increased metabolic rate - Epinephrine, Thyroxine - Cardiotonics (e.g. digitalis preparations) - Narcotics - Cardiac Glycoside or Digitalis Glycoside - digoxin (Lanoxin) - decrease heart rate by prolonging cardiac conduction, especially at the AV node - Beta blocker (e.g. propranolol) - Calcium channel blockers (verapamil)

ELECTROLYTE IMBALANCE PR/HR PR/HR - Blood Potassium (Hypokalemia) - Blood Potassium (Hyperkalemia) and irregular pulse 7

PR/HR PR/HR HYPOVOLEMIA

- Blood Calcium (Hypercalcemia) - Blood Calcium (Hypocalcemia)

STRESS

PR/HR in adults, loss of blood results in an adjustment of the heart rate to increase blood pressure as the body compensates for the blood loss adults may lose 10% of their normal circulating volume without adverse effects PR/HR sympathetic nervous stimulation increases overall activity of the heart (epinephrine, norepinephrine) stress increases the rate as well as the force of the heartbeat Fear, anxiety as well as severe pain stimulate the sympathetic system * when a person is sitting or standing, blood usually pools in dependent vessels of the venous system pooling results to transient decrease in venous blood return to the heart reduction in BP results increased HR Certain diseases such as some heart conditions or those that impair oxygenation can alter the pulse rate PR/HR - Acute MI PR/HR - Hyperglycemia PR/HR - Congestive Heart Failure PR/HR - Hypertensive Heart Disease SITE MOST APPROPRIATE FOR ASSESSMENT

POSITION CHANGES PATHOLOGY

RADIAL TEMPORAL CAROTID APICAL

BRACHIAL FEMORAL POPLITEAL POSTERIOR TIBIAL DORSALIS PEDIS

- Readily accessible - Used when radial pulse is not accessible - Used during cardiac arrest/shock in adults - Used to determine circulation to the brain - Routinely used for infants and children up to 3 years of age - Used to determine discrepancies with radial pulse - Used in conjunction with certain medications - Used to monitor clients with cardiac, pulmonary or renal disease - Used to measure blood pressure - Used during cardiac arrest for infants - Used in cardiac arrest/shock - Used to determine circulation to the leg - Used to determine circulation to the lower left leg - Used to determine circulation to the foot - Used to determine circulation to the foot

****PURPOSE OF ASSESSING A PERIPHERAL PULSE establish a baseline data for subsequent evaluation identify whether the pulse rate is within the normal range determine whether the pulse rhythm is regular and the pulse volume appropriate determine the equality of corresponding peripheral pulses on each side of the body monitor and assess changes in the clients health status monitor clients at risk for pulse alterations evaluate blood perfusion to the extremeties

PROCEDURE: 1.) - Identify yourself - verify clients identity - explain procedure what, why, and how the client can cooperate 2.) Aseptic techniques 3.) Privacy 4.) Select the pulse point 5.) Position client in a comfortable resting position. 6.) Palpate and count the pulse 7.) Assess the pulse rhythm and volume 8.) Document the pulse rate, rhythm and volume PULSE VOLUME LEVEL (0-4) 0 = No pulse/absent 1 = thready 2 = weak 3 = normal 4 = bounding NORMAL VALUES ADULTS 60 -100 ppm PULSE RHYTHM Regular or Irregular Equipment: 1. Watch

KOZIER NOTES PULSE a wave of blood created by the contraction of the left ventricle of the heart PULSE WAVE represents the stroke volume output or the amount of blood that enters the arteries with each ventricular contraction COMPLIANCE OF THE ARTERIES ability of the arteries to contract and expand CARDIAC OUTPUT volume of blood pumped into the arteries by the heart equals the result of the stroke volume (SV) times the heart rate (HR) per minute In a healthy person the pulse reflects the heartbeat

PERIPHERAL PULSE pulse located away from the heart APICAL PULSE central pulse; located at the apex of the heart; also referred to as the Point of Maximal Impulse (PMI)

10

ASSESSING AN APICAL PULSE

CLINICAL SIGNS OF CARDIOVASCULAR ALTERATIONS 1. 2. 3. 4. 5. 6. 7. Dyspnea difficulty in breathing Fatigue Pallor Cyanosis bluish discoloration of skin and mucous membranes Palpitations Syncope (fainting) Impaired peripheral tissue perfusion (as evidenced by skin discoloration and cool temp.)

FACTORS THAT MIGHT ALTER THE PULSE emotional status activity level medications that affect heart rate such as digoxin, beta blockers, or calcium channel blockers

Equipment: 1. Watch with a second hand 2. Stethoscope 3. Antiseptic wipes Procedure: 1.) - Identify yourself - verify clients identity - explain procedure what, why, and how the client can cooperate 2.) Aseptic techniques 3.) Privacy 4.) Position client in a comfortable supine or sitting position. Expose the area of the chest over the apex of the heart 5.) Locate the apical pulse - Manubrium Angle of Louis slide to the left of the sternum (palpate the 2 nd intercostals space place your middle or next finger in the 3 rd ICS until you locate the 5th ICS move finger toward the MCL 6.) Auscultate and count heart beats clean earpiece and diaphragm warm diaphragm insert earpiece of the stethoscope tap finger on diaphragm 11

place stethoscope on site of apical pulse if you have difficulty auscultating the apical pulse, ask the client to roll ontonhis/her left side or the sitting client to lean slightly forward 7.) Assess Rhythm (regular/irregular) and strength (strong or weak) of heartbeat

ASSESSING AN APICAL RADIAL PULSE

CLINICAL SIGNS OF HYPOVOLEMIC SHOCK 1. 2. 3. 4. 5. 6. 7. Hypotension Pallor Cyanosis Cold, clammy skin Thirst Alterations of mental status Suppression of kidney function

Equipment 1. Watch with a second hand 2. Stethoscope 3. Antiseptic wipes Procedure: 1.) - Identify yourself - verify clients identity - explain procedure what, why, and how the client can cooperate 2.) Aseptic techniques 3.) Privacy 4.) Position the client appropriately 5.) Locate the apical and radial pulse sites 6.) count the apical and radial pulse rates Two-nurse technique One nurse technique

12

ASSESING RESPIRATIONS
***PURPOSE - acquire baseline data - monitor abnormal respirations and respiratory patterns and identify changes - monitor respirations before or following the administration of a general anesthetic or any medications that influence RR - monitor clients at risk for respiratory alterations 1. fever 2. pain 3. acute anxiety 4. COPD 5. asthma 6. respiratory infection 7. pulmonary edema or emboli 8. chest trauma or constriction 9. brain stem injury PREPARATION Assess 1. 2. 3. 4. 5. 6. 7. 8. Skin and mucous membrane color cyanosis or pallor Position assumed for breathing e.g. use of orthopneic position Signs of cerebral anoxia irritability, restlessness, drowsiness, loss of consciousness Chest movements retractions between the ribs or above or below the sternum Activity Tolerance Chest pain Dyspnea Medications affecting respiratory rate a. Narcotics - RR (e.g. morphine, large doses of barbiturates such as secobarbital sodium depress the respiratory centers in the brain, thereby depressing the RR and the depth.)

Factors that affect Respirations INCREASE Exercise Stress Increased Environmental Temp. Lowered Oxygen concentration altitudes Body Position DECREASE Certain medications (narcotics) Decreased environmental Temp. high Increased intercranial pressure

at

13

Supine - Respiration 1. Increase in the volume of the blood inside the thoracic cavity 2. compression of the chest Equipment: 1. Watch with second hand Procedure: 1.) - Identify yourself - verify clients identity - explain procedure what, why, and how the client can cooperate 2.) Aseptic techniques 3.) Privacy 4.) Observe or palpate RR 5.) Observe depth watch movement of chest rhythm - regular or irregular character sound they produce and the effort they require 6.) document the respiratory rate, depth, rhythm and character 1 cycle of respiration = 1 inhalation and 1 exhalation Respiratory Rate Normal values = 16 20 cpm Respiratory Depth: Normal (500 ml of air) - Tidal volume Deep Shallow

Respiratory Rhythm: Regular Irregular

Respiratory quality or character amount of effort a client exerts in breathing (e.g. labored breathing) sound of breathing (e.g. wheeze) 14

Pulse Oximeter indirectly measures the amount of hemoglobin in the arterial blood that is saturated with oxygen; provides a digital readout of both the clients pulse rate and oxygen saturation. Altered Breathing Patterns Rate: - Bradypnea less than or equal to 15 cpm - Tachypnea more than or equal to 21 cpm - Apnea absence of breathing Volume: Hyperventilation overexpansion of the lungs characterized by rapid and deep breaths Hypoventilation underexpansion of lungs, characterized by shallow respirations

Rhythm: - Cheyne-Stokes breathing from very deep to very shallow breathing and temporary apnea Ease or effort: Dyspnea difficult and labored breathing Orthopnea ability to breathe in only upright sitting or standing positions

Altered Breath Sounds 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 contninuous, 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 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 15

Nonproductive cough a dry, harsh cough without secretions

KOZIER NOTES Respiration act of breathing Inhalation/Inspiration intake of air into the lungs Exhalation/Expiration breathing out; movement of gases from the lungs to the atmosphere Costal (thoracic breathing) involves the external intercostals muscles and other accessory muscles such as the sternocleidomastoid muscles. Diaphragmatic (abdominal) breathing involves the contraction and relaxation of the diaphragm and it is observed by the movement of the abdomen Control of Respiration 1. Respiratory centers in the medulla oblongata and pons 2. chemoreceptors located centrally in the medulla and peripherally in the aortic and carotid bodies (respond to changes in O2, CO2 and H+ concentrations in the blood)

16

ASSESSING BLOOD PRESSURE

***PURPOSE 1. obtain baseline data 2. determine clients hemodynamic status (e.g. cardiac output; stroke volume of the heart and blood vessel resistance) 3. identify and monitor changes in BP resulting from a disease process or medical therapy (e.g. presence or history of CV disease, renal disease, circulatory shock, acute pain, rapid infusion of fluids or blood) SIGNS AND SYMPTOMS OF HYPERTENSION 1. 2. 3. 4. 5. Headache Ringing in ears Flushing of face Nosebleeds Fatigue

SIGNS OF HYPOTENSION 1. 2. 3. 4. 5. 6. Tachycardia Dizziness Mental confusion Restlessness Cool and clammy skin Pale or cyanotic skin

FACTORS AFFECTING BLOOD PRESSURE LAB 1. 2. 3. 4. 5. Activity Emotional Stress Pain time client last smoked time client last ingested caffeine Newborn mean systolic pressure of about 75 mm Hg BP rises with age reaching peak at the onset of puberty and tends to decline somewhat Elders- elasticity of the arteries is decreased produces an elevated systolic pressure. Because the walls do not retract as flexibly with decreased pressure, the diastolic may also be high

KOZIER AGE

EXERCISE

Increase cardiac output ( let client rest for 20 to 30 mins following 17

exercise before taking BP) STRESS RACE GENDER MEDICATIONS Stimulation of Sympathetic Nervous System increases Cardiac Output and vasoconstriction of the arterioles, thus increasing BP Severe pain can decrease BP greatly by inhibiting the vasomotor center and producing vasodilation

African American males over 35 > European American males same age After puberty, females BP < BP of males same age (hormonal) After menopause, women have higher BP than before

OBESITY DIURNAL VARIATIONS DISEASE PROCESS

Antihypertensives 1. thiazide diuretic cause blood vessels to dilate, help kidneys eliminate salt and water, decrease fluid volume throughout the body 2. Adrenergic blockers (alpha-blockers, beta-blockers, alpha-betablockers, peripherally acting adrenergic blockers) block the effects of the sympathetic division 3. Centrally acting alpha-agonists by stimulating certain receptors in the brain stem, these agonists inhibit the effect of the sympathetic division 4. Angiotensin-converting enzyme (ACE) Inhibitors dilate arterioles by preventing the formation of Angiotensin II by blocking the action of ACE, which converts angiotensin I to angiotensin II 5. Angiotensin II Blockers directly block angiotensin II, lesser side effects 6. Calcium channel blockers dilate arterioles; may be long term or short term 7. Direct Vasodilators Hypertension - use of birth control pills (oral contraceptives) - Hormonal disorders a. Cushings syndrome high levels of cortisol b. Hyperthyroidism overactive thyroid gland c. Hyperaldosteronism overproduction of aldosterone, often by a tumor in one of the adrenal glands d. Pheochromocytoma ( a tumor that is located in the adrenal gland that produces epinephrine and norepinephrine) - Caffeine- increase PR and BP - Smoking constricts blood vessels tem increase in BP Predisposed to hypertension BP lowest in early morning where metabolic rate is lowest, rises throughout the day and peaks in the late afternoon or early evening Any condition affecting cardiac output, blood volume, blood viscosity, compliance of the arteries

Check the client for allergy to latex cuff 18

Equipment : Stethoscope, Blood pressure cuff, Sphygmomanometer PROCEDURE 1.) - Identify yourself - verify clients identity - explain procedure what, why, and how the client can cooperate 2.) Aseptic techniques 3.) Privacy 4.) Position client appropriately 5.) wrap the deflated cuff evenly around the upper arm. 6.) If this is the clients initial exeamination, perform a preliminary palpatory determination of systolic pressure 7.) position the stethoscope clean the earpieces with antiseptic wipes insert ear piece ensure that the stethoscope hangs freely from the ears to the diaphragm place the bell side over the brachial pulse site place stethoscope directly on skin 8.) Auscultate clients BP 9.) If this is clients initial examination, repeat procedure in clients other arm

KOZIER NOTES Arterial Blood Pressure is the measure of the pressure exerted by the blood as it flows through the arteries Systolic Pressure pressure of the blood as a result of the contraction of the ventricles, that is, the pressure of the height of the blood wave Diastolic Pressure pressure when the ventricles are at rest; lower pressure, present at all times in the arteries Pulse pressure the difference bet. Systolic and diastolic NV=40 - elevated exercise = 100 - arteriosclerosis - low - severe heart failure (25 mm Hg) 19

DETERMINANTS OF BP 1. Pumping Action of the Heart Pumping action blood pumped into arteries cardiac output BP

2. Peripheral Vascular Resistance Factors that create resistance in the arterial system a. capacity of the arterioles and capillaries b. compliance of the arteries c. viscosity of the blood Smaller space within the vessel resistance - Vasoconstriction - BP (smoking) - Vasodilation - BP 3. Blood Volume directly proportional to BP

BP

4. Blood Viscosity - BP when blood is highly viscous the proportion of RBC to blood plasma is high. This proportion is called the hematocrit. Viscosity increases when the hematocrit is more than 60% to 65% Classification of Blood Pressure CATEGORY Normal Prehypertension Hypertension Stage 1 Hypertension Stage 2 Hypertension SYSTOLIC BP mm Hg < 120 120-139 140-159 >160 DIASTOLIC BP mm Hg < 80 80 89 90-99 >100

BP that is persistently above normal - asymptomatic and often a contributing factor to MI 1. Primary hypertension elevated BP of unknown cause 2. Secondary hypertension known cause

Factors associated with hypertension 1. 2. 3. 4. 5. 6. 7. 8. thickening of arterial walls inelasticity of arteries cigarette smoking obesity heavy alcohol consumption lack of exercise high blood cholesterol levels continued exposure to stress 20

Hypotension BP that is below normal a systolic reading consistently between 85 to 110 mm Hg in an adult whose normal pressure is higher than this Orthostatic hypotension BP that falls when a client sits or stands - caused by peripheral vasodilation in which blood leaves the central body organs, especially the brain, and moves into the periphery Hypotension can also be caused by - analgesics such as Meperidine HCl (Demerol) - bleeding - severe burns - dehydration

21