Health Assessment & Physical Exam & Vital Signs

Front 1

Components of health assessment? (4)

Back 1

1)nursing interview
2)behavioral examination
3)physical examination
4)comprehensive

Front 2

This part of the health assessment includes biographical data, nursing health history, chief complaint, present illness, past medical history, health patterns, and Review of Systems.

Back 2

Nursing interview

Front 3

This part of the health assessment is either initial or focused and the complexity is determined by the clients needs

Back 3

Physical examination

Front 4

This examine is performed when the client enters the health care system

Back 4

Initial

Front 5

Ongoing, to assess an area of concern or evaluate an intervention

Back 5

Focused

Front 6

A systemic orderly process by which the nurse collects objective data about the clients body, mind, and spirit. It is critical investigation and evaluation of the clients present status

Back 6

Physical exam

Front 7

The purpose of data collection is? (6)

Back 7

1) evaluate the clients present state of health
2) supplement, confirm, or refute data obtained in the nursing history
3) develope individualized client care
4)evaluate the outcomes of care
5) make clinical judgements about the clients health status
6)identify areas for health promotion and disease prevention.

Front 8

How is the accuracy of data collections and interpretation checked?

Back 8

1)validation
2)knowing normal findings for the clients age, sex, condition in life

Front 9

Def- Comparing data with another source

Back 9

Validation

Front 10

What are the student nurses responsibilities? (4)

Back 10

1) collect data in a professional manner using proper techniques
2) validate and analyze the data
3) recognize normal and abnormal findings
4)communicate significant changes and abnormal findings to the clinical instructor as soon as data is obtained,

Front 11

What is the preferred professional greeting?

Back 11

A handshake

Front 12

What other the other culturally accepted gestures?

Back 12

Smile or nod

Front 13

During first encounter what should the patient know about you as the student nurse?

Back 13

Name and title should be clearly stated

Front 14

What 5 preparations of the client are made before a physical exam?

Back 14

1) inform the client what you will be doing and why it is important.
2) verify clients identity using agency policy
3) state that all information is kept confidential.
4) position client ( sitting or low fowlers are the most common PE positions)
5) offer client s chance to urinate before starting exam.

Front 15

What is the timeframe of a physical exam.

Back 15

15-20 min

Front 16

What are the 5 professional behaviors that the nurse ensures during the physical exam?

Back 16

1) organization by the following correct steps of a procedure to examine an area or part of the body,
2) organize by using the cephalocaudal or head to toe approach (taught in basics) or
Body system approach (highly advanced)
3) remain non-threatening to the client
4) complete by following national guidelines and evidence based practices.
5) professionally communicate in the medical record and to the appropriate healthcare team members in a timely manner

Front 17

What professnal behaviors will ensure a non-threatening environment to the client? (4)

Back 17

A) provide privacy by asking the visitors to leave the room and close drapes and door.
B) ensure a warm room with adequate lighting.
C) follow standard precautions by washing hands with warm water before and after the PE
D) begin with familiar procedures such as providing vital signs, measuring height and weight.

Front 18

Name the (4) techniques of a physical, exam.

Back 18

1)Inspection
2)palpation
3)percussion (not in basics)
4)auscultation

Front 19

Visual examination, to observe, to look, to notice, to smell. The nurse notices or observes shape, size, color, position and movement, symmetry, equality

Back 19

Inspection

Front 20

Using the sense of touch, to feel, to stroke the surface of an area to detect its characteristics such as temp ( use the dorsal surface of the hand ) turgor texture masses

Back 20

Palpation

Front 21

The pads of the fingers should not be used for palpation. True or false?

Back 21

False- pads of fingers not the tips are used since there is a high concentration of sensory nerve endings in the pads which are most sensitive to tactile discrimination

Front 22

The effectiveness of palpation is affected by the clients state of____________.

Back 22

Relaxation

Front 23

During the palpation examine the nurse should observe what for discomfort?

Back 23

Verbal and facial expressions for discomfort

Front 24

Types of palpation ? Two types

Back 24

Light palpation and deep palpation

Front 25

Light palpation is performed by?

Back 25

Placing the hand parallel to clients skin surface; maintain skin contact while moving in circle

Front 26

Def- listening to the sounds produced in the body; aided by the use of a stethoscope which focuses and amplifies sound.

Back 26

Auscultation

Front 27

High pitched sounds are heard best with the?

Back 27

Diaphragm

Front 28

The legal implication of all documentation must include evidence that the nurse has followed what two things?

Back 28

* The nursing process
* standard of nursing practice

Front 29

Initial observations of the client should include what three things?

Back 29

* Position
* client activity or interaction
(reading, visiting with family?)
* response ( Awake? Alert? Oriented?)

Front 30

What would an example of an awake response be?

Back 30

Patients eyes are open

Front 31

What would an example of an alert response be?

Back 31

The patient responses the stimuli such as the nurse entering the room

Front 32

A person would be oriented if they can state what 3 things?

Back 32

1) person -State full name
2) place-what is the name of the building (city or state) that we are in?
3) time- what time of the day is it or the month or year.

Front 33

What are the five signs of distress that require immediate actin by the nurse?

Back 33

1) Airway
2) Breathing difficulty
3) Circulation
4) change in LOC
5) complaint by client

Front 34

Definition Used of sight or smell to collect data

Back 34

Inspection

Front 35

Used to inspect with eyes.
Example: compare one leg to other. See if something appears the same

Back 35

Symmetry

Front 36

Can be used when assessing an amount either by measuring both legs with tape measure or by feeling and assessing volume of pulse

Back 36

Equality

Front 37

Used to describe match of verbal and non verbal behavior

Back 37

Congruence

Front 38

Superficial, used to assess if depression illiciates a painfull response, also used to locate superficial lumps and bumps.

Back 38

Light palpation

Front 39

How deep should pressure be applied to perform light palpation?

Back 39

1-2 cm

Front 40

Auscultation without the use of an instrument is called?

Back 40

Direct auscultation

Front 41

Ascultation with the use of an instrument is called?

Back 41

Indirect auscultation

Front 42

This device increase the sound of pulse,

Back 42

Doppler

Front 43

When sound Doppler be used?

Back 43

If pulse cannot be felt

Front 44

Five uses of auscultation

Back 44

1) korotkoff sounds (bp)
2) heart sounds
3) lung sounds
4) sounds of peristalsis or bowel sounds
5) turbulent blood flow

Front 45

1)Wheezing (bronchi closing) or strider noise (larynx closing)
2) frothy sputum
3) sudden or violent coughing
4) coughing up blood ( hemoptisis)
Are all examples of?

Back 45

Possible airway obstructions / sign or distress

Front 46

Def - no breathing

Back 46

Apnea

Front 47

Def - difficulty breathing

Back 47

Dyspenea

Front 48

< 12 breaths per min

Back 48

Bradydyspnea

Front 49

Ischemia

Back 49

Poor tissue perfussion

Front 50

Why is pain produced by poor circulation/ poor perfusion?

Back 50

Poor perfusion results in anaerobic respiration which produces lactic acid that causes pain.

Front 51

Def- small steps then get faster, pt cannot stop abruptly

Back 51

Propulsive gait

Front 52

Pt can move individual arm based in commands.

Back 52

Active movement

Front 53

Patient cannot move limb and nurse has to pick up and move

Back 53

Passive movement

Front 54

Pallor color can be caused due to

Back 54

Sudden drop of temp, decreased blood flow, anemia

Front 55

Jaundice is caused by an increase in

Back 55

Bilirubin

Front 56

Abnormal redness

Back 56

Eruthema or hyperemia

Front 57

Bells palsy and facial drooping, parkinson's disease and asymmetry is caused due to a deficate in what nerve?

Back 57

Cranial nerve VII (7) facial

Front 58

Visual acuity is controlled by what cranial nerve?

Back 58

Cranial nerve II (2) optic

Front 59

If a person can identify a common object at 1-20ft it is said there acuity is?

Back 59

Intact

Front 60

Nearsidedness

Back 60

Myopia

Front 61

Farsidedness

Back 61

Hyperopia

Front 62

Lens is unable to change shape to accommodate close vision; has difficulty reading small print. Starts in middle years of life ~45 yrs

Back 62

Presbyopia

Front 63

Drooping of the lid over the pupil

Back 63

Ptosis

Front 64

Deficent to what cranial nerve causes drooping over the pupil or abnormalities to the pupil

Back 64

Crainial nerve III (oculomotor)

Front 65

PERRLA stands for?

Back 65

Pupils equal, round, react to light and accommodation

Front 66

Normal size of pupil is what?

Back 66

3-7 mm

Front 67

What are the two main purposes of vital signs?

Back 67

1) Monitor essential physiologic function of vital organs
2) to evalutate health status

Front 68

Observing trends in vital signs allows the nurse to?(4)

Back 68

1) do clinical problem solving
2) make decisions about treatments/interventions
3) evaluate effectiveness of medications and treatments
4) evaluate response to illness

Front 69

When are vital signs taken? (5)

Back 69

1) on admission
2) per hospital routine or dr orders
3) before and after surgery or diagnostic procedure, medications or nursing interventions affecting vital signs
4) before, during and after blood/blood product transfusion
5) when there is a change in clients condition or a report of physical distress

Front 70

Heat of body determined by the balance of heat produced and heat lost.

Back 70

Body temperature (T)

Front 71

Two types of temp?

Back 71

1) core
2) surface

Front 72

Def- reflects temperature of internal body tissues (muscles or viscer)

Back 72

Core temp

Front 73

Examples of core temp? 2 t

Back 73

Tympanic and rectal

Front 74

Def- temperature varies according to site used

Back 74

Surface

Front 75

Examples of core temps

Back 75

Temporal tympanic recal

Front 76

Surface temp is greater than core temp. T/F

Back 76

False surface temp varies based on location and is lower than core temps

Front 77

What two neurovascular aspects control body temperature?

Back 77

Hypothalamus and feedback system

Front 78

Thermoregulatory center- maintains set point. Receives messages from thermal receptors to produce body heat or increase body loss.

Back 78

Hypothalamus

Front 79

Def- when nerve cells in the hypothalamus become heated/chilled changing the set point causes compensatory mechanisms to take place. These are characteristics of what system?

Back 79

Feedback system

Front 80

What is the primary source of heat?

Back 80

Metabolism controlled by thyroid and metabolic rate

Front 81

BMR

Back 81

Heat production at rest

Front 82

What 2 actions increases body metabolism

Back 82

1)Muscle activity (excerise)
2)Shivering

Front 83

Mechanism of heat transfer

Back 83

Heat loss

Front 84

Taking a cool bath (transfer through direct contact)

Back 84

Conduction

Front 85

Using an electric fan to cool off (through air currents)

Back 85

Convection

Front 86

Sweating and respiration
(conversion of liquid to vapor)

Back 86

Evaporation

Front 87

Fever, pyrexia

Back 87

100.4 F or 38 C

Front 88

< 96.8 F or 36 C

Back 88

Hypothermia, subnormal

Front 89

Over 85 yrs old normal body temp

Back 89

95-97 F

Front 90

Normal oral temp values

Back 90

97.6 to 99.6 F or 36.5 C to 37.5 C
Average 98.6

Front 91

Rectal temp is how many degrees higher or lower than oral?

Back 91

1 F or 0.5 C higher than oral

Front 92

Axillary temp is how many degrees higher or lower than oral?

Back 92

1 F or 0.5 C lower than oral

Front 93

Tempanic temp is how many degrees higher or lower than oral?

Back 93

0.5 F higher than oral

Front 94

Taking a cool bath (transfer through direct contact)

Back 94

Conduction

Front 95

Using an electric fan to cool off (through air currents)

Back 95

Convection

Front 96

Sweating and respiration
(conversion of liquid to vapor)

Back 96

Evaporation

Front 97

Fever, pyrexia

Back 97

100.4 F or 38 C

Front 98

Hypothermia: subnormal,
< 96.8 F or 36 C

Back 98

Hypothermia, subnormal

Front 99

Over 85 yrs old normal body temp

Back 99

95-97 F

Front 100

Normal oral temp values

Back 100

97.6 to 99.6 F or 36.5 C to 37.5 C
Average 98.6

Front 101

Rectal temp is how many degrees higher or lower than oral?

Back 101

1 F or 0.5 C higher than oral

Front 102

Axillary temp is how many degrees higher or lower than oral?

Back 102

1 F or 0.5 C lower than oral

Front 103

Tempanic temp is how many degrees higher or lower than oral?

Back 103

0.5 F higher than oral

Front 104

Average axillary temp?

Back 104

97.6

Front 105

Average oral temp?

Back 105

98.6

Front 106

Average rectal temp?

Back 106

99.6

Front 107

What type of thermometer contains gallium, indium and tin plastic?

Back 107

Mixture

Front 108

This thermometer most be shaken down and held at eye level to read

Back 108

Mixture

Front 109

(a) A digital pen-like probe with cover connected to a microprocessor chip used for oral, axillary, or rectal temperature
(b) infared sensor tip

Back 109

Electronic

Front 110

Disposable plastic strips change color; use for oral or axillary temp. Also temp sensitive tape applied to forehead or abdomen.

Back 110

Chemical

Front 111

Changes color according to skin temp

Back 111

Temp sensitive tape

Front 112

This type of route is more accurate than oral but inconvenient and invasive; gloves must be worn.r

Back 112

Rectal

Front 113

How far should a thermometer be inserted rectally for an Adult? Child?
Infant?

Back 113

-Adult-1.5 inches
-Child 1 inch
- Infant 0.5 inches

Front 114

How long should a rectal thermometer be held in place?

Back 114

2-4 minutes

Front 115

What is the safest most noninvasive temperature route?

Back 115

Axillary

Front 116

How long should a gallium thermometer be held in place for an axillary temp?

Back 116

8-10 minutes

Front 117

Which temp route receives heat from the hypothalamus?

Back 117

Tympanic

Front 118

Fever can result from what three things?

Back 118

Infection, inflammatory, or immunologic

Front 119

What triggers the fever response and acts on the hypothalamus to raise bodies set point above normal?

Back 119

Endogenous pyrogens

Front 120

Why is a fever beneficial? (3)

Back 120

1) stimulates immune system to produce disease fighting WBCs.
2) decreases iron plasma, which suppresses bacterial growth
3) in viral infections it increases production of interferons

Front 121

Harmful causes of increased temp?
Fever over 41 C may cause?

Back 121

1)Increased Basic Metabolic Rate, P, R rates;
2) excessive sweating may lead to dehydration
3) prolonged fever my result in tissue catabolism
4) muscle wasting
5) aching
6) negative nitrogen balance
7) weightloss
8) apathy
9) delirium
10) withdrawal
Fever above 41C
1) Seizure
2) neurological complications

Front 122

The febrile episode has what 3 phases?

Back 122

-Chill Phase
-Plateau Phase
-Fever break

Front 123

During this febrile phase set point rises, client experiences chill and shivering Bc the body is trying to conserve heat

Back 123

Chill phase

Front 124

When the chill phase subsides, client experiences a warm dry feeling because the new temperature set point is reached

Back 124

Plateau phase

Front 125

When vasodilation occurs; client experiences sweating (diaphoresis) Bc the setpoint decreases and the body is attempting to lose heat or return to its normal setpoint

Back 125

Fever break (heat is lost)

Front 126

Nursing care of clients with fever
(4)

Back 126

1) assess for causality (dehydration, infection, environment - exposure to extreme heat or cold)
2) monitor VS
3) Assess skin color (flushed face) and temperature (hot,dry skin)
4) Determine phase of febrile episode; assess comfort level

Front 127

Define- During the systolic phase of the cardiac cycle, the left ventricle ejects blood into the aorta in a wave like pulse stroke. Can be felt in the peripheral arteries

Back 127

Pulse / Heart rate

Front 128

Normal BPM

Back 128

60-100 bpm

Front 129

Volume of blood pumped out during one min

Back 129

Cardiac output

Front 130

The pulse is regulated by
the ___________ via the________.

Back 130

Autonomic nervous system (ANS)
Via the parasympathetic VAGUS nerve

Front 131

The _____ nerve slows the heart rate.

Back 131

VAGUS

Front 132

To increase the pulse rate the __________ releases _________ and __________.

Back 132

Sympathetic nervous system,
Epinephrine,
Norepinephrine

Front 133

What are the 10 factors that affect heart rate or pulse?

Back 133

1) age
2) sex
3) activity
4) fever
5) medications
6) hemorrhage
7) stress
8) position changes
9) vagal stimulation
10) pain

Front 134

If a pulse deficit is present what physiological deficiency may be present

Back 134

A pulse deficit occurs when the apical pulse is greater than the peripheral pulse and this could indicate a Left Ventricle contraction problem.

Front 135

A pulse deficit indicates ?

Back 135

poor peripheral perfusion

Front 136

def- pattern or spacing between beats

Back 136

rhythm

Front 137

def- strength or force; quality

Back 137

amplitude

Front 138

name and describe all pulse amplitudes

Back 138

0 = absent,
+1= difficult to feel; obliterates easily
+2= normal, easy to feel; obliterates with stronger force
+3= strong, bounding; difficult to obliterate

Front 139

number of heartbeats per minute,

Back 139

pulse

Front 140

def- reflects expansibility or compliance of arteries.
-normal is soft, pliable. -abnormal is hard, twisted, tourted

Back 140

elasticity

Front 141

def- always compare peripheral pulses on right to the left.

Back 141

Equality

Front 142

What five characteristics related to pulse should be reported immediately?

Back 142

1) absent, weak, thready pulse;
pulse deficit
2) significant change in resting pulse
3) change in volume or rhythm
4) cool, pale skin

Front 143

how should pulse be documented?

Back 143

location, rate, rhythm, volume, elasticity
Ex: radial 88/m regular, +2 smooth
or
apical 54/m, irregular

Front 144

what is stroke volume?

Back 144

total volume of blood into aorta with each contraction

Front 145

what is cardiac output?

Back 145

volume of blood pumped out of the heart during one min.

Front 146

cardiac output = ____+____

Back 146

Heart rate + Stroke volume = Cardiac output

Front 147

act of breathing for one minute

Back 147

respiration

Front 148

cycle of inspiration and expiration counts as ?

Back 148

one breath

Front 149

Three main muscles of respiration

Back 149

A. Diaphragm
B. Intercostal
C. Accessory

Front 150

intercostals are named for what?

Back 150

rib above it

Front 151

What are the three processes of respiration?

Back 151

A. Ventilation
B. Diffusion
C. Perfusion

Front 152

def- moving air in and out

Back 152

ventilation

Front 153

getting through aveoli

Back 153

Diffusion

Front 154

what is stroke volume?

Back 154

total volume of blood into aorta with each contraction

Front 155

what is cardiac output?

Back 155

volume of blood pumped out of the heart during one min.

Front 156

cardiac output = ____+____

Back 156

Heart rate + Stroke volume = Cardiac output

Front 157

act of breathing for one minute, the mechanism the body uses to exchange gases between the atmosphere, the blood, and the cells.

Back 157

respiration

Front 158

mechanical movement of gases into and out of the lungs

Back 158

ventilation

Front 159

Three main muscles of respiration

Back 159

A. Diaphragm
B. Intercostal
C. Accessory

Front 160

intercostals are named for what?

Back 160

rib above it

Front 161

What are the three processes of respiration?

Back 161

A. Ventilation
B. Diffusion
C. Perfusion

Front 162

def- moving air in and out

Back 162

ventilation

Front 163

the movement of CO2 and O2 between the alveoli and the RBC

Back 163

Diffusion

Front 164

what is stroke volume?

Back 164

total volume of blood into aorta with each contraction

Front 165

what is cardiac output?

Back 165

volume of blood pumped out of the heart during one min.

Front 166

cardiac output = ____ times ____

Back 166

Heart rate times Stroke volume = Cardiac output

Front 167

act of breathing for one minute, the mechanism the body uses to exchange gases between the atmosphere, the blood, and the cells.

Back 167

respiration

Front 168

mechanical movement of gases into and out of the lungs

Back 168

ventilation

Front 169

Three main muscles of respiration

Back 169

A. Diaphragm
B. Intercostal
C. Accessory

Front 170

intercostals are named for what?

Back 170

rib above it

Front 171

What are the three processes of respiration?

Back 171

A. Ventilation
B. Diffusion
C. Perfusion

Front 172

def- moving air in and out

Back 172

ventilation

Front 173

the movement of CO2 and O2 between the alveoli and the RBC

Back 173

Diffusion

Front 174

the distribution of RBC to and from the pulmonary capillaries

Back 174

perfusion

Front 175

What are the five Neural and Chemical Regulation aspects control respirations?

Back 175

1) Neural Regulation
2) Cerebral Cortex
3) Medulla oblongata
4) Chemical regulation
5) Chemoreceptors

Front 176

What 4 things need to be observed when assessing respiration?

Back 176

-rhythm
-rate
-effort/ease
-depth

Front 177

normal breaths per minute for an adult

Back 177

12-20 breaths per minute

Front 178

def- normal unlabored breathing

Back 178

eupnea

Front 179

def- abnormal respiration use of accessary muscles, open mouth breathing

Back 179

labored

Front 180

def- breathlessness difficulty breathing

Back 180

dyspnea

Front 181

def- must assume a particular position to breath, nasal flarring

Back 181

orthopenea

Front 182

< 12 breaths per minute?

Back 182

bradypnea

Front 183

> 20 breaths per minute

Back 183

tachypnea

Front 184

def-no breathing

Back 184

apnea

Front 185

describes normal depth of respiration

Back 185

-full

Front 186

describes very little movement during respiration

Back 186

-hypoventilation

Front 187

increase in respiratory rate, results in excess amounts of CO2 elimination

Back 187

-hyperventilation

Front 188

expands small airways

Back 188

sigh

Front 189

def- abnormal very deep, very rapid breath pattern, ketoacidosis and metabolic disfunction are associated

Back 189

Kussmaul

Front 190

def- happens to the critical ill, very repititous breathing, characterized by slow breathing, then deep breathing, slow breathing, then no breathing

Back 190

Cheyne-Stokes

Front 191

breathing characterized by totally erratic, happens during death

Back 191

Agonal

Front 192

Factors that influence the character of respiration (8)

Back 192

- exercise
- acute pain
- anxiety
- smoking
- body position
- medications
- neurological injury
- hemoglobin function

Front 193

normal respiration limits for an elderly patient?

Back 193

22-24 breaths per minute

Front 194

device that measures O2 saturation

Back 194

pulse ox

Front 195

normal pulse ox?

Back 195

95-100%

Front 196

life threatening pulse ox level?

Back 196

< 70%

Front 197

measures the arterial wall pressure created as blood flows through the arteries throughout the cardiac cycle.

Back 197

Arterial Blood Pressure

Front 198

high value, as the left ventricle ejects blood, more pressue

Back 198

systolic BP

Front 199

lower value, when the heart relaxes

Back 199

diastolic pressure

Front 200

pulse pressure equals?

Back 200

difference in systolic and diastolic BP.

Front 201

normal pulse pressure?

Back 201

30-50 mm Hg

Front 202

what could be indicative of low pulse pressure?

Back 202

may indicate neurological or cardiac dysfunction

Front 203

what would have to be present to treat hypotension?

Back 203

symptoms

Front 204

name the different stages and ranges of hypertension

Back 204

stage 1= 140/90 - 159/99
stage 2= 160/100-or above

Front 205

what are normotensive bp values?

Back 205

90/60 - 119/79

Front 206

name pre-hypertension bp values

Back 206

120/80 - 139/89

Front 207

resistance to blood flow determined by the tone of vascular musculature and the diameter of the blood vessel

Back 207

peripheral resistance

Front 208

volume of blood circulating within the vascular system
(don't over think : )

Back 208

blood volume

Front 209

thickness of blood

Back 209

viscosity

Front 210

normal pcv?

Back 210

37-52%

Front 211

ability of the arteries to stretch

Back 211

elasticity ( increased elasticity results in lower blood pressure)

Front 212

decreased blood volume

Back 212

hypovolemia

Front 213

increased blood volume

Back 213

hypervolemia

Front 214

factors affecting blood pressure (8)

Back 214

1) Age
2) Stress
3) Gender
4) Race
5) Diurnal Variations
6) Medications
7) Activity
8) Disease Process

Front 215

As a person ages elasticity in arteries decreases resulting in?

Back 215

increased blood pressure

Front 216

What act on sympathetic response causes vasoconstriction and increases peripheral blood pressure?

Back 216

Stress

Front 217

True/False
Males have higher blood pressure than women until menopause then blood pressures between genders level out?

Back 217

True

Front 218

What ethnicity is more prone to elevated blood pressure?

Back 218

African American

Front 219

Blood pressure is lower or higher in the morning?

Back 219

Blood pressure decrease at night time and is lower in the morning that it is as the day progresses

Front 220

A diet low in ____ and high in ___ can lower blood pressure.

Back 220

Sodium, Potassium

Front 221

Describe each Korotkoff sound 1.

Back 221

K1- clear, rhythmic tapping series that corresponds to the pulse rate and gradually increases intensity. onset of this sound corresponds to the systolic pressure

Front 222

Describe Korotkoff sound 2

Back 222

K2- murmur or swishing sound

Front 223

Describe Kortokoff sound 3

Back 223

K3- Becomes crisper and more intense tapping

Front 224

What is significant regarding Kortokoff 4?

Back 224

K4- The onset of K4 is the diastolic reading in infants and children, pregnant women, and patients with elevated cardiac output or peripheral vasoconstriction

Front 225

What is K5?

Back 225

disapperance of bp sound; Diastolic value in adolescence and most adults

Front 226

present when the systolic blood pressure drops to
90 mmHg or below.

Back 226

Hypotension

Front 227

What contributors could cause hypotension? (2)

Back 227

-hemorrhage
-myocardial infarction

Front 228

occurs when arteries dilate, the peripheral vascular resistance decreases, the circulating blood volume decreases, or the heart fails to provide cardiac output

Back 228

hypotension

Front 229

signs and symptoms associated with hypotension.(8)

Back 229

- pallor
- skin mottling
- clamminess
- confusion
- dizziness
- chest pain
- increased heart rate
- decrease urine output

Front 230

referred to as postural _______, is a reduction of systolic blood pressure of at least 20mm Hg or reduction of diastolic blood pressure of at least 10mm Hg within 3 minutes of quiet standing

Back 230

orthostatic hypotension

Front 231

two methods to assess BP.

Back 231

Direct- Arterial line
Indirect
a. palpatory (systolic reading only)
b. auscultatory

Front 232

disappearance of sound when obtaining a blood pressure; typically occurs between the first and second korotkoff sounds.

Back 232

ausculatory gap