Week Two

Question 1

What is the pulse range for an adult?

Answer 1

50-95bpm

Question 2

How long do you assess a pulse?

Answer 2

How long to assess? → 1 minute if it is irregular but typically count for 30 seconds and multiply by 2

Question 3

Which radial pulse should you assess on a patient?

Answer 3

It is preferred to take the left radial pulse (just because the left is preferred does not mean you cannot use the right)

Question 4

How should the patient be positioned when assessing a patients pulse?

Answer 4

Make sure the patient’s arm is at heart level!

Question 5

What are some factors that affect the pulse?

Answer 5

Anxiety vs. relaxation

Pain (increase pulse rate if patient is experiencing acute pain)

Exercise

Fever/warm environment can increase but low temperature can decrease pulse

Medications can increase or decrease

Medical emergencies

Lung conditions

Gender

Age (babies have higher pulse rates)

Stimulants increase pulse rates

Question 6

What can cause alterations in HR and pulse?

Answer 6

Mastectomy

IV site

Amputation

Do they have a fistula?

“Have you had recent surgery?”

Question 7

What are the 2 phases of the cardiac cycle?

Answer 7

1) Diastole is the relaxation phase of the ventricles when they fill with blood

2) Systole is the contraction of the ventricles when they empty of blood

Question 8

What are the 4 characteristics of pulse?

Answer 8

1) Rate (50-95bpm)

2) Rhythm (regular or irregular)

3) Amplitude/Strength (Strong, thready, bounding, weak)

4) Equality (the assessment of the pulses bilaterally)

Question 9

How to describe the amplitude/strength of a pulse?

Answer 9

0 = not palpable or absent

1+ = Diminished weak, and barely palpable, easy to obliterate (thready)

2+ = Normal, obliterate with slight pressure (average)

3 + = Bounding, obliterate with firm pressure, or unable to obliterate (caffeine, energy drinks etc., cause a bounding pulse)

Question 10

Who typically has a slow HR?

Answer 10

Many factors influence what a clients usual resting pulse is… for example athletes often have slow but very effective and strong pulses because their hearts are conditioned, pulse rates also vary across the lifespan

Question 11

What is the normal range for BP?

Answer 11

135/85

Question 12

What does BP refer to?

Answer 12

To the pressure exerted on the arterial walls by the force of the heart’s contractions

The level of this pressure varies in response to the different phases of the cardiac cycle and psychological influences on BP regulation

Question 13

What are the 5 ways that BP is determined?

Answer 13

1) Cardiac Output

2) Peripheral Resistance

3) Blood Volume

4) Viscosity

5) Elasticity

Question 14

What does cardiac output indicate?

Answer 14

will let us know if the heart is healthy or impaired

Question 15

What does peripheral resistance indicate?

Answer 15

if there are lung issues then heart has pump harder, does our patient have any obstructions that is making the heart pump harder? Ex., edema

Question 16

What affects blood volume?

Answer 16

ex., dehydration affects this and makes BP low

Question 17

What is viscosity?

Answer 17

how thick is this person’s blood? Usually another underlying medical condition

Question 18

What is elasticity?

Answer 18

How flexible are the vessels? Older individuals vessels lose elasticity over time

Question 19

What can pulse pressure indicate?

Answer 19

Pulse pressure can provide valuable information about the clients risk profile for various health conditions, as well as information about the cardiovascular systems functioning

Question 20

What is adequate BP essential for?

Answer 20

The perfusion of all body tissues with oxygenated blood

Transportation of essential nutrients

Removal of waste materials by the liver, the kidney’s and the lungs

Question 21

What is hypertension?

Answer 21

Readings above 135/85 mmHg become increasingly undesirable with HTN being diagnosed if these levels exceed 140mmHg systolically and/or 90mmHg diastolically over several office visits

Question 22

What is White Coat Syndrome?

Answer 22

A phenomenon often seen in health care settings is white coat HTN characterized by BP readings that are high in healthcare settings but normal otherwise `

Question 23

What can a high BP do to the body?

Answer 23

High BP over a sustained period of time can contribute to vascular wall damage, atherosclerosis, and vascular disease that can damage many body organs and body systems

Question 24

What is hypotension?

Answer 24

When the BP is abnormally low below 135

Assess if they are feeling dizzy or weak if they have a low BP

Question 25

What is orthostatic hypotesion?

Answer 25

A drop in the SBP that occurs when there is a change in patient position from lying to sitting or standing

When there is a change in at least 20mmHg in the BP when assessing lying, sitting, or standing AND when the HR goes up 20 BPM or more when doing lying, sitting and standing

Question 26

What can affect a patient’s BP?

Answer 26

Body position
Activity level
Psychological state
Internal psychological processes
Medications
Pain
Underlying health conditions
Exercise
Physical environment
Different ethnicities
Diet
Gender

Question 27

How is BP regulated?

Answer 27

An individual’s HR, arterial resistance, the venous tone are regulated by the medulla oblongata in response to feedback that it receives stretch receptors (baroreceptors) in the heart and arteries

Hormonal influences on the cardiovascular system are also affected by baroreceptor reflexes (ex. Angiotensin and Aldosterone)

Kidneys affect blood pressure

Baroreceptor identification of low BP also causes the hypothalamus to influence the posterior pituitary to release vasopressors

Question 28

What are some sites to avoid when measuring BP?

Answer 28

If the patient has a dialysis graft (fistula) to prevent damage to the graft

If it is on the same side that a mastectomy occurred because you can get inaccurate BP readings and cause the development of lymphedema in the arm

If the arm is painful or swollen

If the arm has an IV site infusing because it can contribute to the IV site becoming infiltrated

Question 29

What are Korotkoff Sounds?

Answer 29

As the cuff pressure is slowly lowered, you will listen for the sound of blood flow returning to the brachial artery, these sounds are called Korotkoff sounds, and they pass through 5 phases while you auscultate the BP until they are no longer heard

Question 30

Do you use the diaphragm or the bell to auscultate the AC brachial artery?

Answer 30

The diaphragm

Question 31

How should a patient be positioned when checking their BP?

Answer 31

The arm should be bare and supported, with the cuff at the level of the heart!

The patients legs should not be crossed!!

Ask the patient not to speak during the exam

Question 32

When should you not take a patients BP?

Answer 32

You need to wait 30 minutes after a patient ate, drank, smoked or exercised

Question 33

How do you know if the BP cuff will fit a patient?

Answer 33

Measure their arm with the bladder and make sure that it goes around no more than 80% around my patients arm or you could use the width of the cuff at about 40%

Question 34

After placing the cuff on the patient, how many fingers should the nurse be able to place under the cuff?

Answer 34

2 fingers

Question 35

After determining when the brachial pulse disappears on the dial, how much more do you pump up the cuff?

Answer 35

20-30mmHg higher than the value that you felt the last beat

Question 36

How do you prepare the client for the BP measurement?

Answer 36

Ensure the client has not had caffeine in the past hour

Ensure the client has not smoked in the past 15-30 minutes

Ensure the client has not exercised in the past 30 minutes

Ensure the client has not taken medications or substances that are stimulants

Ensure the client has emptied their bladder

Ensure the room is warm and calm

Remove tight and restrictive clothing from the client’s forearm

Help make the client feel free from anxiety, stress or pain

Question 37

What does the general survey begin with?

Answer 37

a review of the patients primary health problems

Question 38

What does a general survey include an assessment of?

Answer 38

• Vital signs
• Height & Weight
• General Behaviour
• Appearance

Question 39

What does a general survey provide information about?

Answer 39

The general survey provides information about characteristics of an illness, a patient’s hygiene, skin condition and body image, emotional state, recent changes in weight and developmental status

Question 40

What are the 4 components of a general survey?

Answer 40

1) Body Structure

2) Mobility

3) Behaviour

4) Physical Appearance

Question 41

When doing a general survey, what do you assess for Body Structure?

Answer 41

Stature

Nutrition (proportion in regards to body fat)

Symmetry (are there arms the same length on either side)

Posture (How is your client sitting?)

Position (are they in the chair or in the bed?)

Body Build & Contour (apple, pear etc.,)

Question 42

When doing a general survey, what do you assess for mobility?

Answer 42

1) Gait (coordinated?)

2) ROM (all limbs equally)

Question 43

When doing a general survey, what do you assess for behaviour?

Answer 43

Facial expression (Symmetry, appropriate eye contact)

Mood/Affect (Cooperative, animated or flat, anxious, calm)

Speech (Pattern, Clear, Articulate)

Dress

Personal Hygiene (clothing, hair, skin, nails, clean outfit? odours?)

Question 44

When doing a general assessment, what do you assess for an overall physical appearance?

Answer 44

Age (Appears vs. Actual)

Sex

LOC (AxOx3 or AxOx4 → situation, why are you here?)

Skin Colour; lesions (Any variations or lesions)

Facial features (Symmetry)