WEEK 1 Flashcards
What is a normal blood pressure?
Normal: Less than 120/80 mm Hg
What is elevated blood pressure?
Elevated: Systolic between 120-129 and diastolic less than 80
What is considered Stage 1 hypertension?
Systolic between 130-139 or diastolic between 80-89
What is considered Stage 2 hypertension?
Systolic at least 140 or diastolic at least 90 mm Hg
What is considered hypertensive crisis (sudden/ severe increase in BP) ?
- Systolic over 180 and/or diastolic over 120
- With patients needing prompt
changes in medication if there are no other indications of problems, or immediate
hospitalization if there are signs of organ damage
What is the systolic reading?
How much pressure is pushing on your blood vessel walls as your heart contracts and pumps out blood to your body.
What is your diastolic reading?
The pressure on your blood vessel walls when your heart relaxes between contractions.
What can affect a blood pressure reading?
- Exercise
- Meals
- Bathroom: full bladder can give you an elevated reading
- Alcohol, Caffeine, Tobacco
- Cuff size
- Clothing: don’t put cuffs over clothing
- Temperature: if you’re cold you might get a higher reading than expected
- Position
- Stress
- Talking
- Age
- Ethnicity
- Gender
- Daily variation
- Medications
How should a patient be positioned when obtaining blood pressure?
o Should be seated with back and arms supported
o Feet on floor uncrossed
o Arm at heart level
o If laying- arm at heart level
NOTE: Patient should be in a seated position for at least 5 minutes for most accurate measurement
Why would you NOT use a particular limb to obtain blood pressure?
o Trauma
o Casted or bandaged
o Blood cot
o Lymph nodes removed (radical mastectomy)
o Presence of fistula (used for hemodialysis in renal failure)
Is the blood pressure measured in the leg higher or lower than in the arm?
Normally higher (lower could signal Peripheral vascular disease (PVD)
Where is the stethoscope placed when obtaining blood pressure in the arm? Where is the cuff
placed?
1)- Locate the brachial or radial artery as appropriate and place the stethoscope’s diaphragm over it below the bottom of the cuff.
- Do not let the chest piece touch the
cuff or clothing.
- Do not place the diaphragm under the cuff or place excessive pressure
on the stethoscope head
2) Position the cuff in the antecubital space. Apply the cuff above the artery by centering
the arrows marked on the cuff over the artery so that the end of the cuff is 2 to 3 cm
above the antecubital fossa to allow room for placement of the stethoscope.
Why is blood pressure sometimes measured by the 2-step method?
To establish the patient’s baseline blood pressure- inflating the cuff too tight or many times
because you didn’t inflate enough the first time can lead to inaccurate readings
What is Hypertension?
Blood pressure that is higher than normal
- More common than hypotension
- Thickening of walls
- Loss of elasticity
- Family history
- Risk Factors
What is Hypotension?
Low blood pressure
- Dilation of arteries
- Loss of blood volume
- Decrease of blood flow to vital organs
- Orthostatic/postural
So what does blood pressure determine?
Determines if a patient has hypotension, hypertension, or orthostatic hypotension which can be defining characteristics of the following diagnoses
- Activity Intolerance
- Anxiety
- Decreased cardiac Output
- Risk for Injury
- Acute Pain
- Ineffective Peripheral Tissue Perfusion
What is a normal temperature reading in degrees Fahrenheit and Celcius?
Normal: 96.8 F (36C) to 99F (37.2C)
What is considered a fever?
100.4 F or 38 C
Temperature sites for patients?
- Oral
- Rectal( most accurate, used for babies)
- Axillary
- Tympanic Membrane
- Temporal Artery
- Esophageal
- Pulmonary artery
What factors affect body temperature?
- Age
- Exercise
- Hormone level
- Cardiac rythm
- Stress
- Enviroment
- Temperature alterations
What are temperature alterations?
- Fever(pyrexia)
- Heat-loss mechanisms are unable to keep pace with excessive heat production
- Febrile( FEVER)
- Afebrile( NO FEVER)
- Hyperthermia(high body temp)
- Heatstroke
- Heat exhaustion
- Hypothermia(low body temp)
What are some types of body temperature regulation?
- Neural and vascular control
- Heat production
- Heat loss
- Behavioral control
- Skin temperature regulation
What is the Nursing Process?
- Assessment
- Nursing diagnosis
- Planning
- Implementation
- Acute care
- Evaluation
What is a pulse?
Palpable bunding of blood flow noted at various points on the body
How do you assess pulse? What is the character of the pulse?
Sites include
- Temporal
- Carotid
- Apical
- Brachial
- Radial
- Ulnar
- Femoral
- Popliteal
- Posterior Tibial
- Dorsalis pedis
Character of pulse
- Rate
- Rhythm
- Strength
- Quality
What can a pulse determine?
- Activity intolerance
- Anxiety
- Acute pain
- Decreased cardiac output
- Deficient/ excess fluid volume
- Impaired gas exchange
- Ineffective peripheral tissue perfusion
What is the normal respiratory rate for an adult? How do you asses it?
12-20 breaths/min
Must be an inhale and exhale for 1 full breath
- They can either be deep, normal, or shallow
How do you assess diffusion and perfusion?
- Measure oxygen saturation of the blood
- Measurement of arterial oxygen saturation
What is diffusion? What is perfusion?
- Movement of oxygen and carbon monoxide between alveoli and red blood cells
- Distribution of red blood cells to and from the pulmonary capillaries
What is a normal oxygen saturation for an adult?
94-100%
What factors could affect oxygen saturation?
- COPD (emphysema/bronchitis)
- asthma
- anemia
- heart disease
- PE
- covid-19
- pneumonia
- pneumothorax
- sleep apnea
- congenital heart defects
- interstitial lung disease
- ARDS
Factors that increase the risk of contracting an infection?
o Age
o Young and old
• Breaks in skin integrity or alteration in other mechanisms that protect against
infection (see #2)
• Antibiotic use
• History of infections
• Decreased immune system
o Immunocompromised patients
o Multiple comorbidities
o Poor nutrition
o Recent illness
o Immunosuppressant medications
• Indwelling medical devices
• Hospital/ healthcare settingsIdentify body mechanisms against infection
• Skin
• Mucous membranes
• Tears
• Earwax
• Stomach acid
• Normal flow of urine
• WBCs and immune responding cells
o Inflammation
o Tissue repair
o Vascular response
o ExudatesDefine nosocomial, iatrogenic, endogenous infections
• Nosocomial
o Hospital or healthcare-acquired infection
• Iatrogenic
o a type of HAI that results from a diagnostic or therapeutic procedure
• Endogenous
o The patient’s own flora becomes altered and an overgrowth results
What is the medical asepsis/clean technique? When is this used?
Medical asepsis, or clean technique, includes procedures for reducing the number
of organisms present and preventing the transfer of organisms.
o Hand hygiene o Alcohol swabs o Personal protective equipment o Standard precautions apply to contact with blood, body fluid, nonintact skin, and mucous membranes from all patients
What is the surgical asepsis/Sterile technique? When is this used
• Technique that is considered free of microorganisms and minimizes risk of
contamination
• The OR/ IR, labor and delivery rooms, invasive procedures, when the integrity of
the skin is accessed, impaired, or broken
When is soap and water hand hygiene preferable to alcohol-based hand sanitizers? Are there
organisms that are not killed by hand sanitizer?
• When visibly dirty, soiled with blood or body fluids, before eating, after using the
bathroom
• Cdiff and Bacillus anthracis
How often should you wash your hands in a hospital setting?
- Before and after every contact with patient
- Before eating
- After bathroom
- When dirty
How often should you wash your hands in a hospital setting?
- Before and after every contact with patient
- Before eating
- After bathroom
- When dirty
- Between changing gloves
How long should you use lather hands when using soap and water?
20 seconds
Principles of proper body mechanics
Stable Center of Gravity
Wide Base of Support
Proper Body Alignment
What is Fowler’s position?
A bed positioned where the head and trunk are raised b/w 40-90 degrees
Often used for patients who have cardiac issues, trouble breathing, or nasogastric tube in place
What is lateral position?
Involves the patient lying on either her right or left side. A pillow is often placed b/w legs for comfort
What is a Lithotomy position?
Patient is lying flat on her back with legs elevated at hip level or above
Commonly used for gynecological procedures and childbirth
What is Prone position?
The patient lies on their stomach with their head turned left or right
Position allows for drainage of the mouth after oral or neck surgery
What is Sim’s position?
A prone/lateral position in which the patient lies on his side with his upper leg flexed and drawn in towards the chest and upper leg flexed at the elbow
Useful for administrating enemas, perineal examinations, and comfort in pregnancy
What is a Supine position?
A position where the patient is flat on his back. Considered most natural at rest position
Often used for abdominal, facial, and extremity procedures.
Define activity tolerance/intolerance. What should be monitored before, during, and after
ambulation for a weak or debilitated patient?
Physiologic tolerance of activities of daily living.
Activity intolerance is generalized weakness
and debilitation secondary to acute or chronic illness. Symptoms include weakness, dizziness, or pain with ambulation; increased HR, RR, changes in blood pressure; dyspnea/shortness of
breath
Vital signs; ask patients to report pain, dizziness, weakness
- On which side do you stand when ambulating a patient with a weak side
Weak side
