NOTES_3 Ch 30: Vital Signs - BP and Pain Flashcards
Define Blood Pressure
The force exerted on the arterial wall by pulsing blood under pressure from the heart.
What are some factors that influence BP?
S.A.M.S. A.G.E.D
- Stressed
- Activity/Weight
- Medications
- Smoking
- Age
- Gender
- Ethnicity
- Daily Variation
Which is more common, hypotension or hypertension?
Hypertension
Hypertension can be…
asymptomatic
Symptoms of Hypotension
- Pallor (paleness)
- Skin mottling (spots or smears of color)
- Clamminess
- Confusion
- Increased heart rate
- Decreased Urine output
What is considered a normal blood pressure reading?
<120/80
What is the BP range indicating Prehypertension?
- Systolic: 120-139
- Dyastolic: 80-89
What is the BP range indicating Stage 1 hypertension?
- Systolic: 140-159
- Diastolic: 90-99
What is the BP range indicating Stage 2 hypertension?
- Systolic: 160 and above
- Diastolic: 100 and above
What is required before a diagnostis of Hypertension?
Multiple BP readings over several visits
(to establish consistancy)
When taking a lower extremety BP, what is the site of auscultation?
Popliteal Artery
How does a lower-extremety BP compare to a brachial artery BP?
- Systolic pressure is usually higher by 10-40 mmHg
- Diastolic pressure should be same
When should you take a lower-extremity BP?
- When the upper extremites are inaccessible for BP measurement
- (due to IV, casts, etc)
Orthostatic Hypotension is a drop of __ mmHg or more from the recorded sitting BP.
20
Orthostatic Hypotension may be related to
- fluid volume deficit
- medications (diuretics or anti-hypertensive)
Orthostatic Hypotension symptoms include
- Dizziness
- Light-headedness
- Falling
Describe the effect of the following BP assessment errors:
- Bladder/cuff to wide
- Bladder/cuff to narrow/short
- Cuff wrapped too loosely/unevenly
Effects
- Bladder/cuff to wide = False Low Reading
- Bladder/cuff to narrow/short = False High Reading
- Cuff wrapped too loosely/unevenly = False High Reading
Describe the effect of the following BP assessment errors:
- Deflating cuff to slowly
- Deflating cuff to rapidly
- Arm below heart level
- Arm above heart level
- Arm not supported
Effects
- Deflating cuff to slowly = False High Diastolic
- Deflating cuff to rapidly = False Low Systolic and False high Diastolic
- Arm below heart level = False High BP
- Arm above heart level = False Low BP
- Arm not supported = False High BP
What are some primary preventions for hypertension?
- Education
- Vaccines/Immunizations
- Lifestyle modifications
- Diet
- Exercise
- Smoking cessasion
What does hypertension damage?
- Brain
- Heart
- Vessels
- Kidneys
Reports of pain are _____ data received from the patient.
subective
Nurse must advocate for patient by _____ reports of pain.
believing
What are three components of Pain to keep in mind?
- It is an unpleasant sensory/emotional experience associated with actual or potential tissue damage
- Pain is whateever the person experiencing it says it is; exists whenever a person says it does
- Pain self-report is always the most reliable indication of pain
What are two types of Pain?
- Acute
- Chronic
Define Acute Pain
- Patient is protective of the area
- Identifiable cause, short duration
- Limited tissue damage
Define Chronic Pain
- Prolonged pain associated with cancer or another long term ailment
What is the PQRST Pain Assessement?
- P: Precipitating or palliative - what makes it better/worse
- Q: Quality - aching, shooting, stabbing, sharp, dull
- R: Region - location of pain
- S: Severity - 1-10
- T: Timing - when is it worse
What are the factors to report associated with Pain?
COLDSPA
- Character
- Onset
- Location
- Duration
- Severity
- Patter
- Associated Factors
What scale is used to assess pain for someone who is non-verbal?
FLACC
- Face
- Leg
- Arm
- Sudden reactionary movements to the above
- Consolability
- Crying
All pain holds significant ______ for the person experiencing it and the Nurse must remain _____ and _____ for proer pain control.
meaning, objective, advocate
What are the three drug groups?
- Non-opiods
- Opioids
- Adjuvants (chemo, radiation)
NSAID stands for
Non Steroidal Anti Inflammatory Drug
NSAIDS are highly effective as _____, _____, and _____ agents.
analgesic, antipyretic and anti-inflammatory
What is the difference between selective and nonselective NSAIDS?
- NSAIDs (nonselective) can cause gastrointestinal bleeding
- NSAIDs (selective) causes less gastrointestinal reactions
What are some examples of Non-Opiod Analgesics?
- Acetaminophen (Tylenol)
- NSAIDs (nonselective)
- Asprin
- Ibuprofen (motrin)
- Naproxen (Naprosyn)
- NSAIDs (selective
- Celecoxib (Celebrex)
Name four Opiod Analgesices
- Morphine
- Oxycodone
- Methadone
- Codeine
What are four side effects of opioids?
- Respiratory depression
- Sedation
- Nausea/vomiting
- Constipation
