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z_NUR112: MIDTERM_NOTES > NOTES_3 Ch 30: Vital Signs - BP and Pain > Flashcards

NOTES_3 Ch 30: Vital Signs - BP and Pain Flashcards

1
Q

Define Blood Pressure

A

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

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2
Q

What are some factors that influence BP?

A

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

  • Stressed
  • Activity/Weight
  • Medications
  • Smoking
  • Age
  • Gender
  • Ethnicity
  • Daily Variation
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3
Q

Which is more common, hypotension or hypertension?

A

Hypertension

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4
Q

Hypertension can be…

A

asymptomatic

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5
Q

Symptoms of Hypotension

A
  • Pallor (paleness)
  • Skin mottling (spots or smears of color)
  • Clamminess
  • Confusion
  • Increased heart rate
  • Decreased Urine output
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6
Q

What is considered a normal blood pressure reading?

A

<120/80

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7
Q

What is the BP range indicating Prehypertension?

A
  • Systolic: 120-139
  • Dyastolic: 80-89
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8
Q

What is the BP range indicating Stage 1 hypertension?

A
  • Systolic: 140-159
  • Diastolic: 90-99
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9
Q

What is the BP range indicating Stage 2 hypertension?

A
  • Systolic: 160 and above
  • Diastolic: 100 and above
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10
Q

What is required before a diagnostis of Hypertension?

A

Multiple BP readings over several visits

(to establish consistancy)

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11
Q

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

A

Popliteal Artery

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12
Q

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

A
  • Systolic pressure is usually higher by 10-40 mmHg
  • Diastolic pressure should be same
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13
Q

When should you take a lower-extremity BP?

A
  • When the upper extremites are inaccessible for BP measurement
  • (due to IV, casts, etc)
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14
Q

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

A

20

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15
Q

Orthostatic Hypotension may be related to

A
  • fluid volume deficit
  • medications (diuretics or anti-hypertensive)
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16
Q

Orthostatic Hypotension symptoms include

A
  • Dizziness
  • Light-headedness
  • Falling
17
Q

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
A

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
18
Q

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
A

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
19
Q

What are some primary preventions for hypertension?

A
  • Education
  • Vaccines/Immunizations
  • Lifestyle modifications
    • Diet
    • Exercise
    • Smoking cessasion
20
Q

What does hypertension damage?

A
  • Brain
  • Heart
  • Vessels
  • Kidneys
21
Q

Reports of pain are _____ data received from the patient.

A

subective

22
Q

Nurse must advocate for patient by _____ reports of pain.

A

believing

23
Q

What are three components of Pain to keep in mind?

A
  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
24
Q

What are two types of Pain?

A
  1. Acute
  2. Chronic
25
Q

Define Acute Pain

A
  • Patient is protective of the area
  • Identifiable cause, short duration
  • Limited tissue damage
26
Q

Define Chronic Pain

A
  • Prolonged pain associated with cancer or another long term ailment
27
Q

What is the PQRST Pain Assessement?

A
  • 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
28
Q

What are the factors to report associated with Pain?

A

COLDSPA

  • Character
  • Onset
  • Location
  • Duration
  • Severity
  • Patter
  • Associated Factors
29
Q

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

A

FLACC

  • Face
  • Leg
  • Arm
    • Sudden reactionary movements to the above
  • Consolability
  • Crying
30
Q

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

A

meaning, objective, advocate

31
Q

What are the three drug groups?

A
  1. Non-opiods
  2. Opioids
  3. Adjuvants (chemo, radiation)
32
Q

NSAID stands for

A

Non Steroidal Anti Inflammatory Drug

33
Q

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

A

analgesic, antipyretic and anti-inflammatory

34
Q

What is the difference between selective and nonselective NSAIDS?

A
  • NSAIDs (nonselective) can cause gastrointestinal bleeding
  • NSAIDs (selective) causes less gastrointestinal reactions
35
Q

What are some examples of Non-Opiod Analgesics?

A
  • Acetaminophen (Tylenol)
  • NSAIDs (nonselective)
    • Asprin
    • Ibuprofen (motrin)
    • Naproxen (Naprosyn)
  • NSAIDs (selective
    • Celecoxib (Celebrex)
36
Q

Name four Opiod Analgesices

A
  1. Morphine
  2. Oxycodone
  3. Methadone
  4. Codeine
37
Q

What are four side effects of opioids?

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

z_NUR112: MIDTERM_NOTES (14 decks)

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