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Fundamentals of Nursing Lab > Vital signs - Blood Pressure & Pain > Flashcards

Vital signs - Blood Pressure & Pain Flashcards

1
Q

What is arterial blood pressure?

A

It is the measure of pressure exerted by blood as it flows through the arteries

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2
Q

What is systolic pressure?

A

It is the pressure of the blood as a result of contraction of ventricles & pressure of the height of blood wave

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3
Q

What is the diastolic pressure?

A

It is the pressure when ventricles are at rest. The lower pressure present at all times within arteries

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4
Q

What is the pulse pressure?

A

It is the difference between diastolic & systolic pressures

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5
Q

What is the normal pulse pressure ?

A

About 40 mmHg and can be as high as 100 mmHg during exercise

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6
Q

What is the blood pressure of a healthy adult?

A

120/80 mmHg

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7
Q

What are the classifications of blood pressure?

A

Hypertension - a blood pressure consistently above normal
stage 1 : 130-139 systolic, 80-89 diastolic
stage 2 : > 140 systolic, >90 diastolic
Hypotension - a blood pressure below normal
systolic reading consistently between 85-100 mmHg
Elevated BP : 120 - 129 systolic

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8
Q

What is orthostatic hypotension?

A

It is when blood pressure decreases when the client changes from a supine to a sitting or standing position

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9
Q

How do we assess for orthostatic hypotension in a client?

A
  1. place client in supine position for at least 5 minutes
  2. record clients pulse & blood pressure
  3. assist the client to slowly sit or stand
  4. support the client in case of faintness
  5. immediately recheck the pulse & blood pressure in the same sites as previously
  6. measure the pulse & blood pressure again after 3 minutes
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10
Q

What determines whether a client has orthostatic hypotension after assessment?

A

If there is a drop in blood pressure of
20 mmHg systolic or
10 mmHg diastolic or
an increase in pulse of 20 beats / min

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11
Q

What are the parts of a sphygmomanometer?

A
  • cuff
  • valve
  • bulb
  • tube
  • bladder
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12
Q

The bladder width should be …

A

40% of arm circumference

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13
Q

When do we NOT measure a client’s blood pressure on a certain body part?

A
  • if any part of the limb is injured or diseased
  • if a cast or bulky bandage is present on any part of the limb
  • if client has had surgical removal of a breast or axillary lymph node on that side
  • client has an IV infusion or blood transfusion
  • client has an arteriovenous fistula for renal dialysis
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14
Q

What are the purposes of assessing blood pressure?

A
  • to obtain a baseline measure of arterial blood pressure
  • to determine client’s hemodynamic status
  • to identify & monitor changes in the blood pressure resulting from a disease process & medical therapy
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15
Q

What must we assess the client for before measuring BP to acquire an accurate reading?

A
  • signs & symptoms of hypertension
  • signs & symptoms of hypotension
  • factors affecting blood pressure
  • whether BP cuff contains latex since some people are allergic to it.
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16
Q

What are the signs & symptoms of hypertension?

A
  • headache
  • ringing in ears
  • flushing of face
  • nosebleeds
  • fatigue
17
Q

What are the signs & symptoms of hypotension?

A
  • tachycardia
  • dizziness
  • mental confusion
  • restlessness
  • cool & clammy skin
  • pale or cyanotic skin
18
Q

What are the factors that affect blood pressure?

A
  • activity
  • age
  • race
  • sex
  • medications
  • obesity
  • diurnal variations
  • medical conditions
  • body temperature
  • emotional stress
  • pain
  • time client last smoked or ingested caffeine
19
Q

List the equipment required to measure blood pressure

A
  1. stethoscope
  2. sphygmomanometer
  3. blood pressure cuff of appropriate size
  4. alcohol wipes
  5. Doppler ultrasound
  6. aneroid or digital
20
Q

What are the implementation steps to assessing blood pressure?

A
  1. Ensure equipment is intact & functioning properly
  2. Make sure client has not smoked or ingested caffeine within 30 mins prior to measurement
  3. position client appropriately
    - sitting for adults, unless otherwise specified, with both feet flat on the floor
    -elbow slightly flexed with palm facing upwards & supported at heart level
  4. expose the upper arm
  5. wrap deflated cuff evenly around upper arm
  6. locate brachial artery & apply center of the bladder directly over the artery to achieve accurate readings
  7. for adults, place lower border of the cuff approximately 2.5cm (1 inch) above antecubital space
  8. if this is client’s first examination :
    perform preliminary palpatory determination of systolic pressure to estimate maximal pressure to which the sphygmomanometer needs to be elevated in subsequent determinations
  9. palpate brachial artery with fingertips & close valve on the bulb
  10. Pump up the cuff until you no longer feel the brachial pulse
  11. note the pressure on the sphygmomanometer at which the pulse is no longer felt. This gives an estimate of systolic pressure
  12. release the pressure completely in the cuff & wait 1-2 minutes before making further measurements
  13. cleanse stethoscope earpieces with antiseptic wipes & insert in ears
  14. place bell side or stethoscope over brachial pulse site because blood pressure is low frequency sounds.
    place directly on skin
    hold diaphragm with thumbs & index finger
  15. Pump cuff until sphygmomanometer reads 30 mmHg above point where brachial pulse disappeared
  16. release the valve on the cuff carefully so that the pressure decreases at the rate of 2-3 mmHg per second to prevent error in measurement
  17. as pressure falls, determine the pressure reading when the pulse can be clearly heard with the stethoscope, then identify the point on the manometer when the pulse begins to fade away
    the first reading is the systolic pressure
    the second reading is the diastolic pressure
  18. Deflate cuff completely
  19. if reconfirmation of reading is needed, wait 1-2 minutes before making further determinations
  20. if this is the client’s initial examination, repeat the procedure on the other arm.
    there mustn’t be a difference greater than 10 mmHg between the arms
  21. Remove cuff from arm & disinfect
  22. Document & report pertinent assessment dates according to agency policy
  23. relate BP to other VS, baseline data & health status
  24. report any significant change in client’s blood pressure
21
Q

How is the palpitation method to measuring BP implemented?

A

Palpate radial or brachial pulse sites as the cuff pressure is released
The reading at the point where the pulse reappears is an estimate value of systolic value

22
Q

How does a nurse assess pain?

A

Using the OLD CART method :-
O = onset
L = location
D = duration
C = characteristics
A = Aggressive factor
R = radiation/relieve
T = treatment

23
Q

What causes hypertension?

A
  • thickening of arterial walls
  • inelasticity of arteries
  • cigarette smoking
  • obesity
  • heavy alcohol consumption
  • lack of physical exercise
  • high blood cholesterol levels
  • continued exposure to stress
24
Q

What causes orthostatic hypotension?

A

A result of peripheral vasodilation during sitting or laying down to improve blood circulation to peripherals, causing blood to leave the central body organs, especially the brain, often causing client to feel when they move to sit or stand due to a delay in sensory response.

25
Q

What causes hypotension?

A
  • analgesics
  • bleeding
  • severe burns
  • dehydration
26
Q

What are the sites of measuring blood pressure?

A
  • Upper arm , brachial artery ( common )
  • forearm or wrist using electronic blood pressure monitor
  • Thigh , popliteal artery ( when b.p can’t be measured on either arms due to traumatic injury or to compare b.p of each thigh for bilateral equality )
27
Q

What are the common errors when measuring blood pressure?

A
  • bladder/cuff is too narrow or too wide
  • arm is not supported ; not at heart level
  • insufficient rest before assessment
  • repeated assessment too quickly
  • cuff too loose or unevenly wrapped
  • cuff deflated too quickly or too slowly
  • assessing while client eats, smokes or is in pain
  • failure to measure in same arm
  • failure to identify auscultatory gap

Fundamentals of Nursing Lab (8 decks)

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