Week 5: Clinical Reasoning Flashcards
1
Q
Blood Pressure assessment informs nurse
A
- Hypertension
- Hypotension
- Orthostatic hypotension
2
Q
Nurses must be aware of in terms of blood pressure
A
- factors which may impact on blood pressure, including user error
- nursing interventions required when caring for a person
with an alteration in blood pressure
3
Q
Korotkoff sounds
A
Phase 1: Sharp tapping (systolic)
Phase 2: A swishing/whooshing sound
Phase 3: Thump softer than the tapping in phase 1
Phase 4: A softer blowing muffled sound that fades
Phase 5: Silence (diastolic)
4
Q
Assessing Perfusion
A
Press down on nail beds or pads for 5secs
Release and observe
Count how long it takes the area to return to baseline colour
* ≤ 2 secs is normal
* Up to 3 sec in certain conditions