Week 5: Clinical Reasoning Flashcards

1
Q

Blood Pressure assessment informs nurse

A
  • Hypertension
  • Hypotension
  • Orthostatic hypotension
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2
Q

Nurses must be aware of in terms of blood pressure

A
  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
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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)

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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

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