Week 5: Clinical Reasoning

Question 1

Blood Pressure assessment informs nurse

Answer 1

• Hypertension
• Hypotension
• Orthostatic hypotension

Question 2

Nurses must be aware of in terms of blood pressure

Answer 2

1. factors which may impact on blood pressure, including user error
2. nursing interventions required when caring for a person
   with an alteration in blood pressure

Question 3

Korotkoff sounds

Answer 3

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)

Question 4

Assessing Perfusion

Answer 4

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