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NUR 216 Final Exam Review
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NUR 216 Final Exam Review General survey components A written summary of overall health Gather information from the first initial encounter with patient, make observations throughout assessment Done at first encounter What is included in the general survey components Physical appearan...

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  • August 16, 2024
  • 14
  • 2024/2025
  • Exam (elaborations)
  • Questions & answers

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  • nur 216 final exam review

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NUR 216 Final Exam Review
General survey components

A written summary of overall health
Gather information from the first initial encounter with patient, make observations throughout
assessment
Done at first encounter

What is included in the general survey components

Physical appearance
Body structure
Mobility
Behavior
Vital signs

First orientation to be lost

Time

Subjective data

pt report symptoms

Objective data

Observed

Precautions

Use gloves in situations involving possible contact with blood or bodily fluids, mucous membranes, non-
intact skin (ex. exposed skin that is chapped, abraded or with dermatitis)

Ranges for RR

Normal 12-20
Low >12 = COPD
High <1 = dehydration, respiratory distress, anxiety, fever

Ranges for HR

Normal 60 to 100/min
Lower than 60 (bradycardia)
Higher than 100 (tachycardia)

Ranges for BP

Normal 120/80
Elevated - 120-129 / <80 (ATI book 141)
HTN Stage 1 - 130--89
HTN Stage 2 - > or = 140 / > or = 90

, HTN with 3 separate visits
Hypotension - systolic < 90

Ranges for SpO2

Normal 95-100%
Hypoxia - below 90% (ATI)

Temperature ranges

36 - 38 degrees Celsius
96.8 - 100.4 degrees Fahrenheit

Sodium intake effects on BP

Raises BP

Pulse oximeter alternate locations when fingers are unavailable

Earlobe

Factors that affect HR

Exercise (however, marathon runners will have bradycardia for resting HR)
Fever
Medications
Changing positions
Acute pain
Hyperthyroidism
Anemia
Stress
Shock

Types of pain

Visceral - dull crampy, organ pain
Somatic - joint, muscles, ligament pain
Neuropathic - related to nerves, diabetics have this type of pain
Acute - < 6 months
Chronic - > 6 months

PQRST

Provoking - what makes it better or worse?
Quality - what does it feel like?
Region - where is the pain located?
Severity - pain rating
Timing - onset/duration

How to appropriately utilize an interpreter

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