NUR 306 Lecture Notes - Lecture 2: Posterior Tibial Artery, Caffeine, Bradypnea
Document Summary
Collect objective data, determine changes, teaching moment. Only the area being assessed should be exposed. Begins the moment you meet the patient. State of health, posture, motor activity, manner of speaking. Vital signs: blood pressure, pulse, respiratory rate, temperature, pulse oximetry. Inspection: surface characteristics, color, shape, symmetry, abnormalities, signs of distress, odors. Ballottement (knee): size, shape of free floating objects. Heart sounds, lungs, bowel sounds, vascular sounds. Blood pressure: assess circulatory blood volume as the heart contracts and relaxes, measures the force against the arterial walls. Systolic: pressure in the arteries when the heart muscle contracts. Diastolic: pressure in the arteries between heart beats (muscles is resting) Take bp in both arms 2 min apart. Avoid smoking or drinking caffeinated beverages 30 min before. Most accurate bp reading is in the left arm. Bladder of the arm should be 40% of the arm and 2/3 of the length of the arm.
