BP, pulse, temperature Flashcards
1
Q
What should be done during a physical assessment (5)
A
- Familiarise yourself with equipment, ensure functional
- Explain the procedure to the patient
- Obtain consent
- Ensure privacy and comfort
- Ensure cleaning of hands and equipment
2
Q
What are the basics of body temperature (5)
A
- Body temperature is regulated by the hypothalamus.
- “Core temperature” is the temperature below the subcutaneous tissue.
- Temperature is measured at sites that correlate to core temperature (but aren’t necessarily the same)
- Temperature rise and fall indicates bodily changes
- Natural changes in temperature over the course of a day
3
Q
What factors can cause body temperature to fluctuate (6)
A
- Age
- Exercise
- Ovulation
- Nutritional intake
- Time of the day
- Environmental Temperature
4
Q
What are reasons for monitoring temperature (3)
A
- Monitoring for signs of infection
- Monitoring for fluctuations in normal readings
- Monitoring for hyperthermia or hypothermia
5
Q
What are the ranges of body temperature (5)
A
- Body temperature generally approximately 37℃, with some variation depending on site of measured temperature.
- Pyrexia – Low grade 37.8-38℃
- moderate 38-40℃
- hyperpyrexia 40℃+
- Hypothermia – Below 35℃
6
Q
What is the approximate average temperature of the axilla (Centre of armpit)
A
36.1℃
7
Q
What is the approximate average temperature of the mouth (base of tongue)
A
37℃
8
Q
What is the approximate average temperature of the tympanic (ear)
A
37.4℃ - most accurate
9
Q
What is the approximate average temperature of the forehead (usually scanned)
A
36.5℃
10
Q
What is the approximate average temperature of the rectum (4cm in)
A
37.2℃ - only with suitable training
11
Q
What are key points of using tympanic thermometers (7)
A
- Visualise ear
- look out for hearing aids – remove (where possible), or use alternate method
- look out for ear discomfort/pain
- look out for evidence of acute ear infection (i.e. redness, swelling, discharge)
- Wax build-up may affect observed temperature
- Ensure client has not had a hot or cold drink/food or exercised within previous 15 minutes.
- Ensure soiled equipment (i.e. probe covers) is appropriately disposed of.
12
Q
What are key points of measuring pulse (3)
A
- The pulse is a pressure wave of blood caused by the alternating expansion and recoil of elastic arteries during each cardiac cycle.
- The pulse represents each ventricular contraction of the heart which causes a rise in blood pressure and subsequent expansion of the arteries.
- It enables monitoring fluctuations of the heart rate, rhythm and strength
13
Q
What are key terms involving pulse (7)
A
- Rate – How fast the heart is beating
- The normal rate for adults 60-100bpm.
- Rate varies depending on age, physical fitness etc
- Tachycardia: heart rate more than100bpm
- Bradycardia: heart rate less than 60bpm
- Rhythm – Sequence of beats.
- Volume/character – Strength of pulse.
14
Q
What must be done when taken a pulse (8)
A
- Explain the procedure and gain consent.
- Ensure you’ve cleaned your hands
- Need a watch with a second hand
- Identify the site you intend to use
- Most commonly, the radial pulse is used
- To do this turn the person’s arm to have the palm facing upwards.
- At the wrist following the thumb down press two fingers lightly into the area just below the thumb base.
- Count the beats noting the rhythm and strength for a full 60 seconds.
15
Q
What are the basics of blood pressure (6)
A
- Blood Pressure is defined as the pressure exerted within the blood vessel walls as the heart pumps and circulates the blood around the body.
- Reported as two numbers i.e. 120 (systolic) / 80 (diastolic) mmHg. Typically verbalised as 120 over 80
- Systolic blood pressure: The peak pressure of blood in the arteries caused by the contraction of the ventricles in the heart (i.e. the pressure when the heart beats)
- Systolic = top number
- Diastolic blood pressure: The minimum pressure of the blood against the wall of the vessel (i.e. the pressure when the heart is at rest).
- Diastolic = bottom number
16
Q
What are the ranges of blood pressure values (5)
A
- A wide range of “normal” blood pressure values, generally ranging from 100/60 to 140/90 mmHg
- Hypotension: Often defined as being <100mmHg systolic. Can be a response to illness, volume depletion etc
- Hypertension: >140/90 mmHg. Can be a response to narrowing of arteries, temporary response to stress, pain or other stressors.
- Blood pressure can fluctuate within a wide range and still be considered normal
- Over the course of a day, a persons blood pressure will naturally fluctuate. Particularly at night, whilst sleeping.
17
Q
What are the direct methods of measuring blood pressure (2)
A
- Pressure transducer inserted into an artery allows for direct electronic display
- Only used in highly dependent patients
18
Q
What are the indirect methods of measuring blood pressure (2)
A
- Can involve electronic or manual (i.e. using stethoscope) methods**
- Use brachial artery of the arm
19
Q
What is a sphygmomanometer (7)
A
- Consists of a compression bag enclosed in an unyielding cuff
- Inflating bulb, pump or other device by which the pressure is increased
- A meter from which the applied pressure is read
- A control valve to deflate the system
- Centre of cuff should be placed over the brachial artery
- Ensure cuff is correct size for patient.
- Incorrectly sized cuffs can falsely increase or decrease measured blood pressure
20
Q
What are the pros of electronic BP measurement (3)
A
- Multiple readings can be taken easily
- Do not require huge amounts of staff training
- Can be used by patients (i.e. for home measurement)
21
Q
What are the cons of electronic BP measurement (3)
A
- Inaccuracy in atrial fibrillation or other abnormal rhythms
- Inflexibility of cuff sizes may lead to misleading readings
- Reliant on batteries/power supply
22
Q
How is blood pressure estimated (3)
A
- If pressure is applied to the brachial artery that exceeds the systolic blood pressure, then the pulse in the lower arm will no longer be observable.
- Can be used to estimate the systolic pressure
- Used in manual blood pressure measurement to provide a guide to where the look for the Korotkoff sounds.
23
Q
How should you take blood pressure (6)
A
- Explain procedure to the patient
- Wash hands, clean equipment where needed
- Assess the suitability of the arm (If IV infusion, dialysis fistula, lymphoedema etc then use other arm or alternative site)
- Gain consent
- Roll up sleeve and remove restrictive clothing. Restrictive clothing can affect measured BP
- Position patient appropriately
24
Q
How should the patient be positioned to take blood pressure (3)
A
- Seated position is normal practice
- Feet flat on the floor
- Ask them not to talk while the measurement is being taken
