Vital Signs (Basics In Nursing)

Front 1

What 4 things are assessed when taking vital signs? What is often assessed along with vital signs?

Back 1

- temperature
- pulse
- respiration
- blood pressure

(pain is often assessed with vital signs)

Front 2

What is the primary purpose of taking vital signs?

Back 2

to monitor essential physiologic function of vital organs

Front 3

In addition to monitoring vital organ function, what other purpose does taking vital signs serve?

Back 3

evaluates health status and gives us baseline information regarding health

Front 4

How long should you wait before assessing a person's vital signs who was active?

Back 4

about 15 minutes

Front 5

Guidelines are in place when assessing vital signs to offer a range for reference. However, when assessing an individual patient what must you also consider?

Back 5

trends or patterns established by that particular patient

Front 6

Observing trends in Vital Signs allows the nurse to do what 4 things?

Back 6

- clinical problem solving
- make decisions about treatments/interventions
- evaluate effectiveness of medications and treatments
- evaluate the response to illness

Front 7

What are 5 occasions when vital signs are taken?

Back 7

- on admission
- per hospital routine or physician's order
- before and after surgery or diagnostic procedure, medications or nursing interventions affecting VS
- before, during, and after blood/blood product transfusion
- when there is a change in client's condition or a report of physical distress

Front 8

True/false:

A nurse must obtain a doctor's order to take vital signs.

Back 8

False-

A nurse can use his/her own judgment to take vital signs. REMEMBER- You have to take them minimally according to policy or orders, but can access more often using YOUR judgment!

Front 9

(def)

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

Back 9

body temperature

Front 10

Body temperature is stated in what two degrees?

Back 10

Fahrenheit or Celsius

Front 11

What are two examples of temperature methods used to detect core temperature?

Back 11

Tympanic and rectal

Front 12

What are two examples of temperature methods used to detect surface temperature?

Back 12

Oral and axillary

Front 13

What part of the brain is the thermoregulatory center?

Back 13

hypothalamus

Front 14

The hypothalamus receives messages from ___________ ____________.

Back 14

thermal receptors

Front 15

What type of regulatory response would you see when the nerve cells in the hypothalamus become heated?

Back 15

Compensatory mechanisms, such as sweating and vasodilation to promote heat loss

Front 16

What type of reaction might you see in the body when the hypothalamus detects a low body temperature?

Back 16

shivering and vasoconstriction

Front 17

How does vasoconstriction apply to body temperature?

Back 17

vasoconstriction conserves body heat

Front 18

Temperature deep in the body is referred to as what?

Back 18

core temperature

Front 19

What is the primary source of heat production in the body?

Back 19

metabolism

Front 20

(def)

heat production at rest

Back 20

BMR

Front 21

True/False:

Shivering decreases body temperature.

Back 21

False-

Shivering is the body's mechanism of INCREASING body temperature.

Front 22

What are the 4 methods of heat transfer?

Back 22

- radiation
- conduction
- convection
- evaporation

Front 23

Heat loss caused by sitting in a cold room is an example of what mechanism of heat transfer?

Back 23

radiation

Front 24

(def)

diffusion of heat by electromagnetic waves

Back 24

radiation

Front 25

Heat loss caused by taking a cool bath is an example of what mechanism of heat transfer?

Back 25

conduction

Front 26

(def)

transfer of heat through direct contact

Back 26

conduction

Front 27

Heat loss caused by using an electric fan to cool off is an example of what mechanism of heat loss?

Back 27

convection

Front 28

(def)

transfer of heat via air currents

Back 28

convection

Front 29

Heat loss caused by sweating and respiration is an example of what mechanism of heat transfer?

Back 29

evaporation

Front 30

(def)

the conversion of liquid to vapor

Back 30

evaporation

Front 31

(def)

raised body temperature; fever

Back 31

pyrexia

Front 32

Pyrexia is described as a fever over ______ F or _______ C.

Back 32

100.4 F or 38 C

Front 33

(def)

the condition of having a body temperature greatly above normal

Back 33

hyperthermia

Front 34

(def)

the condition of having a subnormal temperature

Back 34

hypothermia

Front 35

To be classified as hypothermia, the body's temperature must be lower than _____ F or ______ C.

Back 35

96.8 F or 36 C

Front 36

What is the normal value for an oral temperature?

Back 36

97.6 to 99.6 F or 36.5 to 37.5 C

Front 37

How much higher is a rectal temperature vs. an oral temperature?

Back 37

1 F or 0.5 C

Front 38

How much lower is an axillary temperature vs. and oral temperature?

Back 38

1 F or 0.5 C

Front 39

True/False:

A tympanic temperature is 0.5 F higher than an oral temperature.

Back 39

True

Front 40

What are the 4 types of thermometers?

Back 40

- mixture of gallium, indium and tin enclosed in plastic
- electronic
- chemical
- temperature-sensitive tape

Front 41

What type of thermometer requires you to shake it down and hold it at eye level to read?

Back 41

Mixture

Front 42

What type of thermometer has a pencil like probe with a cover?

Back 42

electronic

Front 43

Chemical thermometers that are disposable plastic strips are used for what two methods of assessment?

Back 43

oral and axillary

Front 44

What type of thermometer would be applied to the skin and changes color according to the skin temperature?

Back 44

temperature-sensitive tape

Front 45

What is the most commonly used method of temperature assessment?

Back 45

oral

Front 46

How long should you wait to take a temperature after a patient has eaten, drank or smoked?

Back 46

30 minutes

Front 47

How long does it take to take an oral temperature using a gallium thermometer?

Back 47

3-5 minutes

Front 48

What are some contraindications to taking an oral temperature?

Back 48

- mouth breathing
- uncooperative
- seizures
- unconscious
- younger than 6 years old
- nasal/oral surgery or trauma

Front 49

What is the most accurate method of assessing temperature?

Back 49

rectal

Front 50

What PPE should be donned when taking a rectal temperature?

Back 50

gloves

Front 51

True/False:

Lubricant is not required for taking a rectal temperature.

Back 51

false - you should always lubricate the tip of the thermometer

Front 52

Rectal thermometers should be inserted towards the ___________.

Back 52

umbilicus

Front 53

How far should a rectal thermometer be inserted in adults? children? infants?

Back 53

adults - 1.5 inches
children - 1 inch
infants - 1/2 inch

Front 54

How long must you hold a rectal gallium thermometer in place?

Back 54

2-4 minutes

Front 55

What are some contraindications in assessing rectal temperature?

Back 55

- rectal/prostate surgeries or disorders
- diarrhea or impacted stool
- serious heart disease
- newborns

Front 56

Why would you not want to assess the temperature rectally in a patient with serious heart disease?

Back 56

- vagal stimulation may sow the heart rate

Front 57

Why would you not want to assess the temperature rectally in a newborn?

Back 57

- you could perforate the rectal wall

Front 58

What is the safest and least invasive method of assessing temperature?

Back 58

axillary

Front 59

How long must you hold a gallium thermometer in place to assess axillary temperature?

Back 59

8-10 minutes

Front 60

Would the tympanic method of assessing temperature provide you with an accurate surface or core temperature?

Back 60

core

Front 61

________, __________, or __________ processes may cause fever.

Back 61

Infection, inflammatory, or immunologic processes

Front 62

(def)

a substance, typically produced by a bacterium, that produces fever when introduced or released into the blood.

Back 62

pyrogens

Front 63

What happens to the body's setpoint temperature when endogenous pyrogens are introduced into the blood?

Back 63

the hypothalamus raises the body's setpoint in response to the pyrogens being present

Front 64

What are some beneficial consequences of fever?

Back 64

- stimulate the body to produce WBCs
- decreases iron in blood plasma which suppresses bacterial growth
- increases production of interferon, a virus-fighting substance

Front 65

What are some harmful consequences of fever?

Back 65

- increases BMR, P and R rates
- excessive sweating may lead to dehydration
- prolonged fever may result in tissue catabolism, muscle wasting, aching, negative nitrogen balance, weight loss, apathy, delirium and withdrawl
- fever over 41 C may lead to seizures or neurological complications

Front 66

Fever above _____ C may lead to seizures or neurological complications.

Back 66

41

Front 67

What are the 3 phases of the febrile episode?

Back 67

- chill phase
- plateau phase
- fever break

Front 68

During which phase of the febrile episode is heat conserved? During which phase is heat lost?

Back 68

During the "chill phase" heat is conserved. During the "fever break" heat is lost.

Front 69

During which phase of the febrile episode does the setpoint rise?

Back 69

Chill phase

Front 70

Why does the client experience chills and shivering during the "chill phase" of the Febrile Episode?

Back 70

because the body is trying to conserve heat

Front 71

What occurs during the plateau phase of the Febrile Episode?

Back 71

Chills subside and the client experiences a warm and dry feeling because the new temperature setpoint is reached

Front 72

During which phase of the Febrile Episode would a patient experience vasodialation?

Back 72

Fever break

Front 73

Why does a client experience sweating (diaphoresis) during the "fever break" phase of the Febrile episode?

Back 73

because the setpoint decreases, and the body is attempting to lose heat or return to its normal setpoint

Front 74

What is the proper way to clean a thermometer prior to use? What about after use?

Back 74

Prior to use, clean from the bulb to your hand (clean to dirtiest). After use, clean from hand to bulb (clean to dirtiest)

Front 75

Which temperature route best reflects the core body temperature?

Back 75

rectal is said to be most accurate

Front 76

When assessing a client with fever, you should always assess for causality as well. What are some examples of situations that may cause fever?

Back 76

- dehydration
- infection
- environment (exposure to extreme heat/cold)

Front 77

What other assessment measures should be done for a client experiencing fever?

Back 77

- monitor all vitals (not only fever)
- assess for causality
- assess skin color and temperature
- determine phase of febrile episode
- assess comfort level

Front 78

Which of the following symptoms of fever would adversely affect an already weakened patient?

-increase WBCs
-increase BMR
-suppress bacterial growth
-decrease level of iron in the blood

Back 78

Increase BMR - this results in an increase in caloric intake, weight loss, and increases need for oxygen

Front 79

What are 2 nursing interventions that will decrease heat production in a client with fever?

Back 79

- limit physical activity
- promote rest

Front 80

What are 2 nursing interventions that will increase heat loss in a client with fever?

Back 80

- remove external covers
- keep linens and clothing dry

Front 81

What can be done to meet the increased BMR needs of a febrile patient? (2)

Back 81

- Administer O2 as ordered
- Provide adequate nutrition and fluids

Front 82

How can you promote client comfort in a febrile patient? (4)

Back 82

- frequent oral care
- control environmental temperature
- bed bath
- change linens

Front 83

During the systolic phase of the cardiac cycle, the left ventricle ejects approximately how many mL of blood into the aorta?

Back 83

60-70 mL

Front 84

How is Pulse or Heart Rate measured?

Back 84

by counting the number of palpable pulse beats per minute

Front 85

What is the adult normal range for pulse?

Back 85

60-100 bpm

Front 86

What does palpate mean?

Back 86

feel

Front 87

What body system regulates the pulse rate?

Back 87

Autonomic Nervous System

Front 88

Would the parasympathetic Vagus nerve increase or slow the pulse rate?

Back 88

slows the pulse rate

Front 89

What is increased via the sympathetic nervous system to increase pulse?

Back 89

epinephrine and norepinephrine

Front 90

How long should "you" count the pulse?

Back 90

30 seconds

(multiply results by 2)

Front 91

What are some factors affecting P or HR?

Back 91

- age
- sex
- activity
- fever
- medications
- hemorrhage
- stress
- position changes
- vagal stimulation
- pain

Front 92

Which would you expect to have a higher pulse, a 6 month old female or a 22 year old male?

Back 92

6 month old female

Front 93

Do men or women have a higher pulse rate?

Back 93

women

Front 94

How long should you wait to take a pulse after activity?

Back 94

30 minutes

Front 95

Would an athlete have a higher or lower than average heart rate?

Back 95

lower

Front 96

A patient is in recovery after surgery. You observe an increase in heart rate followed by a sudden, drastic decrease. What would this be indicative of?

Back 96

hemmorrhage

Front 97

Would medications increase or decrease heart rate?

Back 97

It depends on the medication

Front 98

What effect does stress have on heart rate?

Back 98

it increases it

Front 99

Does the body's position affect heart rate?

Back 99

Yes, for example standing after lying will result in a decrease in blood pressure

Front 100

Will pain increase or decrease heart rate?

Back 100

increase

Front 101

Where is the vagus nerve located in the body?

Back 101

In the GI tract, extending from the mouth to the anus

Front 102

How does straining to have a bowel movement, gagging or vomiting affect heart rate?

Back 102

It decrease heart rate due to vagal nerve stimulation

Front 103

Where are the vagal receptors located in the body?

Back 103

- Carotid artery sinus in the upper third of the neck

Front 104

The carotid artery sinus houses vegal receptors. How does this affect our procedure for taking a carotid pulse?

Back 104

We palpate the carotid artery in the lower half of the neck

Front 105

What are 2 methods for assessing pulse?

Back 105

- palpation
- auscultation

Front 106

What fingers should be used to assess the pulse? Which should be avoided?

Back 106

Middle 3 to palpate (pads of fingertips more sensitive); avoid using the thumb

Front 107

What are 2 tools used to ausculate pulse?

Back 107

- stethoscope
- doppler ultrasound

Front 108

What are the 6 major Peripheral pulses?

Back 108

- Carotid
- Radial
- Brachial
- Femoral
- Popliteal
- Pedal pulses

Front 109

What is the most accurate peripheral pulse?

Back 109

carotid pulse

Front 110

True/false:

You should never check both carotid pulses at the same time.

Back 110

True - palpation of both at the same time could hinder blood flow to the brain

Front 111

What type of pulse assessment is used in CPR?

Back 111

Carotid

Front 112

Where should you place your fingers when assessing a carotid pulse?

Back 112

between the trachea and the sternocleidomastoid muscle on the LOWER half of the neck

Front 113

What is the most common type of pulse assessment?

Back 113

Radial

Front 114

What pulse assessment is used in infant CPR?

Back 114

brachial pulse

Front 115

True/False:

Assessing both dorsalis pedis pulses at the same time is necessary to check for equal rates.

Back 115

False- both pulses would be checked to assess equal volume or synchronized beats

Front 116

What site for pulse assessment is used when taking blood pressure?

Back 116

Brachial

Front 117

What pulse locations would be assessed when checking for circulation?

Back 117

- femoral
- popliteal
- pedal pulses (dorsalis pedis, posterior tibial)

Front 118

Which location would yield a higher blood pressure rating, the brachial or popliteal pulse?

Back 118

popliteal yields higher results

Front 119

How long should you auscultate a central pulse?

Back 119

a full minute

Front 120

What is the next assessment step if you detect an abnormal peripheral pulse?

Back 120

ausculate the apical pulse

Front 121

A nurse is caring for a patient with CV disease. What type of pulse assessment would be standard on this patient?

Back 121

apical pulse

Front 122

What is the standard location of the apical pulse?

Back 122

the apex of the heart (usually heard loudest at the 5th intercostal space, midclavicular line)

Front 123

Where should you begin your count when assessing a pulse?

Back 123

always start at 0

Front 124

What two sounds correlate with cardiac cycle?

Back 124

systole and diastole (S1 and S2)

Front 125

What anatomical landmarks should you follow to locate the apical pulse?

Back 125

- locate the suprasternal notch, angle of Louis, which is level with the 2nd ICS

- count rib spaces down to the 5th ICS, midclavicular line

Front 126

What is the purpose of detecting an apical-radial pulse?

Back 126

to assess if there is a pulse deficit

Front 127

When assessing apical-radial pulse, what might you deduct if the radial pulse produced is diminished or absent?

Back 127

that the left ventricle contraction is weak

Front 128

A ________ __________ occurs when the apical pulse is greater than the peripheral pulse.

Back 128

pulse deficit

Front 129

What does a pulse deficit indicate?

Back 129

poor peripheral circulation/perfusion

Front 130

What are the 5 things that you should assess the pulse for?

Back 130

- rhythm
- amplitude (volume)
- rate
- elasticity
- equality

Front 131

(def)

the pattern or spacing between pulse beats; may be regular or irregular

Back 131

rhythm

Front 132

An irregular rhythm in pulse is known as what?

Back 132

dysrhythmia

Front 133

The strength or force of a pulse is known as what?

Back 133

amplitude (volume)

Front 134

The amplitude of a pulse is measured on a scale from 0 to +3. Describe each individual measurement.

Back 134

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

Front 135

(def)

the number of heart beats per minute

Back 135

rate

Front 136

How long should you count a regular rhythm pulse?

Back 136

30 seconds (multiply by 2)

Front 137

How long should you count an irregular rhythm pulse?

Back 137

60 seconds

Front 138

A pulse lower than 60 is called what?

Back 138

bradycardia

Front 139

A pulse greater than 100 is called what?

Back 139

tachycardia

Front 140

Describe normal and abnormal elasticity of arteries.

Back 140

normal = soft, pliable
abnormal = hard, twisted, tortuous

Front 141

How do you determine the equality of a pulse?

Back 141

assess the left and right pulse at the same time

Front 142

What type of changes should be reported immediately?

Back 142

- absent, weak, thready pulse
- pulse deficit
- significant change in resting pulse
- change in volume or rhythm
- cool, pale skin

Front 143

A nurse assesses a patient's radial pulse at 88. She/he finds it easy to feel and puts moderate force to obliterate the pulse. Upon further examination, she/he finds that the artery feels soft and pliable and that the rhythm is regular. How is this information documented?

Back 143

radial 88/m regular, +2 smooth

Front 144

True/False:

When performing an apical-radial pulse, it is imperative that both nurses starts their individual watches at the exact same time to ensure an accurate count.

Back 144

False-

An apical-radial pulse requires that both nurses use the SAME watch!

Front 145

What are some pulse/blood pressure changes you may expect to see in the elderly?

Back 145

- loss of compliance (elasticity)
- Blood pressure may be higher to compensate for the loss of arterial compliance
- after activity, it takes longer for the pulse to return to "resting" state

Front 146

True/false:

The elderly usually have a higher heart rate.

Back 146

False -

While blood pressure may be higher to compensate for compliance issues, heart rate is usually the same.

Front 147

(def)

the act of breathing (exchange of gases) for 1 minute;

Back 147

respiration

Front 148

What is the average length of inspiration? Expiration?

Back 148

Inspiration = 1-1 1/2 seconds
Expiration = 2-3 seconds

Front 149

What 3 muscles 'may' be used in respiration?

Back 149

- diaphragm
- intercostals
- accessory

Front 150

What is the major muscle of respiration?

Back 150

diaphragm

Front 151

What muscle(s) would you expect to be used when a patient is having difficulty breathing?

Back 151

- diaphragm
- intercostals
- accessory (ex. neck muscles)

Front 152

What are the 3 processes of respiration?

Back 152

- ventilation
- diffusion
- perfusion

Front 153

(def)

mechanical movement of respiration; the act of breathing

Back 153

ventilation

Front 154

(def)

the movement of O2 and CO2 between alveoli and RBCs

Back 154

diffusion

Front 155

(def)

the distribution of RBCs from pulmonary capillaries to the rest of the body

Back 155

perfusion

Front 156

Neural regulation of respiration involves what 2 parts of the brain?

Back 156

- medulla oblongata
- cerebral cortex

Front 157

You observe a client's respiration without their knowledge. What part of the brain is likely controlling the breathing that you document?

Back 157

medulla oblongata - responsible for involuntary, automatic control of breathing

Front 158

What part of the brain would likely be controlling breathing if the patient was aware that you were counting their respiration rate?

Back 158

cerebral cortex - voluntary control of respirations

Front 159

What structures detect the presence of CO2 and O2 in the blood?

Back 159

chemoreceptors located in the aorta and carotid arteries

Front 160

What 4 things should you assess when observing respirations?

Back 160

- rhythm
- rate
- effort/ease
- depth

Front 161

Rhythm of respirations should be recorded as either ________ or _______.

Back 161

regular or irregular

Front 162

If you cannot see the chest rise/fall when assessing respirations, how should you position the client?

Back 162

place the client's arm over their abdomen

Front 163

In the "Assessment of Vital Signs", at what point should you assess respirations?

Back 163

immediately after taking their pulse

Front 164

How long should you count respirations?

Back 164

30 seconds

Front 165

What is the normal range for respirations?

Back 165

12-20 breaths per second

Front 166

(def)

regular respirations between 12-20; no effort required to breath

Back 166

eupnea

Front 167

(def)

respirations below 12 breaths per minute

Back 167

bradypnea

Front 168

(def)

respirations above 20 per minute

Back 168

tachypnea

Front 169

(def)

absence of breathing

Back 169

apnea

Front 170

(def)

difficulty breathing; shortness of breath

Back 170

dyspnea

Front 171

(def)

breathing done with great effort and difficulty

Back 171

labored

Front 172

(def)

shortness of breath (dyspnea) which occurs when lying flat, causing the person to have to sleep propped up in bed or sitting in a chair

Back 172

orthopnea

Front 173

What 3 descriptions are used to describe varying depths of respirations?

Back 173

- full
- hypoventilation
- hyperventilation

Front 174

What description would you use to describe breathing that was very shallow and undetectable by chest or abdomen movements?

Back 174

hypoventilation

Front 175

If a client is experiencing hypoventilation, how might you have to observe respiration depth?

Back 175

observe shoulders or use stethoscope

Front 176

(def)

very deep movement of the chest/abdomen when breathing

Back 176

hyperventilation

Front 177

What do you do if a client sighs or yawns while counting respirations?

Back 177

You count that as a breath, both are part of the normal breathing cycle

Front 178

Rapid, deep breathing as seen with diabetes ketoacidosis is known as what?

Back 178

Kussmaul

Front 179

Respirations that go from shallow -> deeper -> shallow -> apnea, as seen in head injuries are known as what?

Back 179

Cheyne-Stokes

Front 180

Totally erratic respirations displaying no pattern (often seen when death is imminent) are known as what?

Back 180

agonal

Front 181

How does exercise influence respirations?

Back 181

increases the rate

Front 182

How does acute pain influence respirations?

Back 182

increases the rate and rhythm

Front 183

How does anxiety influence respirations?

Back 183

increases the rate and depth

Front 184

How does smoking influence respirations?

Back 184

increases the rate at rest

Front 185

What body position offers full expansion of the chest cavity, easing breathing?

Back 185

upright/straight

Front 186

What change in respirations would you expect to see in a client who receives narcotics?

Back 186

slower rate

Front 187

How might a neurological injury affect respirations?

Back 187

- decreases rate; changes rhythm

Front 188

What occurs to respirations when a client has low hemoglobin function?

Back 188

the rate increases

Front 189

What effect does the decrease in the arterial elasticity of elderly clients have on their respiration rate?

Back 189

respirations are shallower and slightly faster

Front 190

A nurse assesses the respiration rate of an 83 year old black female at 23 per minute. Why is this not an immediate cause of concern?

Back 190

Respiration rate in elderly clients is often higher due to the decrease in elasticity of arteries/veins

Front 191

Arterial blood pressure measure what?

Back 191

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

Front 192

BP is written as a fraction consisting of what 2 parts?

Back 192

systolic BP
diastolic BP

Front 193

What is the systolic and diastolic blood pressures of a BP 120/80?

Back 193

systolic = 120
diastolic = 80

Front 194

Which BP, systolic or diastolic, is the pressure created as the left ventricle ejects blood?

Back 194

systolic

Front 195

Which BP, systolic or diastolic, is when the heart relaxes?

Back 195

diastolic

Front 196

(def)

the difference in systolic and diastolic BP

Back 196

pulse pressure

Front 197

What is the normal range of pulse pressure?

Back 197

30-50 mm Hg

Front 198

What might be the cause of an abnormal pulse pressure?

Back 198

neurological or cardiac dysfunction

Front 199

What is the range of normotensive BP? Pre-hypertensive? Hypertensive Stage 1 and 2?

Back 199

normontensive 90/60 - 139/89
pre-hypertensive 120/80 - 139/89
hypertensive stage 1 - 140/90 - 159/99
hypertensive stage 2 - 160/100 and above

Front 200

A blood pressure below 90/60 in an adult who's BP is normally higher than that is termed what?

Back 200

hypotension

Front 201

For a blood pressure below 90/60 to be considered hypotensive, what must be present?

Back 201

symptoms or a significant change

Front 202

(def)

volume of blood (stroke volume) pumped by the heart in one minute

Back 202

Cardiac Output (CO)

Front 203

(def)

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

Back 203

Peripheral resistance

Front 204

(def)

amount of blood circulating within the vascular system

Back 204

blood volume

Front 205

(def)

thickness of blood

Back 205

viscosity

Front 206

(def)

ability of arteries to stretch

Back 206

elasticity

Front 207

What measures the ratio of blood cells to plasma?

Back 207

Hematocrit

Front 208

A patient's hematocrit test indicates a high number of RBCs in ratio to blood plasma. How would you expect this to affect the blood's viscosity?

Back 208

the blood would be thicker than normal

Front 209

How does age affect BP?

Back 209

Higher age = lower elasticity, build-up of plaque in arteries

Front 210

How does stress affect BP?

Back 210

stress stimulates flight or fight response (sympathetic system) and increases vasoconstriction

Front 211

What are the differences in BP between males and females?

Back 211

Males have higher blood pressure than females until menopause when it tends to equal out

Front 212

What race tends to have higher BP?

Back 212

African Americans

Front 213

Would you expect to see a higher BP in the morning or evening? Why?

Back 213

Higher BP in evening when metabolic rate peaks

Front 214

True/False:

Medications may increase or decrease BP.

Back 214

True

Front 215

How long should you wait to take the BP of a person who was exercising. Why?

Back 215

30 minutes because exercise does increase BP (although the change is NOT as dramatic as pulse changes)

Front 216

A client is diagnosed with diabetes mellitus. What type of BP reading would you expect to see in this client?

Back 216

BP will be high, probable hypertension

Front 217

Would you expect a higher or lower BP in an obese patient?

Back 217

higher

Front 218

True/False:

Smoking and/or high alcohol consumption results in higher BP

Back 218

True

Front 219

What are 3 known complications of hypertension?

Back 219

- CVA
- Kidney Failure
- Eyesight problems

Front 220

Although hypertension is commonly asymptomatic, what symptoms are associated with this disorder?

Back 220

- headaches
- nosebleeds
- flushing
- fatigue

Front 221

What are some symptoms of hypotension?

Back 221

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

Front 222

To be diagnosed with hypertension, the client's BP must be measures ____ or more times and averaged out.

Back 222

2

Front 223

Orthostatic hypertension is a side effect of many ___________ medications.

Back 223

hypertensive

Front 224

(def)

a drop in BP of 20 or more systolic or 10 or more diastolic when you change from a sitting/lying position to a standing position

Back 224

orthostatic hypertension

Front 225

What type of method would be used to directly assess BP?

Back 225

an arterial line

Front 226

What are 3 methods of assessing BP?

Back 226

palpatory (systolic only)
ausculatory (systolic and diastolic)
electronic (systolic and diastolic)

Front 227

How would you document a palpatory BP?

Back 227

value/p

Front 228

The width of a BP cuff should be ___-___ % of the circumference of the midpoint of the limb on which the cuff is used.

Back 228

40-50%

Front 229

If a BP cuff is too narrow, what will happen to the reading? What if it is too wide?

Back 229

too narrow = false high
too wide = false low

Front 230

What are 2 types of sphygmomanometers?

Back 230

aneroid (dial) or mercury

Front 231

The sounds heard when listening to the blood pressure are called what?

Back 231

Korotkoff's sounds

Front 232

What sound indicates the systolic BP when ausculating?

Back 232

K1

Front 233

What sound indicates the diastolic BP when ausculating?

Back 233

K5 (adults) K4 (children)

Front 234

What are examples of situations where you would not take the BP from the arm?

Back 234

- mastectomy
- recent blood drawn
- stroke deficit
- IV
- A line
- Shunt for dialysis
- surgery or any deviation to the hand, arm, shoulder, or axilla

Front 235

If you take a BP using the leg, what deviation do you expect to see in the reading?

Back 235

expect the systolic to be 20-30 higher

Front 236

Why should you always palpate systolic pressure prior to taking BP?

Back 236

to avoid misreading due to an auscultory gap

Front 237

What are the follow up recommendations for the following:

Normal BP, Prehypertension, Hypertension Stage I, Hypertension Stage II

Back 237

Normal - recheck in 2 years
Prehypertension - Recheck in 1 year
Stage I Hypertension - Confirm in 2 months
Stage II Hypertension - Confirm in 1 month

Front 238

What is the protocal for a BP of 180/100 or greater?

Back 238

Treat immediately to 1 week depending on clinical situation

Front 239

When checking BP, the cuff should be inflated to _____ mercury above the palpated systolic pressure.

Back 239

30

Front 240

Where should you position the stethoscope when assessing BP in the arm?

Back 240

over the brachial artery

Front 241

How far above the brachial artery should the cuff be positioned?

Back 241

1 inch

Front 242

When taking BP, what point indicates Systolic pressure?

Back 242

when the 1st sound is heard

Front 243

When taking BP, what point indicates Diastolic pressure?

Back 243

when the sound disappears

Front 244

What is the very 1st step in the blood pressure procedure?

Back 244

Wash hands

Front 245

When releasing the valve of the BP cuff, what is the desired rate that the mercury will fall every second?

Back 245

2-3 mm