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Clinical 2
Chapter 11
| Question | Answer |
|---|---|
| Blood pressure | The measurement of the force of the blood against the arterial walls during contraction and relaxation of the heart |
| Systole pressure | Measurement of the greatest amount of force against the arterial wall ( occurs during contraction phase of the heart --recorded as the top # and is the first sound ) |
| Diastolic pressure | Measurement of the least amount of force Against the arterial wall ( occurs during the relaxation phase when the ventricles are refilling ) |
| Systolic | Top # |
| Diastolic | Bottom # follows the last sounds heard |
| BP | Is written as a fraction and measured in mm/hg |
| KROTKOFF SOUND | Sounds that occur during measurement of BP |
| KROTKOFF sound phase 1 | Tapping |
| KROTKOFF sound phase 2 | Swishing |
| KROTKOFF sound phase 3 | Knocking |
| KROTKOFF sound phase 4 | Muffling |
| KROTKOFF sound phase 5 | Silence |
| PULSE PRESSURE | Difference between the systolic and diastolic pressure |
| Pulse pressure | Normal range adult 30 - 50 |
| Normal BP values and pulse rate( adults ) | 10yrs and above 100/30 Pulse rate 60/90 |
| Normal BP values and pulse rate (children) | 3-10 yrs 80/120 Pulse 40/80 |
| HYPERTENSION ( HTN) HIGH BLOOD PRESSURE | BP consistently 130/90 ( consistently pt with high BP are considered controlled with a BP 130/90 ) |
| SIGNS AND SYMPTOMS (S&S) OF HYPERTENSION | Headache/ ringing in the ear/ spots or floaters in front of the eyes |
| UNCONTROLLED HYPERTENSION | Can affect the eyes / kidneys / heart / brain / lungs |
| HYPOTENSION | Consistently low BP ( usually is result from a second cause ) |
| UNCONTROLLED HYPOTENTION | Secondary cause could be from blood loss / hypocalcemia / change in position from lying to standing / sepsis treatment/ underlying cause found usually resolves the issues |
| S&S of HYPOTENTION | Light headed dizzy syncopea |
| ORTHOSTATIC HYPERTENSION | BP that is drops with a change in position /lying / standing / sitting No specific TX -- advice to pt sit up for a few mins before standing |
| OBTAINING ORTHOSTATIC BP / HR | Do in the following positions /. Lying / sitting / standing Then wait 2 minutes between each position before obtaining measurement |
| Variables that affect BP | Pain / anxiety / time of day ( durian rhythm) / medications/ exercise/ actives / gender / race / diet / positioning/ inappropriate cuff size / elevated cuff too small false / BP cuff too big False low BP |
| VS ( vital signs) | Can provide an overall picture of PT general state of health ( should be done at well visits to establish a baseline ) |
| VS INCLUDE | Temperatures/ pulse / restoration/ BP / pain scale (5TH VITAL SIGN ) / pulse oximetry |
| TEMPERATURES / FEBRILE | With fever |
| TEMPERATURES / AFEBRILE | Without fever |
| METHODS OF TEMPERATURES ORAL | Most common ORAL Normal values 98.6 f |
| METHODS OF TEMPERATURES AXILLARY | AXILLARY Least accurate Normal values 97.6 f |
| METHODS OF TEMPERATURES TEMPORAL ARTERY | TEMPORAL Most accurate considered a core temperature Normal values 99.6 f |
| METHODS OF TEMPERATURES RECTAL | RECTAL most accurate Normal values 99.6 f |
| METHODS OF TEMPERATURES AURAL | Inaccurate |
| LOW GRADE FEVER | 100 - 101 |
| MODERATE FEVER | 101 - 103 |
| HIGH FEVER | 103. - 105 |
| HYPERPREXIA | > 105 |
| CAUSES OF FEVER | Infection. /. injury ( crushing of bone from accident) / neoplasms ( new growth) / connective tissue disease ( lupus/ MS ). / heart stroke / drug interaction ( general anesthesia- first sign of reaction blood transfusion) / malignant -hyperthermia |
| FEVER PATTERNS | Continuous/ intermittent ( comes and goes) lysis ( when fever breaks )/ crisis and remitting |
| PULSE | Measurement of heart beats per minute ( usually by palpating the radial pulse |
| PULSE TIMES 2 | Count for 30 second then times by 2 Record as BPM // ALWAYS EVEN NUMBER |
| IRREGULAR PULSE | Count for a full minute / if difficult to Palpate then preform " APICAL PULSE " |
| HEART RATE ( HR) Over 100 bpm | HR> 100 bpm tachycardia |
| HEART RATE (HR) Under 60 bpm | HR < 60 bpm bradycardia |
| CHARACTERIS OF THE HR | Fast or slow |
| RHYTHM | Regular / irregular |
| STRENGTH / VOLUME | Strong or weak ( weak - threads pulse ) |
| ADULT HR | 10 yrs 60 - 100 bpm |
| CHILD HR | 3 - 10 yrs 60 - 120 bpm |
| EXTREME ATHLETES | < 60 bpm |
| PULSE SITES | All arteries |
| TEMPORAL | TA TEMP ( side of forehead) |
| CAROTID | PULSE SITE DURING CPR ( side of neck ) |
| BRACHIAL | USED FOR BP ( pinky side of ac space) |
| RADIAL | SITE WORD - MOST COMMON PULSE USED ( thumb side - inner wrist ) |
| FEMORAL | CREASE IN GROIN ( assess blood flow to lower extremities) |
| POPLITEAL | BEHIND THE KNEE ( assess blood flow to lower leg ) |
| POSTERIAL TIBIAL | BEHIND THE TIBIA / ANKLE ( assess blood flow to the feet) |
| DORSALIS PEDIS | TOP OF FOOT ( assess blood flow to feet / most common pulse site to do a diabetic foot check) between great toe and big toe |
| APICAL PULSE | Uses stethoscope to auscultate heart beat LOCATED@ THE 5TH INTERCOSTAL SPACE MID CLAVICAL LINE DIRECTLY OVER THE APEX OF THE HEART |
| APICAL RADIAL PULSE DEFICIT | Measures the apical & radial @the same time ( requires two people to proform) I.e.; aprical >100 bpm Radial > 50 bpm = PD 50 |
| APICAL / RADIAL | Difference between the two is the pulse deficit ( may indicate a fiblatrial fibulation) |
| RESPIRATION | Process of inhale / exhale ( each cycle counts as 1 respiration) |
| RESPIRATION RECORD | Record per minute / count resp. For 30 seconds then x2 ( do not tell patient you are recording respiration) |
| Recording respiration | Stay in pulse taking position and then count respiration after counting pulse. |
| AVERAGE ADULT RANGE OF RESPIRATION | ADULT > 10 yrs ( 12 a 16 min ) |
| AVERAGE RANGE OF CHILD RESPIRATION | CHILD ( 3-10yrs ) 18 - 30 min |
| TACHYPENIA | RAPID / SHALLOW RESPIRATIONS |
| DYSPENIA | DIFFICULTY OR LABORED BREATHING |
| ORTHOPENIA | EASE OF BREATHING IN SITTING OR STANDING POSITION |
| HYPERPENIA | ( HYPERVENTILATION) RAPID / DEEP / RESPIRATION |
| BRADYPENIA | ABNORMALLY SLOW RESPIRATION |
| CHEYNE STROKES | Deep breathing followed by period of apnea ( pattern usually proceeds death ) |
| ATOXIC | Irregular / unpredictable patterns ( usually indicates brain damage) |
| RALES | Wet sound ( may indicate CHF ) |
| RHONCHI | Course sounds ( may indicate URI / BRONCHITIS) |
| WHEEZING | High pitched whistling indicating narrowing of the bronchioles ( asthma / COPD) |
| STRIDOR | Barking seal - like cough sounds ( narrowing of upper airways / croup (virus) |
| PLEURAL RUB | Crackle / crinkling ( sound result of lungs rubbing against pleural sac ) |
| PULSE OXIMETRY | Measurement of arterial oxygen saturation in the tissue ( NORMAL VALUE > 95%) If less < then 95% then intervention is necessary |
Created by:
Tbella
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