Podcast
Questions and Answers
Which factor directly influences the changes observed in vital signs?
Which factor directly influences the changes observed in vital signs?
- Dressing type
- Different times of day
- Ovulation state
- All of the above (correct)
When assessing vital signs, why is it important to consider environmental factors?
When assessing vital signs, why is it important to consider environmental factors?
- It facilitates accurate communication with the patient.
- Environmental factors can alter vital sign measurements. (correct)
- Environmental factors ensure cooperation with the physician.
- It ensures the equipment used is reliable.
Why is it important for nurses to measure vital signs at regular intervals?
Why is it important for nurses to measure vital signs at regular intervals?
- To analyze vital signs with the patient.
- To systematically detect changes in the patient's condition. (correct)
- To facilitate effective communication with the patient.
- To ensure constant communication with physicians.
When should vital signs most appropriately be assessed relative to surgical procedures?
When should vital signs most appropriately be assessed relative to surgical procedures?
What is the primary physiological significance of measuring body temperature?
What is the primary physiological significance of measuring body temperature?
Which physiological mechanism allows the body to dissipate heat through the skin?
Which physiological mechanism allows the body to dissipate heat through the skin?
Which part of the brain acts as the thermoregulation center for the human body?
Which part of the brain acts as the thermoregulation center for the human body?
A patient is diagnosed with hypothermia. What body temperature would classify this condition?
A patient is diagnosed with hypothermia. What body temperature would classify this condition?
Why are glass thermometers containing mercury no longer used?
Why are glass thermometers containing mercury no longer used?
For which patient group is oral temperature measurement typically contraindicated?
For which patient group is oral temperature measurement typically contraindicated?
When measuring tympanic temperature, how far into the ear canal should the thermometer be inserted?
When measuring tympanic temperature, how far into the ear canal should the thermometer be inserted?
In which clinical scenario is rectal temperature measurement most accurate?
In which clinical scenario is rectal temperature measurement most accurate?
What is a crucial step to ensure accuracy when measuring axillary temperature?
What is a crucial step to ensure accuracy when measuring axillary temperature?
What nursing action is most important when a patient feels a noticeable change in their condition?
What nursing action is most important when a patient feels a noticeable change in their condition?
Prior to administering a medication that affects heart rate or respiratory function, what action should the nurse take?
Prior to administering a medication that affects heart rate or respiratory function, what action should the nurse take?
Which guideline is essential when sharing vital sign information with other healthcare team members?
Which guideline is essential when sharing vital sign information with other healthcare team members?
Why is effective communication essential when measuring vital signs?
Why is effective communication essential when measuring vital signs?
A patient who is shivering is experiencing which mechanism of thermoregulation?
A patient who is shivering is experiencing which mechanism of thermoregulation?
Which statement best describes the relationship between heat production and heat loss in maintaining a stable body temperature?
Which statement best describes the relationship between heat production and heat loss in maintaining a stable body temperature?
What factor can significantly elevate body temperature by inducing the sympathetic nervous system?
What factor can significantly elevate body temperature by inducing the sympathetic nervous system?
What physiological response occurs when the body needs to conserve heat in a cold environment?
What physiological response occurs when the body needs to conserve heat in a cold environment?
A patient reports feeling cold, despite the room being warm. Which alteration in thermoregulation may be occurring?
A patient reports feeling cold, despite the room being warm. Which alteration in thermoregulation may be occurring?
A patient has a consistent body temperature of 39°C. Which condition does this indicate?
A patient has a consistent body temperature of 39°C. Which condition does this indicate?
Which protocol should be followed when handling a tympanic thermometer to prevent infection?
Which protocol should be followed when handling a tympanic thermometer to prevent infection?
A nurse is assessing an older adult patient who has a history of dementia. Which temperature measurement site is the safest and most practical?
A nurse is assessing an older adult patient who has a history of dementia. Which temperature measurement site is the safest and most practical?
Which step is critical when measuring axillary temperature to ensure an accurate reading?
Which step is critical when measuring axillary temperature to ensure an accurate reading?
After taking a patient's oral temperature, the nurse notes it is slightly elevated. What should the nurse do first?
After taking a patient's oral temperature, the nurse notes it is slightly elevated. What should the nurse do first?
When is measuring a patient's temperature via the rectal route contraindicated?
When is measuring a patient's temperature via the rectal route contraindicated?
When assessing a patient's pulse, what does the term 'pulse volume' refer to?
When assessing a patient's pulse, what does the term 'pulse volume' refer to?
What finding indicates that assessment of apical and radial pulses should be done simultaneously by two nurses?
What finding indicates that assessment of apical and radial pulses should be done simultaneously by two nurses?
In an infant, which pulse point is most appropriate to locate in an emergency?
In an infant, which pulse point is most appropriate to locate in an emergency?
Prior to peripheral pulse assessment, a patient should be placed in which position?
Prior to peripheral pulse assessment, a patient should be placed in which position?
When should the pulse be counted for a full minute rather than 30 seconds and multiplied?
When should the pulse be counted for a full minute rather than 30 seconds and multiplied?
During an assessment, a nurse notes that a patient's radial pulse is significantly lower than their apical pulse. What term describes this difference?
During an assessment, a nurse notes that a patient's radial pulse is significantly lower than their apical pulse. What term describes this difference?
A patient who is bleeding profusely might exhibit what change in pulse volume?
A patient who is bleeding profusely might exhibit what change in pulse volume?
When assessing a patient's respiration, what information is vital to record beyond just the rate?
When assessing a patient's respiration, what information is vital to record beyond just the rate?
What describes the process of inhaling air into the lungs?
What describes the process of inhaling air into the lungs?
A patient with Kussmaul's respirations would display what breathing pattern?
A patient with Kussmaul's respirations would display what breathing pattern?
Which part of the brain primarily regulates the rate and depth of respiration?
Which part of the brain primarily regulates the rate and depth of respiration?
Normal respiration involves what process?
Normal respiration involves what process?
What instructions should the nurse follow when measuring a patient’s respiratory rate?
What instructions should the nurse follow when measuring a patient’s respiratory rate?
After obtaining a respiratory rate, what is the next step?
After obtaining a respiratory rate, what is the next step?
A patient is experiencing difficult breathing. What term most accurately describes this condition?
A patient is experiencing difficult breathing. What term most accurately describes this condition?
What is the primary reason for evaluating a patient's exercise, fatigue, and eating status prior to measuring respirations?
What is the primary reason for evaluating a patient's exercise, fatigue, and eating status prior to measuring respirations?
When assessing oxygen saturation, a reading below 90% indicates what?
When assessing oxygen saturation, a reading below 90% indicates what?
What does pulse oximetry measure?
What does pulse oximetry measure?
What is the best placement for the probe when assessing oxygen saturation?
What is the best placement for the probe when assessing oxygen saturation?
What does 'pulse pressure' indicate about the cardiovascular system?
What does 'pulse pressure' indicate about the cardiovascular system?
What is the diastolic blood pressure measure?
What is the diastolic blood pressure measure?
Which blood pressure reading reflects the criteria for hypertension as defined by the World Health Organization?
Which blood pressure reading reflects the criteria for hypertension as defined by the World Health Organization?
What condition indicates a need to assess for orthostatic hypotension?
What condition indicates a need to assess for orthostatic hypotension?
Why should the arm be supported at heart level when measuring blood pressure?
Why should the arm be supported at heart level when measuring blood pressure?
When measuring blood pressure, at which point should the lower edge of the cuff be positioned in relation to the antecubital area?
When measuring blood pressure, at which point should the lower edge of the cuff be positioned in relation to the antecubital area?
When measuring blood pressure, before inflating the cuff, what key step should the nurse take to ensure accurate results?
When measuring blood pressure, before inflating the cuff, what key step should the nurse take to ensure accurate results?
Which scenario requires the nurse to measure vital signs most frequently to detect subtle changes?
Which scenario requires the nurse to measure vital signs most frequently to detect subtle changes?
What physiological process is directly assessed when evaluating heat loss through breathing?
What physiological process is directly assessed when evaluating heat loss through breathing?
In which of the following scenarios would measuring a patient's rectal temperature be most appropriate, assuming no contraindications?
In which of the following scenarios would measuring a patient's rectal temperature be most appropriate, assuming no contraindications?
A nurse is preparing to measure an adult patient's temperature via the axillary method. What is an important instruction for the patient?
A nurse is preparing to measure an adult patient's temperature via the axillary method. What is an important instruction for the patient?
A patient reports recent consumption of a hot beverage 10 minutes prior to a scheduled oral temperature measurement. What is the recommended next step for the nurse?
A patient reports recent consumption of a hot beverage 10 minutes prior to a scheduled oral temperature measurement. What is the recommended next step for the nurse?
Which clinical scenario presents a contraindication for assessing an adult patient's temperature via the rectal route?
Which clinical scenario presents a contraindication for assessing an adult patient's temperature via the rectal route?
A patient with a known cardiac history is admitted. While taking the patient’s pulse, the nurse notes an irregular rhythm. What is the most appropriate course of action?
A patient with a known cardiac history is admitted. While taking the patient’s pulse, the nurse notes an irregular rhythm. What is the most appropriate course of action?
A nurse assessing a newborn finds the peripheral pulses are weak and difficult to palpate. Which pulse location is most appropriate to assess in this scenario?
A nurse assessing a newborn finds the peripheral pulses are weak and difficult to palpate. Which pulse location is most appropriate to assess in this scenario?
Which factor is most likely to cause an increased respiratory rate in a healthy adult?
Which factor is most likely to cause an increased respiratory rate in a healthy adult?
A patient's respirations are observed to have an irregular pattern, varying in depth and rate, followed by periods of apnea. What type of breathing pattern is the patient exhibiting?
A patient's respirations are observed to have an irregular pattern, varying in depth and rate, followed by periods of apnea. What type of breathing pattern is the patient exhibiting?
Which instruction should the nurse prioritize when preparing to assess a patient's respiratory rate?
Which instruction should the nurse prioritize when preparing to assess a patient's respiratory rate?
After assessing a patient's respiratory rate, which additional characteristic should the nurse document to provide a comprehensive respiratory assessment:
After assessing a patient's respiratory rate, which additional characteristic should the nurse document to provide a comprehensive respiratory assessment:
In which area is the pulse oximetry probe typically placed to ensure accurate oxygen saturation readings?
In which area is the pulse oximetry probe typically placed to ensure accurate oxygen saturation readings?
Following initial assessment, the oxygen saturation of a patient improves from 88% to 92% after the administration of oxygen. Which action should the nurse take next?
Following initial assessment, the oxygen saturation of a patient improves from 88% to 92% after the administration of oxygen. Which action should the nurse take next?
What physiological event does systolic blood pressure specifically measure?
What physiological event does systolic blood pressure specifically measure?
Which of the following factors can lead to alterations in blood pressure measurements?
Which of the following factors can lead to alterations in blood pressure measurements?
If the nurse cannot auscultate a patient’s blood pressure in the left arm, what is the next appropriate action?
If the nurse cannot auscultate a patient’s blood pressure in the left arm, what is the next appropriate action?
After inflating the blood pressure cuff, at what rate should the nurse release the pressure to accurately determine blood pressure readings?
After inflating the blood pressure cuff, at what rate should the nurse release the pressure to accurately determine blood pressure readings?
By what mechanism does the body increase heat production when exposed to prolonged cold?
By what mechanism does the body increase heat production when exposed to prolonged cold?
What is the rationale behind measuring a patient's pulse rate?
What is the rationale behind measuring a patient's pulse rate?
Flashcards
Vital Signs
Vital Signs
Basic indicators of an individual's health status.
Body Temperature
Body Temperature
The balance between heat produced and heat consumed by the body
Pulse
Pulse
Number of heartbeats per minute.
Respiration
Respiration
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Oxygen Saturation
Oxygen Saturation
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Blood Pressure
Blood Pressure
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Hypothalamus role
Hypothalamus role
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Hypothermia
Hypothermia
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Hyperthermia
Hyperthermia
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Eupnea
Eupnea
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Bradypnea
Bradypnea
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Tachypnea
Tachypnea
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Hypoxemia
Hypoxemia
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Cyanosis
Cyanosis
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Bradycardia
Bradycardia
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Tachycardia
Tachycardia
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Hypotension
Hypotension
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Hypertension
Hypertension
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Average pulse pressure
Average pulse pressure
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Definition of Blood pressure
Definition of Blood pressure
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Study Notes
Vital Signs Overview
- Vital signs are basic indicators of an individual's health status
- Vital signs include body temperature, pulse, respiration, oxygen saturation, and blood pressure
- Many factors like time of day, age, ovulation state, seasons, physical activity, dressing type, environmental heat, stress, and disease can change vital signs
Guidelines on Assessing Vital Signs
- The nurse should know how to obtain and evaluate vital signs and how to inform team members
- Ensure equipment is reliable
- Select equipment based on the patient's condition and characteristics
- Know normal vital sign values
- Consider a patient's medical diagnosis, treatment, and medication
- Evaluate environmental factors when assessing vital signs
- Measure vital signs systematically at regular intervals
- Nurses should communicate effectively with patients when measuring vital signs
- Nurses should work together with the physician
- Analyze vital signs absolutely when measured
Frequency of Vital Signs Measurement
- Measure vital signs:
- When preparing a patient for admission
- Before and after surgery (frequency increases)
- Before and after diagnostic procedures
- Before and after administering drugs that affect the heart and respiratory system
- If there is a sudden decline in the patient's condition
- Before and after medical interventions that may affect life signs
- When the patient reports feeling different
Regulation of Body Temperature
- The thermoregulation center is the hypothalamus; it acts as a thermostat
- The hypothalamus signals:
- Vasodilation to decrease heat
- Sweating to decrease heat
- Muscle tremor to increase heat
- Piloerection to increase heat
Temperature Changes
- Hypothermia: body temperature of 35°C and below
- Hyperthermia: body temperature above 38°C
Normal Body Temperature Values by Measurement Site
- Oral: 36.5°C to 37.5°C, average 37°C
- Ear: 36.5°C to 37.5°C, average 37°C
- Axillary/Forehead: 36°C to 37°C, average 36.5°C
- Rectal: 37°C to 38°C, average 37.5°C
Measuring Body Temperature
- Before every application: -Gather materials -Wash hands and wear gloves if necessary -Give the patient information about the application -Ensure patients are comfortable and obtain permission
Oral Temperature Measurement
- Place the thermometer under the tongue (either right or left side)
- Normal range: 36.5 °C - 37.5 °C
Do not take Oral Measurements for People with the Following Circumstances
- Dyspnea
- Children
- Elderly
- Psychiatric diseases
- Non conscious patients
- After the surgery
- In mouth operations
- In case of infection
- On continuous oxygen
When taking a temperature measurement orally:
- The patient should have a personal thermometer
- Drinking or eating very hot or cold food can affect temperature measurement when measuring orally
- Mouth should be closed during oral measurement, and teeth should not be squeezed
Tympanic Measurement
- Make a measurement within 1-2 seconds
- Put the receiver in the 1/3 of the outer ear
- Before measurement, a disposable plastic cover should be placed over the receiver
Rectal Measurement
- Employed when heat cannot be taken by oral or axillary route
- Advance the thermometer 2.5-3.5 cm in an adult, 2-2.5 cm in children, and 1.2 cm in newborns
- Normal is between 37 °C - 38 °C
Rectal Measurement Steps
- Steps include;
- Closing the room and curtains for privacy
- Position patient in the Sim's position and flex the upper leg
- Wear gloves
- Apply water-soluble lubricant to the probe
- Separate the patient's hips with your hand
- Ask patient to breathe slowly and deeply as you insert the degree into the annus
- Remove the probe when finished
Do not take Rectal Temperatures;
- In rectal bleeding
- Rectum surgeries
- Birth
- In the period of maternity
- Continuously as a routine
- way in children
- Diarrhea cases
Axillary/Forehead Measurement
- The axillary region is the most commonly used region
- Infection is unlikely to be transmitted
- Use a personal thermometer
- Ensure that the armpit is not sweaty
Pulse Overview
- Pulse is the number of heartbeats per minute
Pulse Assessment: points to evaluate
- Pulse Rate (How Many Pulses Per Minute)
- Pulse Rhythm (Regular Pulse-arrhythmia)
- Pulse Volume (Full Pulse) - Weak Pulse (Threaded Pulse)
Pulse Assessment: purpose
- To decide rate, rhythm and contraction of the heart
- To identify peripheral vascular diseases
Pulse Rate: Beats Per Minute Ranges
- Newborn: 120-160/min
- Children: 80-120/min
- Adult: 60-100/min
Pulse Rate: Special terminology
- Bradycardia: Pulse rate below 60 beats per minute
- Tachycardia: Pulse rate above 100 beats per minute
Factors Affecting Pulse Rate
- Exercise
- Hyperthermia
- Hypothermia
- Acute pain and anxiety
- Chronic pain
- Drugs
- Age
- Gender
- Metabolism
- Bleeding
- Posture change
Pulse Rhythm Assessment
- If the heartbeat is regular, it is called a regular rhythm, if it is irregular it is called irregular rhythm
- If there is arrhythmia, the difference between apical pulse and radial pulse should be checked
- In arrhythmia, a deficit (Pulse deficit) develops
Pulse Rhythm and Deficit
- Pulse Deficit: the difference between the apical and peripheral pulse rates, and it can signal arrhythmia
- Occurs even as the heart is contracting, but the pulse is not reaching the periphery
- The radial pulse will be lower than the apical pulse, and these two pulse rates are called Pulse Deficit
Volume, Fullness of Pulse Assessment
- Determined by the fullness and by the left ventricular contraction power
- Normally, when the pulse is palpated, it is easily found and each beat felt is of similar fullness; this is a full or bounding pulse
- Weak Pulse: difficult to palpate, even with the pressure of the fingers, the pulse easily disappears
- The weak pulse develops in bleeding, shock, and heart failure
Pulse location
- The temporal artery is above the zygomatic arch, above and in front of the tragus of the ear
- Carotid artery (neck)
- Apical (location), on the midclavicular line of the fifth intercostal space
- Radial artery (wrist)
- Ulnar artery (wrist)
- Brachial artery (medial border of the humerus)
- Femoral artery (at the groin)
- Popliteal artery (behind the knee)
- Dorsalis pedis (on foot)
- The posterior tibial arteries (near the ankle joint) (foot)
Emergency Pulse Points
- 0-1 age: apical, brachial, or femoral artery
-
1 age: carotid artery
Peripheral Pulse Technique
- The hands are washed.
- Authentication is performed
- The patient/family is informed about the application
- The factors that will affect the patient's condition and pulse rate are evaluated before measuring the pulse
- The patient should not be standing, and should be rested
- The patient is given the appropriate position
- Sign/middle/ring fingers placed on artery without excessive pressure (2 or 3 fingers)
- If the pulse is measured for the first time and irregular, counted for 1 minute. If the heart rate is regular, it is counted for 30 seconds and multiplied by 2 to find the heart rate.
- The findings are recorded.
Respiration Overview
- Respirtation, inspiration and exhalation takes place in the nose, pharnyx, lynrx trachea, bronchi, lungs and alveoli
- Gas is exchanged
Respiration Definition
- A process that begins with breathing and involves the organism taking in and using O2 and releasing CO2
- Two stages: external respiration (O2 and CO2 exchange with surrounding tissues) and internal respiration (O2 and CO2 exchange between blood and atmosphere via lungs)
Respiration Mechanics
Consists of; Ventilation Inspiration Expiration, Diffusion Oxygen diffuses Perfusion Process by which oxygen enters the lung circulation
Respiratory center
- Located in the medulla oblongata and pons in the brainstem
Respiratory Measurement
- Evaluate respiratory rate, depth, and type
Respiratory Assessment
• Respiratory rate • Respiratory depth are very important • Respiratory type,
Respiratory Rate
- Newborn 30-60/min
- Adult 12-20 per min
Respiratory Rate Depth
- Assessed as;
- deep,
- superficial,
- normal
Affected by;
- body position,
- some medications,
- exercise,
- fear
- anxiety.
The diaphragm increases by 1 cm in normal breathing
The costa extend 1.5-2.5 cm forward
Hypoventilation & Hyperventilation,
- Hyperventilation: breathing characterized as irregular with increased rate and depth
- Hypoventilation: breathing characterized as irregular with decreased rate and depth
Respiration Problems/Dysfunction
- Anoxia: Absence of oxygen
- Hypoxia Cells and tissues cannot get enough oxygen ,
- Dynpnea: Breathing is difficult with Discomfort
- Cyanosis: Bluish or purplish discolouration due to low tissue surface saturation
Evaluating Resperation
- Count after the pulse
- Observe rise and fall of chest for 1 min
- One rise and fall equals 1 resperation cycle
- Normal Rate = 12-20 breaths/min
- Note Depth of Breathing
- Eupnea (Normal)
- Tachypnea (Faster)
- Bradypnea (Slower)
- Apnea (Absent)
Procedure of evaluating resperation
- Do not say what you are evaluating for and explain afterwards
- Preparation, -Gather Materials, -Wash hands.
-
Explain Procedure To Patient,
-Evaluate exercise, eating, positioning
Measurements after the examination
- Check your watch and take note of start
- Each expiration and inspiration is 1 breath
- Regular breathing: count for 30 seconds and multiply by 2
- Irregular: count for 1 minute
- Record Findings (do not estimate).
Oxygen Saturation Overview
- Pulse oximetry: procedure used to measure oxygen level or oxygen saturation in the blood
- A noninvasive, painless, general indicator of oxygen delivery to peripheral tissues
- Measures amount of oxygen-rich hemoglobin pulsating through the blood vessels
Normal/Abnormal levels of saturation
- Normal ranges are generally found within values of 95 to 100 percent
- Values under 90 percent are considered low
- Hypoxemia described as the level of oxygen in the human blood decreases
Blood Pressure Overview
- The force of blood exerted on the walls of arteries
- Systolic Pressure occurs when the heart pumps, diastole occurs when the heart rests between breaths
- ideal blood: 90/60mmHg and 120/80mmHg
- high BP is be 140/90mmHg or higher
- low BP is 90/60mmHg or lower
Pulse Pressure Overview
- Numeric difference between systolic and diastolic blood pressure is called pulse pressure
- 120/80 pulse pressure is 40.
- Average : 30-50mmHg.
Factors Affecting Blood Pressure
- Age
- Stress
- Race
- Gender
- Daily life
- Medicines
- Foods
- Exercise
Terminology:
- Hypertension: BP over 140/90mmHg
- Hypotension: arterial BP is below normal value; if systolic is 90mmHg or lower
How to measure blood pressure
- BP Monitor (Sphygmomanometer)
- Stethoscope
- Disinfectant
- Registration Form
- Waste Container
Precautions of measuring BP
- Patient lies supine (semi folwer), and arm should be flexed.
- Must have flexed elbow/ forearm at heart level
- Must wait if the has anxious or has an activity, wait a few minutes before checking the pressure.
Important notes about the use of BP cuff
- Lie in supine for 5 minutes, and sit upright with back support
- BP cuff must be placed over their bare skin, 2-3cm above the antecubital space, leaving brachial artery free.
- Make sure arm pointer starts at 0, and palpate brachial artery.
- Place the stethoscope in ear
- Feel your brachial pulses the palmar part of your hand and put the diaphragm to the patient's artery and hold it fixed. (Do not use thumb to palpate pulse)
Performing test
- inflate the cuff to 200-250 mmHg. -Slowly 3cm/sec to release air from the cuff, -Simultaneously observe the dial or mercury gauge, with stethoscope.
Interpretations of sound
The first knocking sound, is the subject's systolic pressure when the knocking, is that is the diastolic pressure (such as 120/80).
Important notes about BP measurements
- Repeat measurement on other arm, wait at least 2 minutes
- Measure blood pressure for the first time measure on both arms
- Blood pressure in the higher arm is considered the patient's blood pressure.
- Record the values, and re-record Wash hands.
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