Fundamentals 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
• Korotkoff sounds: 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 0.9oF 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
➢ Assess the patient’s normal sleep pattern
➢ Assess the patient’s normal bedtime rituals
, ➢ Assess for current or recent physical illnesses
➢ Assess for current or recent emotional stress
➢ Assess for possible sleep disorders
➢ Assess the patient’s current medications and their possible effects on sleep
• Sleep disorders:
➢ Bruxism: tooth grinding during sleep
➢ Insomnia: chronic difficulty with sleep patterns
▪ Initial insomnia: difficulty remaining asleep
▪ Intermittent insomnia: difficulty remaining asleep
▪ Terminal insomnia: difficulty going back to sleep
➢ Narcolepsy: difficulty in regulating between sleep and awake states; person may fall
asleep without warning
➢ Nocturnal enuresis: bedwetting
➢ Sleep apnea: intermittent periods of cessation of breathing during sleep. Use risk
assessment, alcohol at bedtime increase risk for sleep apnea
➢ Sleep deprivation: decrease in the amount and quality of sleep
➢ Somnambulism: sleepwalking, night terrors or nightmares
• Drugs and their adverse effects on sleep
➢ Hypnotics
▪ Interfere with reaching deep sleep stages
▪ Only temporary increase in quality of sleep
▪ May cause hangover during day
▪ Excess drowsiness, confusion decreased energy
▪ May worsen sleep apnea in older adults
➢ Diuretics
▪ Cause nocturia
➢ Antidepressants and stimulants
▪ Suppress rapid eye movement (REM) sleep
➢ Alcohol
▪ Speeds onset of sleep
▪ Disrupts REM sleep
▪ Awakens person during night and causes difficulty returning to sleep
➢ Caffeine
▪ Prevents person form falling asleep
▪ May cause person to awaken during night
➢ Nonbenzodiazepines
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
• Korotkoff sounds: 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 0.9oF 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
➢ Assess the patient’s normal sleep pattern
➢ Assess the patient’s normal bedtime rituals
, ➢ Assess for current or recent physical illnesses
➢ Assess for current or recent emotional stress
➢ Assess for possible sleep disorders
➢ Assess the patient’s current medications and their possible effects on sleep
• Sleep disorders:
➢ Bruxism: tooth grinding during sleep
➢ Insomnia: chronic difficulty with sleep patterns
▪ Initial insomnia: difficulty remaining asleep
▪ Intermittent insomnia: difficulty remaining asleep
▪ Terminal insomnia: difficulty going back to sleep
➢ Narcolepsy: difficulty in regulating between sleep and awake states; person may fall
asleep without warning
➢ Nocturnal enuresis: bedwetting
➢ Sleep apnea: intermittent periods of cessation of breathing during sleep. Use risk
assessment, alcohol at bedtime increase risk for sleep apnea
➢ Sleep deprivation: decrease in the amount and quality of sleep
➢ Somnambulism: sleepwalking, night terrors or nightmares
• Drugs and their adverse effects on sleep
➢ Hypnotics
▪ Interfere with reaching deep sleep stages
▪ Only temporary increase in quality of sleep
▪ May cause hangover during day
▪ Excess drowsiness, confusion decreased energy
▪ May worsen sleep apnea in older adults
➢ Diuretics
▪ Cause nocturia
➢ Antidepressants and stimulants
▪ Suppress rapid eye movement (REM) sleep
➢ Alcohol
▪ Speeds onset of sleep
▪ Disrupts REM sleep
▪ Awakens person during night and causes difficulty returning to sleep
➢ Caffeine
▪ Prevents person form falling asleep
▪ May cause person to awaken during night
➢ Nonbenzodiazepines
