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...
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
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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