NRS 312 Study Guide - Final Guide: Caffeine, Earlobe, Shingles
Week 3:
Nursing Dx: Acute Pain
• An unpleasant sensory and emotional experience associated with actual or potential tissue
damage or described in terms of such damage; sudden or slow onset of any intensity,
from mild to severe, with an anticipated or predicted end
Nursing Dx: Chronic Pain
• Unpleasant sensory and emotional experience arising from actual or potential tissue
damage or described in terms of such damage; sudden or slow onset of any intensity,
constantly or reoccurring without an anticipated or predictable end and a duration of
greater than three months
Nursing Dx: Impaired Comfort
• Perceived lack of ease, relief and transcendence in physical, psycho spiritual,
environmental, cultural, and/or social dimensions
Vital signs
• Pulse
o Normal: 60-100 bpm
o Tachycardia: >100
o Bradycardia: <60
o Palpation : not the thumb
o Where?: radial carotid, apical, ulnar, femoral, temperoal, poplited, dorsal
pedis/pedal, posterior tibial, brachial.
▪ Apical pulse: one minute
▪ Corotid Pulse: don’t do both at the same time. You could cut off blood
supply to the brain
o Documentation: #bpm looking for consistency’
o Strength: 0-4
▪ 3+ (bounding) 2+ (normal) 1+ (weak)
▪ bounding pulse : Fluid overload, stress, exercise
▪ Weak pulse: Blood loss, dehydration, problems with the heart itself
▪
o Regularity: “regularly irregular – 60 seconds
▪ If regular 30 seconds x 2
o Bilateral Assessment: able to measure both sides of the patient at the same time.
Used after orthopedic surgery in legs to see if they are getting circulation to the
legs.
o Apical radial pulse deficit assessment: someone looks at radial pulse for entire
minute while someone takes the apical pulse.
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▪ Can show poor circulation. Blood is not getting out to the periphery. They
need an anti dysrythmic medication
▪ May need pacemaker to be checked.
• Blood Pressure
o Orthostatic hypotension
▪ Change in BP and pulse when patient moves from lying to sitting to
standing
▪ Associated SX: dizziness, blacking out, and increased risk for injury
▪ Parameters: systolic drops by 20 mmHg, pulse increases by 20 bpm,
diastolic drops by 10 mm Hg
▪ Procedure:
• Assess BP and pulse in lying position
• Sit patient up, wait one to two minutes. Assess BP, pulse,
dizziness
• Stand patient up, wait one to two minutes. Assess BP, pulse,
dizziness
o Normal Values: 120/80-90/60
o Korotoff sounds: blood flow sounds that healthcare providers observe while
taking blood pressure with a sphygmomanometer over the brachial artery
o Documentation example: 118/78 mmHg, 1/29/18. 13:46, location, side
o Use a sphygmomometer
o Orthostatic blood pressure: after a fall. Dizziness is a leading cause of falls.
Blood pools and doesn’t move up to the brain fast enough. Assess blood pressure
and pulse while they are laying down. Have them sit up and ask them about the
same thing and assess. If they are dizzy lay them back down
▪ Wait at least 10 minutes before taking respiration
• Temeperature
o Locations: temporal, oral, axillary, rectal
o Timing: Wait 15 minutes if patient has recently consumed food, liquids or if they
have smoked or exercised
o Body temperature: heat produced minus heat lost
o Normal Range: 36-38 degrees C. 39 degrees is a fever
o Axillary should be .5 degrees lower. Rectal may be .5 degrees higher. Oral is
baseline
• Respirations
o respirations per minute
o Inspection: The rise and fall of the chest
o Palpation: touch; feeling of the rise and fall
o Ausculation: listening to breathes
o Use a stethascope
o normal range: 12-20 BPM
o SP-O2 noraml range: is 94+
o Document air (O2) in liters per minute
find more resources at oneclass.com
find more resources at oneclass.com
Document Summary
Nursing dx: impaired comfort: perceived lack of ease, relief and transcendence in physical, psycho spiritual, environmental, cultural, and/or social dimensions. : radial carotid, apical, ulnar, femoral, temperoal, poplited, dorsal pedis/pedal, posterior tibial, brachial: apical pulse: one minute, corotid pulse: don"t do both at the same time. If regular 30 seconds x 2: bilateral assessment: able to measure both sides of the patient at the same time. Blood is not getting out to the periphery. Assess bp, pulse, dizziness: stand patient up, wait one to two minutes. Assess bp, pulse, dizziness: normal values: 120/80-90/60, korotoff sounds: blood flow sounds that healthcare providers observe while taking blood pressure with a sphygmomanometer over the brachial artery, documentation example: 118/78 mmhg, 1/29/18. 13:46, location, side: use a sphygmomometer, orthostatic blood pressure: after a fall. Blood pools and doesn"t move up to the brain fast enough. Assess blood pressure and pulse while they are laying down.
