NOTES_3 Ch 30: Vital Signs - BP and Pain

Question 1

Define Blood Pressure

Answer 1

The force exerted on the arterial wall by pulsing blood under pressure from the heart.

Question 2

What are some factors that influence BP?

Answer 2

S.A.M.S. A.G.E.D

• Stressed
• Activity/Weight
• Medications
• Smoking
• Age
• Gender
• Ethnicity
• Daily Variation

Question 3

Which is more common, hypotension or hypertension?

Answer 3

Hypertension

Question 4

Hypertension can be…

Answer 4

asymptomatic

Question 5

Symptoms of Hypotension

Answer 5

• Pallor (paleness)
• Skin mottling (spots or smears of color)
• Clamminess
• Confusion
• Increased heart rate
• Decreased Urine output

Question 6

What is considered a normal blood pressure reading?

Answer 6

<120/80

Question 7

What is the BP range indicating Prehypertension?

Answer 7

• Systolic: 120-139
• Dyastolic: 80-89

Question 8

What is the BP range indicating Stage 1 hypertension?

Answer 8

• Systolic: 140-159
• Diastolic: 90-99

Question 9

What is the BP range indicating Stage 2 hypertension?

Answer 9

• Systolic: 160 and above
• Diastolic: 100 and above

Question 10

What is required before a diagnostis of Hypertension?

Answer 10

Multiple BP readings over several visits

(to establish consistancy)

Question 11

When taking a lower extremety BP, what is the site of auscultation?

Answer 11

Popliteal Artery

Question 12

How does a lower-extremety BP compare to a brachial artery BP?

Answer 12

• Systolic pressure is usually higher by 10-40 mmHg
• Diastolic pressure should be same

Question 13

When should you take a lower-extremity BP?

Answer 13

• When the upper extremites are inaccessible for BP measurement
• (due to IV, casts, etc)

Question 14

Orthostatic Hypotension is a drop of __ mmHg or more from the recorded sitting BP.

Answer 14

20

Question 15

Orthostatic Hypotension may be related to

Answer 15

• fluid volume deficit
• medications (diuretics or anti-hypertensive)

Question 16

Orthostatic Hypotension symptoms include

Answer 16

• Dizziness
• Light-headedness
• Falling

Question 17

Describe the effect of the following BP assessment errors:

1. Bladder/cuff to wide
2. Bladder/cuff to narrow/short
3. Cuff wrapped too loosely/unevenly

Answer 17

Effects

1. Bladder/cuff to wide = False Low Reading
2. Bladder/cuff to narrow/short = False High Reading
3. Cuff wrapped too loosely/unevenly = False High Reading

Question 18

Describe the effect of the following BP assessment errors:

1. Deflating cuff to slowly
2. Deflating cuff to rapidly
3. Arm below heart level
4. Arm above heart level
5. Arm not supported

Answer 18

Effects

1. Deflating cuff to slowly = False High Diastolic
2. Deflating cuff to rapidly = False Low Systolic and False high Diastolic
3. Arm below heart level = False High BP
4. Arm above heart level = False Low BP
5. Arm not supported = False High BP

Question 19

What are some primary preventions for hypertension?

Answer 19

• Education
• Vaccines/Immunizations
• Lifestyle modifications
  
  • Diet
  • Exercise
  • Smoking cessasion

Question 20

What does hypertension damage?

Answer 20

• Brain
• Heart
• Vessels
• Kidneys

Question 21

Reports of pain are _____ data received from the patient.

Answer 21

subective

Question 22

Nurse must advocate for patient by _____ reports of pain.

Answer 22

believing

Question 23

What are three components of Pain to keep in mind?

Answer 23

1. It is an unpleasant sensory/emotional experience associated with actual or potential tissue damage
2. Pain is whateever the person experiencing it says it is; exists whenever a person says it does
3. Pain self-report is always the most reliable indication of pain

Question 24

What are two types of Pain?

Answer 24

1. Acute
2. Chronic

Question 25

Define Acute Pain

Answer 25

• Patient is protective of the area
• Identifiable cause, short duration
• Limited tissue damage

Question 26

Define Chronic Pain

Answer 26

• Prolonged pain associated with cancer or another long term ailment

Question 27

What is the PQRST Pain Assessement?

Answer 27

• 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

Question 28

What are the factors to report associated with Pain?

Answer 28

COLDSPA

• Character
• Onset
• Location
• Duration
• Severity
• Patter
• Associated Factors

Question 29

What scale is used to assess pain for someone who is non-verbal?

Answer 29

FLACC

• Face
• Leg
• Arm
  
  • Sudden reactionary movements to the above
• Consolability
• Crying

Question 30

All pain holds significant ______ for the person experiencing it and the Nurse must remain _____ and _____ for proer pain control.

Answer 30

meaning, objective, advocate

Question 31

What are the three drug groups?

Answer 31

1. Non-opiods
2. Opioids
3. Adjuvants (chemo, radiation)

Question 32

NSAID stands for

Answer 32

Non Steroidal Anti Inflammatory Drug

Question 33

NSAIDS are highly effective as _____, _____, and _____ agents.

Answer 33

analgesic, antipyretic and anti-inflammatory

Question 34

What is the difference between selective and nonselective NSAIDS?

Answer 34

• NSAIDs (nonselective) can cause gastrointestinal bleeding
• NSAIDs (selective) causes less gastrointestinal reactions

Question 35

What are some examples of Non-Opiod Analgesics?

Answer 35

• Acetaminophen (Tylenol)
• NSAIDs (nonselective)
  
  • Asprin
  • Ibuprofen (motrin)
  • Naproxen (Naprosyn)
• NSAIDs (selective
  
  • Celecoxib (Celebrex)

Question 36

Name four Opiod Analgesices

Answer 36

1. Morphine
2. Oxycodone
3. Methadone
4. Codeine

Question 37

What are four side effects of opioids?

Answer 37

1. Respiratory depression
2. Sedation
3. Nausea/vomiting
4. Constipation