FUNDAMENTAL HESI REVIEW 1. Edema Lower Leg: excess of watery fluid collecting in the cavities or tissue of the extremity. • Grading scale: ➢ 1+ barely detectable ➢ 2+ indentation of less than 5mm ➢ 3+ indentation of 5 to 10mm ➢ 4+ indentation of greater than 10mm 2. Blood pressure: the pressure of blood in the circulatory system measured by systolic over diastolic • Average blood pressure readings: ➢ Newborn: (1 year): 65-90/30-60mm Hg; (6 years): 87-117/48-64mm Hg ➢ Adolescent: (12 years): 110/65mm Hg; (16 years): 119/75mm Hg ➢ Adult: (18-60 years): <120/80mm Hg • Checking Orthostatic or Postural hypotension changes: Take blood pressure and pulse with patient SUPINE (lying down forward). Then have patient sit and stand for 1 minute. Retake blood pressure and pulse. Record both sets of numbers. If patient is orthostatic, pressure will decrease (20 to 30mm Hg) and pulse will increase (5 to 25 beats per minute) when sitting or standing. Observe for dizziness, fainting, lightheadedness. Remember patient safety. Record what was found • Korotkoffsounds:sounds of blood pressure ➢ Phase I Systole : sharp thud ➢ Phase II Systole : Swishing sound ➢ Phase III Systole : low thud or knocking ➢ Phase IV Diastole : begins fading ➢ Phase V Diastole: silence • Cuff should be 20% wider than the diameter of the limb • Creating a FALSE HIGH reading ➢ Having the cuff that is too narrow ➢ Having a cuff that is too loose ➢ Deflating the cuff to slowly ➢ Having the arm below the heart ➢ Having the arm unsupported • Creating a FALSE LOW reading ➢ Having a cuff that is too wide ➢ Having a cuff that is too tight ➢ Deflating the cuff too quickly ➢ Having the arm above the heart • Technique for taking BP in the leg- use popliteal artery. Systolic usually 10-40mm HG higher than using brachial; diastolic remains the same. 3. Rectal Temperature: insert lubricated thermometer probe with probe cover in place into rectum 1-1 ½ inches (2.5-3.5 cm) toward umbilicus. Reading is usually 0.9o F lower than oral temperature. • Advantage: Very reliable • Disadvantage: may lag behind core temperature during rapid changes ➢ Should not be used for those with diarrhea or who have had rectal surgery 4. Sleep: • A patient’s sleep history: ➢ Have the patient describe his or her specific problem ➢ Have the patient describe his or her symptoms and alleviating factors ➢ Assessthe patient’s normalsleep pattern ➢ Assess the patient’s normal bedtime rituals