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245 Cards in this Set
- Front
- Back
What 4 things are assessed when taking vital signs? What is often assessed along with vital signs?
|
- temperature
- pulse - respiration - blood pressure (pain is often assessed with vital signs) |
|
What is the primary purpose of taking vital signs?
|
to monitor essential physiologic function of vital organs
|
|
In addition to monitoring vital organ function, what other purpose does taking vital signs serve?
|
evaluates health status and gives us baseline information regarding health
|
|
How long should you wait before assessing a person's vital signs who was active?
|
about 15 minutes
|
|
Guidelines are in place when assessing vital signs to offer a range for reference. However, when assessing an individual patient what must you also consider?
|
trends or patterns established by that particular patient
|
|
Observing trends in Vital Signs allows the nurse to do what 4 things?
|
- clinical problem solving
- make decisions about treatments/interventions - evaluate effectiveness of medications and treatments - evaluate the response to illness |
|
What are 5 occasions when vital signs are taken?
|
- on admission
- per hospital routine or physician's order - before and after surgery or diagnostic procedure, medications or nursing interventions affecting VS - before, during, and after blood/blood product transfusion - when there is a change in client's condition or a report of physical distress |
|
True/false:
A nurse must obtain a doctor's order to take vital signs. |
False-
A nurse can use his/her own judgment to take vital signs. REMEMBER- You have to take them minimally according to policy or orders, but can access more often using YOUR judgment! |
|
(def)
the heat of the body determined by the balance of heat produced and heat lost |
body temperature
|
|
Body temperature is stated in what two degrees?
|
Fahrenheit or Celsius
|
|
What are two examples of temperature methods used to detect core temperature?
|
Tympanic and rectal
|
|
What are two examples of temperature methods used to detect surface temperature?
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Oral and axillary
|
|
What part of the brain is the thermoregulatory center?
|
hypothalamus
|
|
The hypothalamus receives messages from ___________ ____________.
|
thermal receptors
|
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What type of regulatory response would you see when the nerve cells in the hypothalamus become heated?
|
Compensatory mechanisms, such as sweating and vasodilation to promote heat loss
|
|
What type of reaction might you see in the body when the hypothalamus detects a low body temperature?
|
shivering and vasoconstriction
|
|
How does vasoconstriction apply to body temperature?
|
vasoconstriction conserves body heat
|
|
Temperature deep in the body is referred to as what?
|
core temperature
|
|
What is the primary source of heat production in the body?
|
metabolism
|
|
(def)
heat production at rest |
BMR
|
|
True/False:
Shivering decreases body temperature. |
False-
Shivering is the body's mechanism of INCREASING body temperature. |
|
What are the 4 methods of heat transfer?
|
- radiation
- conduction - convection - evaporation |
|
Heat loss caused by sitting in a cold room is an example of what mechanism of heat transfer?
|
radiation
|
|
(def)
diffusion of heat by electromagnetic waves |
radiation
|
|
Heat loss caused by taking a cool bath is an example of what mechanism of heat transfer?
|
conduction
|
|
(def)
transfer of heat through direct contact |
conduction
|
|
Heat loss caused by using an electric fan to cool off is an example of what mechanism of heat loss?
|
convection
|
|
(def)
transfer of heat via air currents |
convection
|
|
Heat loss caused by sweating and respiration is an example of what mechanism of heat transfer?
|
evaporation
|
|
(def)
the conversion of liquid to vapor |
evaporation
|
|
(def)
raised body temperature; fever |
pyrexia
|
|
Pyrexia is described as a fever over ______ F or _______ C.
|
100.4 F or 38 C
|
|
(def)
the condition of having a body temperature greatly above normal |
hyperthermia
|
|
(def)
the condition of having a subnormal temperature |
hypothermia
|
|
To be classified as hypothermia, the body's temperature must be lower than _____ F or ______ C.
|
96.8 F or 36 C
|
|
What is the normal value for an oral temperature?
|
97.6 to 99.6 F or 36.5 to 37.5 C
|
|
How much higher is a rectal temperature vs. an oral temperature?
|
1 F or 0.5 C
|
|
How much lower is an axillary temperature vs. and oral temperature?
|
1 F or 0.5 C
|
|
True/False:
A tympanic temperature is 0.5 F higher than an oral temperature. |
True
|
|
What are the 4 types of thermometers?
|
- mixture of gallium, indium and tin enclosed in plastic
- electronic - chemical - temperature-sensitive tape |
|
What type of thermometer requires you to shake it down and hold it at eye level to read?
|
Mixture
|
|
What type of thermometer has a pencil like probe with a cover?
|
electronic
|
|
Chemical thermometers that are disposable plastic strips are used for what two methods of assessment?
|
oral and axillary
|
|
What type of thermometer would be applied to the skin and changes color according to the skin temperature?
|
temperature-sensitive tape
|
|
What is the most commonly used method of temperature assessment?
|
oral
|
|
How long should you wait to take a temperature after a patient has eaten, drank or smoked?
|
30 minutes
|
|
How long does it take to take an oral temperature using a gallium thermometer?
|
3-5 minutes
|
|
What are some contraindications to taking an oral temperature?
|
- mouth breathing
- uncooperative - seizures - unconscious - younger than 6 years old - nasal/oral surgery or trauma |
|
What is the most accurate method of assessing temperature?
|
rectal
|
|
What PPE should be donned when taking a rectal temperature?
|
gloves
|
|
True/False:
Lubricant is not required for taking a rectal temperature. |
false - you should always lubricate the tip of the thermometer
|
|
Rectal thermometers should be inserted towards the ___________.
|
umbilicus
|
|
How far should a rectal thermometer be inserted in adults? children? infants?
|
adults - 1.5 inches
children - 1 inch infants - 1/2 inch |
|
How long must you hold a rectal gallium thermometer in place?
|
2-4 minutes
|
|
What are some contraindications in assessing rectal temperature?
|
- rectal/prostate surgeries or disorders
- diarrhea or impacted stool - serious heart disease - newborns |
|
Why would you not want to assess the temperature rectally in a patient with serious heart disease?
|
- vagal stimulation may sow the heart rate
|
|
Why would you not want to assess the temperature rectally in a newborn?
|
- you could perforate the rectal wall
|
|
What is the safest and least invasive method of assessing temperature?
|
axillary
|
|
How long must you hold a gallium thermometer in place to assess axillary temperature?
|
8-10 minutes
|
|
Would the tympanic method of assessing temperature provide you with an accurate surface or core temperature?
|
core
|
|
________, __________, or __________ processes may cause fever.
|
Infection, inflammatory, or immunologic processes
|
|
(def)
a substance, typically produced by a bacterium, that produces fever when introduced or released into the blood. |
pyrogens
|
|
What happens to the body's setpoint temperature when endogenous pyrogens are introduced into the blood?
|
the hypothalamus raises the body's setpoint in response to the pyrogens being present
|
|
What are some beneficial consequences of fever?
|
- stimulate the body to produce WBCs
- decreases iron in blood plasma which suppresses bacterial growth - increases production of interferon, a virus-fighting substance |
|
What are some harmful consequences of fever?
|
- increases BMR, P and R rates
- excessive sweating may lead to dehydration - prolonged fever may result in tissue catabolism, muscle wasting, aching, negative nitrogen balance, weight loss, apathy, delirium and withdrawl - fever over 41 C may lead to seizures or neurological complications |
|
Fever above _____ C may lead to seizures or neurological complications.
|
41
|
|
What are the 3 phases of the febrile episode?
|
- chill phase
- plateau phase - fever break |
|
During which phase of the febrile episode is heat conserved? During which phase is heat lost?
|
During the "chill phase" heat is conserved. During the "fever break" heat is lost.
|
|
During which phase of the febrile episode does the setpoint rise?
|
Chill phase
|
|
Why does the client experience chills and shivering during the "chill phase" of the Febrile Episode?
|
because the body is trying to conserve heat
|
|
What occurs during the plateau phase of the Febrile Episode?
|
Chills subside and the client experiences a warm and dry feeling because the new temperature setpoint is reached
|
|
During which phase of the Febrile Episode would a patient experience vasodialation?
|
Fever break
|
|
Why does a client experience sweating (diaphoresis) during the "fever break" phase of the Febrile episode?
|
because the setpoint decreases, and the body is attempting to lose heat or return to its normal setpoint
|
|
What is the proper way to clean a thermometer prior to use? What about after use?
|
Prior to use, clean from the bulb to your hand (clean to dirtiest). After use, clean from hand to bulb (clean to dirtiest)
|
|
Which temperature route best reflects the core body temperature?
|
rectal is said to be most accurate
|
|
When assessing a client with fever, you should always assess for causality as well. What are some examples of situations that may cause fever?
|
- dehydration
- infection - environment (exposure to extreme heat/cold) |
|
What other assessment measures should be done for a client experiencing fever?
|
- monitor all vitals (not only fever)
- assess for causality - assess skin color and temperature - determine phase of febrile episode - assess comfort level |
|
Which of the following symptoms of fever would adversely affect an already weakened patient?
-increase WBCs -increase BMR -suppress bacterial growth -decrease level of iron in the blood |
Increase BMR - this results in an increase in caloric intake, weight loss, and increases need for oxygen
|
|
What are 2 nursing interventions that will decrease heat production in a client with fever?
|
- limit physical activity
- promote rest |
|
What are 2 nursing interventions that will increase heat loss in a client with fever?
|
- remove external covers
- keep linens and clothing dry |
|
What can be done to meet the increased BMR needs of a febrile patient? (2)
|
- Administer O2 as ordered
- Provide adequate nutrition and fluids |
|
How can you promote client comfort in a febrile patient? (4)
|
- frequent oral care
- control environmental temperature - bed bath - change linens |
|
During the systolic phase of the cardiac cycle, the left ventricle ejects approximately how many mL of blood into the aorta?
|
60-70 mL
|
|
How is Pulse or Heart Rate measured?
|
by counting the number of palpable pulse beats per minute
|
|
What is the adult normal range for pulse?
|
60-100 bpm
|
|
What does palpate mean?
|
feel
|
|
What body system regulates the pulse rate?
|
Autonomic Nervous System
|
|
Would the parasympathetic Vagus nerve increase or slow the pulse rate?
|
slows the pulse rate
|
|
What is increased via the sympathetic nervous system to increase pulse?
|
epinephrine and norepinephrine
|
|
How long should "you" count the pulse?
|
30 seconds
(multiply results by 2) |
|
What are some factors affecting P or HR?
|
- age
- sex - activity - fever - medications - hemorrhage - stress - position changes - vagal stimulation - pain |
|
Which would you expect to have a higher pulse, a 6 month old female or a 22 year old male?
|
6 month old female
|
|
Do men or women have a higher pulse rate?
|
women
|
|
How long should you wait to take a pulse after activity?
|
30 minutes
|
|
Would an athlete have a higher or lower than average heart rate?
|
lower
|
|
A patient is in recovery after surgery. You observe an increase in heart rate followed by a sudden, drastic decrease. What would this be indicative of?
|
hemmorrhage
|
|
Would medications increase or decrease heart rate?
|
It depends on the medication
|
|
What effect does stress have on heart rate?
|
it increases it
|
|
Does the body's position affect heart rate?
|
Yes, for example standing after lying will result in a decrease in blood pressure
|
|
Will pain increase or decrease heart rate?
|
increase
|
|
Where is the vagus nerve located in the body?
|
In the GI tract, extending from the mouth to the anus
|
|
How does straining to have a bowel movement, gagging or vomiting affect heart rate?
|
It decrease heart rate due to vagal nerve stimulation
|
|
Where are the vagal receptors located in the body?
|
- Carotid artery sinus in the upper third of the neck
|
|
The carotid artery sinus houses vegal receptors. How does this affect our procedure for taking a carotid pulse?
|
We palpate the carotid artery in the lower half of the neck
|
|
What are 2 methods for assessing pulse?
|
- palpation
- auscultation |
|
What fingers should be used to assess the pulse? Which should be avoided?
|
Middle 3 to palpate (pads of fingertips more sensitive); avoid using the thumb
|
|
What are 2 tools used to ausculate pulse?
|
- stethoscope
- doppler ultrasound |
|
What are the 6 major Peripheral pulses?
|
- Carotid
- Radial - Brachial - Femoral - Popliteal - Pedal pulses |
|
What is the most accurate peripheral pulse?
|
carotid pulse
|
|
True/false:
You should never check both carotid pulses at the same time. |
True - palpation of both at the same time could hinder blood flow to the brain
|
|
What type of pulse assessment is used in CPR?
|
Carotid
|
|
Where should you place your fingers when assessing a carotid pulse?
|
between the trachea and the sternocleidomastoid muscle on the LOWER half of the neck
|
|
What is the most common type of pulse assessment?
|
Radial
|
|
What pulse assessment is used in infant CPR?
|
brachial pulse
|
|
True/False:
Assessing both dorsalis pedis pulses at the same time is necessary to check for equal rates. |
False- both pulses would be checked to assess equal volume or synchronized beats
|
|
What site for pulse assessment is used when taking blood pressure?
|
Brachial
|
|
What pulse locations would be assessed when checking for circulation?
|
- femoral
- popliteal - pedal pulses (dorsalis pedis, posterior tibial) |
|
Which location would yield a higher blood pressure rating, the brachial or popliteal pulse?
|
popliteal yields higher results
|
|
How long should you auscultate a central pulse?
|
a full minute
|
|
What is the next assessment step if you detect an abnormal peripheral pulse?
|
ausculate the apical pulse
|
|
A nurse is caring for a patient with CV disease. What type of pulse assessment would be standard on this patient?
|
apical pulse
|
|
What is the standard location of the apical pulse?
|
the apex of the heart (usually heard loudest at the 5th intercostal space, midclavicular line)
|
|
Where should you begin your count when assessing a pulse?
|
always start at 0
|
|
What two sounds correlate with cardiac cycle?
|
systole and diastole (S1 and S2)
|
|
What anatomical landmarks should you follow to locate the apical pulse?
|
- locate the suprasternal notch, angle of Louis, which is level with the 2nd ICS
- count rib spaces down to the 5th ICS, midclavicular line |
|
What is the purpose of detecting an apical-radial pulse?
|
to assess if there is a pulse deficit
|
|
When assessing apical-radial pulse, what might you deduct if the radial pulse produced is diminished or absent?
|
that the left ventricle contraction is weak
|
|
A ________ __________ occurs when the apical pulse is greater than the peripheral pulse.
|
pulse deficit
|
|
What does a pulse deficit indicate?
|
poor peripheral circulation/perfusion
|
|
What are the 5 things that you should assess the pulse for?
|
- rhythm
- amplitude (volume) - rate - elasticity - equality |
|
(def)
the pattern or spacing between pulse beats; may be regular or irregular |
rhythm
|
|
An irregular rhythm in pulse is known as what?
|
dysrhythmia
|
|
The strength or force of a pulse is known as what?
|
amplitude (volume)
|
|
The amplitude of a pulse is measured on a scale from 0 to +3. Describe each individual measurement.
|
0 = absent
+1 = difficult to feel (weak); easy to obliterate +2 = normal; easy to feel; obliterates with stronger force +3 = strong, bounding; difficult to obliterate |
|
(def)
the number of heart beats per minute |
rate
|
|
How long should you count a regular rhythm pulse?
|
30 seconds (multiply by 2)
|
|
How long should you count an irregular rhythm pulse?
|
60 seconds
|
|
A pulse lower than 60 is called what?
|
bradycardia
|
|
A pulse greater than 100 is called what?
|
tachycardia
|
|
Describe normal and abnormal elasticity of arteries.
|
normal = soft, pliable
abnormal = hard, twisted, tortuous |
|
How do you determine the equality of a pulse?
|
assess the left and right pulse at the same time
|
|
What type of changes should be reported immediately?
|
- absent, weak, thready pulse
- pulse deficit - significant change in resting pulse - change in volume or rhythm - cool, pale skin |
|
A nurse assesses a patient's radial pulse at 88. She/he finds it easy to feel and puts moderate force to obliterate the pulse. Upon further examination, she/he finds that the artery feels soft and pliable and that the rhythm is regular. How is this information documented?
|
radial 88/m regular, +2 smooth
|
|
True/False:
When performing an apical-radial pulse, it is imperative that both nurses starts their individual watches at the exact same time to ensure an accurate count. |
False-
An apical-radial pulse requires that both nurses use the SAME watch! |
|
What are some pulse/blood pressure changes you may expect to see in the elderly?
|
- loss of compliance (elasticity)
- Blood pressure may be higher to compensate for the loss of arterial compliance - after activity, it takes longer for the pulse to return to "resting" state |
|
True/false:
The elderly usually have a higher heart rate. |
False -
While blood pressure may be higher to compensate for compliance issues, heart rate is usually the same. |
|
(def)
the act of breathing (exchange of gases) for 1 minute; |
respiration
|
|
What is the average length of inspiration? Expiration?
|
Inspiration = 1-1 1/2 seconds
Expiration = 2-3 seconds |
|
What 3 muscles 'may' be used in respiration?
|
- diaphragm
- intercostals - accessory |
|
What is the major muscle of respiration?
|
diaphragm
|
|
What muscle(s) would you expect to be used when a patient is having difficulty breathing?
|
- diaphragm
- intercostals - accessory (ex. neck muscles) |
|
What are the 3 processes of respiration?
|
- ventilation
- diffusion - perfusion |
|
(def)
mechanical movement of respiration; the act of breathing |
ventilation
|
|
(def)
the movement of O2 and CO2 between alveoli and RBCs |
diffusion
|
|
(def)
the distribution of RBCs from pulmonary capillaries to the rest of the body |
perfusion
|
|
Neural regulation of respiration involves what 2 parts of the brain?
|
- medulla oblongata
- cerebral cortex |
|
You observe a client's respiration without their knowledge. What part of the brain is likely controlling the breathing that you document?
|
medulla oblongata - responsible for involuntary, automatic control of breathing
|
|
What part of the brain would likely be controlling breathing if the patient was aware that you were counting their respiration rate?
|
cerebral cortex - voluntary control of respirations
|
|
What structures detect the presence of CO2 and O2 in the blood?
|
chemoreceptors located in the aorta and carotid arteries
|
|
What 4 things should you assess when observing respirations?
|
- rhythm
- rate - effort/ease - depth |
|
Rhythm of respirations should be recorded as either ________ or _______.
|
regular or irregular
|
|
If you cannot see the chest rise/fall when assessing respirations, how should you position the client?
|
place the client's arm over their abdomen
|
|
In the "Assessment of Vital Signs", at what point should you assess respirations?
|
immediately after taking their pulse
|
|
How long should you count respirations?
|
30 seconds
|
|
What is the normal range for respirations?
|
12-20 breaths per second
|
|
(def)
regular respirations between 12-20; no effort required to breath |
eupnea
|
|
(def)
respirations below 12 breaths per minute |
bradypnea
|
|
(def)
respirations above 20 per minute |
tachypnea
|
|
(def)
absence of breathing |
apnea
|
|
(def)
difficulty breathing; shortness of breath |
dyspnea
|
|
(def)
breathing done with great effort and difficulty |
labored
|
|
(def)
shortness of breath (dyspnea) which occurs when lying flat, causing the person to have to sleep propped up in bed or sitting in a chair |
orthopnea
|
|
What 3 descriptions are used to describe varying depths of respirations?
|
- full
- hypoventilation - hyperventilation |
|
What description would you use to describe breathing that was very shallow and undetectable by chest or abdomen movements?
|
hypoventilation
|
|
If a client is experiencing hypoventilation, how might you have to observe respiration depth?
|
observe shoulders or use stethoscope
|
|
(def)
very deep movement of the chest/abdomen when breathing |
hyperventilation
|
|
What do you do if a client sighs or yawns while counting respirations?
|
You count that as a breath, both are part of the normal breathing cycle
|
|
Rapid, deep breathing as seen with diabetes ketoacidosis is known as what?
|
Kussmaul
|
|
Respirations that go from shallow -> deeper -> shallow -> apnea, as seen in head injuries are known as what?
|
Cheyne-Stokes
|
|
Totally erratic respirations displaying no pattern (often seen when death is imminent) are known as what?
|
agonal
|
|
How does exercise influence respirations?
|
increases the rate
|
|
How does acute pain influence respirations?
|
increases the rate and rhythm
|
|
How does anxiety influence respirations?
|
increases the rate and depth
|
|
How does smoking influence respirations?
|
increases the rate at rest
|
|
What body position offers full expansion of the chest cavity, easing breathing?
|
upright/straight
|
|
What change in respirations would you expect to see in a client who receives narcotics?
|
slower rate
|
|
How might a neurological injury affect respirations?
|
- decreases rate; changes rhythm
|
|
What occurs to respirations when a client has low hemoglobin function?
|
the rate increases
|
|
What effect does the decrease in the arterial elasticity of elderly clients have on their respiration rate?
|
respirations are shallower and slightly faster
|
|
A nurse assesses the respiration rate of an 83 year old black female at 23 per minute. Why is this not an immediate cause of concern?
|
Respiration rate in elderly clients is often higher due to the decrease in elasticity of arteries/veins
|
|
Arterial blood pressure measure what?
|
arterial wall pressure created as blood flows through the arteries throughout the cardiac cycle
|
|
BP is written as a fraction consisting of what 2 parts?
|
systolic BP
diastolic BP |
|
What is the systolic and diastolic blood pressures of a BP 120/80?
|
systolic = 120
diastolic = 80 |
|
Which BP, systolic or diastolic, is the pressure created as the left ventricle ejects blood?
|
systolic
|
|
Which BP, systolic or diastolic, is when the heart relaxes?
|
diastolic
|
|
(def)
the difference in systolic and diastolic BP |
pulse pressure
|
|
What is the normal range of pulse pressure?
|
30-50 mm Hg
|
|
What might be the cause of an abnormal pulse pressure?
|
neurological or cardiac dysfunction
|
|
What is the range of normotensive BP? Pre-hypertensive? Hypertensive Stage 1 and 2?
|
normontensive 90/60 - 139/89
pre-hypertensive 120/80 - 139/89 hypertensive stage 1 - 140/90 - 159/99 hypertensive stage 2 - 160/100 and above |
|
A blood pressure below 90/60 in an adult who's BP is normally higher than that is termed what?
|
hypotension
|
|
For a blood pressure below 90/60 to be considered hypotensive, what must be present?
|
symptoms or a significant change
|
|
(def)
volume of blood (stroke volume) pumped by the heart in one minute |
Cardiac Output (CO)
|
|
(def)
resistance to blood flow determined by the tone of vascular musculature and the diameter of blood vessels |
Peripheral resistance
|
|
(def)
amount of blood circulating within the vascular system |
blood volume
|
|
(def)
thickness of blood |
viscosity
|
|
(def)
ability of arteries to stretch |
elasticity
|
|
What measures the ratio of blood cells to plasma?
|
Hematocrit
|
|
A patient's hematocrit test indicates a high number of RBCs in ratio to blood plasma. How would you expect this to affect the blood's viscosity?
|
the blood would be thicker than normal
|
|
How does age affect BP?
|
Higher age = lower elasticity, build-up of plaque in arteries
|
|
How does stress affect BP?
|
stress stimulates flight or fight response (sympathetic system) and increases vasoconstriction
|
|
What are the differences in BP between males and females?
|
Males have higher blood pressure than females until menopause when it tends to equal out
|
|
What race tends to have higher BP?
|
African Americans
|
|
Would you expect to see a higher BP in the morning or evening? Why?
|
Higher BP in evening when metabolic rate peaks
|
|
True/False:
Medications may increase or decrease BP. |
True
|
|
How long should you wait to take the BP of a person who was exercising. Why?
|
30 minutes because exercise does increase BP (although the change is NOT as dramatic as pulse changes)
|
|
A client is diagnosed with diabetes mellitus. What type of BP reading would you expect to see in this client?
|
BP will be high, probable hypertension
|
|
Would you expect a higher or lower BP in an obese patient?
|
higher
|
|
True/False:
Smoking and/or high alcohol consumption results in higher BP |
True
|
|
What are 3 known complications of hypertension?
|
- CVA
- Kidney Failure - Eyesight problems |
|
Although hypertension is commonly asymptomatic, what symptoms are associated with this disorder?
|
- headaches
- nosebleeds - flushing - fatigue |
|
What are some symptoms of hypotension?
|
- dizziness
- confusion - fainting - decreased urine output - chest pain - clamminess - skin mottling - pallor - increased heart rate |
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To be diagnosed with hypertension, the client's BP must be measures ____ or more times and averaged out.
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2
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Orthostatic hypertension is a side effect of many ___________ medications.
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hypertensive
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(def)
a drop in BP of 20 or more systolic or 10 or more diastolic when you change from a sitting/lying position to a standing position |
orthostatic hypertension
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What type of method would be used to directly assess BP?
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an arterial line
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What are 3 methods of assessing BP?
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palpatory (systolic only)
ausculatory (systolic and diastolic) electronic (systolic and diastolic) |
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How would you document a palpatory BP?
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value/p
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The width of a BP cuff should be ___-___ % of the circumference of the midpoint of the limb on which the cuff is used.
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40-50%
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If a BP cuff is too narrow, what will happen to the reading? What if it is too wide?
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too narrow = false high
too wide = false low |
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What are 2 types of sphygmomanometers?
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aneroid (dial) or mercury
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The sounds heard when listening to the blood pressure are called what?
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Korotkoff's sounds
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What sound indicates the systolic BP when ausculating?
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K1
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What sound indicates the diastolic BP when ausculating?
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K5 (adults) K4 (children)
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What are examples of situations where you would not take the BP from the arm?
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- mastectomy
- recent blood drawn - stroke deficit - IV - A line - Shunt for dialysis - surgery or any deviation to the hand, arm, shoulder, or axilla |
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If you take a BP using the leg, what deviation do you expect to see in the reading?
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expect the systolic to be 20-30 higher
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Why should you always palpate systolic pressure prior to taking BP?
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to avoid misreading due to an auscultory gap
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What are the follow up recommendations for the following:
Normal BP, Prehypertension, Hypertension Stage I, Hypertension Stage II |
Normal - recheck in 2 years
Prehypertension - Recheck in 1 year Stage I Hypertension - Confirm in 2 months Stage II Hypertension - Confirm in 1 month |
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What is the protocal for a BP of 180/100 or greater?
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Treat immediately to 1 week depending on clinical situation
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When checking BP, the cuff should be inflated to _____ mercury above the palpated systolic pressure.
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30
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Where should you position the stethoscope when assessing BP in the arm?
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over the brachial artery
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How far above the brachial artery should the cuff be positioned?
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1 inch
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When taking BP, what point indicates Systolic pressure?
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when the 1st sound is heard
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When taking BP, what point indicates Diastolic pressure?
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when the sound disappears
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What is the very 1st step in the blood pressure procedure?
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Wash hands
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When releasing the valve of the BP cuff, what is the desired rate that the mercury will fall every second?
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2-3 mm
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