NOTES_3 Ch 30: Vital Signs - BP and Pain Flashcards
(37 cards)
Define Blood Pressure
The force exerted on the arterial wall by pulsing blood under pressure from the heart.
What are some factors that influence BP?
S.A.M.S. A.G.E.D
- Stressed
- Activity/Weight
- Medications
- Smoking
- Age
- Gender
- Ethnicity
- Daily Variation
Which is more common, hypotension or hypertension?
Hypertension
Hypertension can be…
asymptomatic
Symptoms of Hypotension
- Pallor (paleness)
- Skin mottling (spots or smears of color)
- Clamminess
- Confusion
- Increased heart rate
- Decreased Urine output
What is considered a normal blood pressure reading?
<120/80
What is the BP range indicating Prehypertension?
- Systolic: 120-139
- Dyastolic: 80-89
What is the BP range indicating Stage 1 hypertension?
- Systolic: 140-159
- Diastolic: 90-99
What is the BP range indicating Stage 2 hypertension?
- Systolic: 160 and above
- Diastolic: 100 and above
What is required before a diagnostis of Hypertension?
Multiple BP readings over several visits
(to establish consistancy)
When taking a lower extremety BP, what is the site of auscultation?
Popliteal Artery
How does a lower-extremety BP compare to a brachial artery BP?
- Systolic pressure is usually higher by 10-40 mmHg
- Diastolic pressure should be same
When should you take a lower-extremity BP?
- When the upper extremites are inaccessible for BP measurement
- (due to IV, casts, etc)
Orthostatic Hypotension is a drop of __ mmHg or more from the recorded sitting BP.
20
Orthostatic Hypotension may be related to
- fluid volume deficit
- medications (diuretics or anti-hypertensive)
Orthostatic Hypotension symptoms include
- Dizziness
- Light-headedness
- Falling
Describe the effect of the following BP assessment errors:
- Bladder/cuff to wide
- Bladder/cuff to narrow/short
- Cuff wrapped too loosely/unevenly
Effects
- Bladder/cuff to wide = False Low Reading
- Bladder/cuff to narrow/short = False High Reading
- Cuff wrapped too loosely/unevenly = False High Reading
Describe the effect of the following BP assessment errors:
- Deflating cuff to slowly
- Deflating cuff to rapidly
- Arm below heart level
- Arm above heart level
- Arm not supported
Effects
- Deflating cuff to slowly = False High Diastolic
- Deflating cuff to rapidly = False Low Systolic and False high Diastolic
- Arm below heart level = False High BP
- Arm above heart level = False Low BP
- Arm not supported = False High BP
What are some primary preventions for hypertension?
- Education
- Vaccines/Immunizations
- Lifestyle modifications
- Diet
- Exercise
- Smoking cessasion
What does hypertension damage?
- Brain
- Heart
- Vessels
- Kidneys
Reports of pain are _____ data received from the patient.
subective
Nurse must advocate for patient by _____ reports of pain.
believing
What are three components of Pain to keep in mind?
- It is an unpleasant sensory/emotional experience associated with actual or potential tissue damage
- Pain is whateever the person experiencing it says it is; exists whenever a person says it does
- Pain self-report is always the most reliable indication of pain
What are two types of Pain?
- Acute
- Chronic
