NUR 2100 Week 2 Study Guide - Vital Signs, Pain, & Physical Assessment

Vocabulary flashcards covering vital signs reference ranges, assessment techniques, priority nursing concepts, pain management, and physical examination sequence based on ATI NUR 2100 Week 2.

Orthostatic Hypotension

A significant drop in blood pressure accompanied by dizziness upon standing, indicating an increased fall risk requiring safety interventions.

Capillary Refill

An indicator of peripheral perfusion that should normally be $<3\,\text{seconds}$; prolonged time indicates potential circulatory compromise or impaired perfusion.

Daily Weights

One of the most sensitive clinical indicators of rapid fluid balance changes in a patient.

Hypotension

A blood pressure reading with a systolic pressure $<90\,\text{mm Hg}$ or diastolic pressure $<60\,\text{mm Hg}$, or below the expected reference range based on baseline.

Normal Blood Pressure

A blood pressure reading of $<120/80\,\text{mm Hg}$.

Elevated Blood Pressure

A blood pressure reading of $120\text{--}129/<80\,\text{mm Hg}$.

Hypertensive Stage 1

A blood pressure reading of $130\text{--}139/80\text{--}89\,\text{mm Hg}$.

Hypertensive Stage 2

A blood pressure reading of $\ge 140/\ge 90\,\text{mm Hg}$ (or systolic $>140\,\text{mm Hg}$ / diastolic $>90\,\text{mm Hg}$).

Hypertensive Crisis

A blood pressure reading with a systolic pressure $>180\,\text{mm Hg}$ and/or a diastolic pressure $>120\,\text{mm Hg}$.

Systolic Blood Pressure

The maximum pressure exerted on arterial walls when the heart contracts and forces blood into the aorta.

Diastolic Blood Pressure

The minimum pressure exerted on arterial walls when the heart muscle is relaxed.

Expected Pulse Rate

A resting pulse rate of $60\text{--}100\,\text{beats/minute}$.

Tachycardia

A pulse rate greater than $100\,\text{beats/minute}$.

Bradycardia

A pulse rate less than $60\,\text{beats/minute}$.

Apical Pulse Assessment

Cardiac rhythm assessment performed by auscultating at the fifth intercostal space along or near the left midclavicular line for a full minute.

Expected Body Temperature

Body temperature range of $36^\circ\text{C}\text{--}37.9^\circ\text{C}\,\, (96.8^\circ\text{F}\text{--}100.3^\circ\text{F})$, averaging approximately $36.8^\circ\text{C}\,\, (98.6^\circ\text{F})$.

Fever

An elevated body temperature starting at $38^\circ\text{C}\,\, (100.4^\circ\text{F})$ according to ATI reference standards.

Expected Respiratory Rate

A resting respiratory rate of $12\text{--}20\,\text{breaths/minute}$.

Tachypnea

A respiratory rate greater than $20\,\text{breaths/minute}$.

Bradypnea

A respiratory rate less than $12\,\text{breaths/minute}$, commonly caused by opioids and sedatives.

Expected Oxygen Saturation

Oxygen saturation levels between $95\%\text{--}100\%$, with values below $95\%$ indicating decreased saturation.

Wheezes

High-pitched musical adventitious lung sounds commonly associated with airway narrowing or obstruction.

Dysphagia

Difficulty swallowing that creates a high priority concern for aspiration, choking, and respiratory complications.

Numeric Rating Scale (NRS)

A $0\text{--}10$ pain intensity scale where $1\text{--}3$ indicates slight pain, $4\text{--}7$ moderate pain, and $8\text{--}10$ severe pain.

Acute Pain

Pain that lasts for seconds up to less than $6\,\text{months}$.

Chronic Pain

Pain that lasts for $6\,\text{months}$ or longer, which may be continuous or intermittent.

TENS (Transcutaneous Electrical Nerve Stimulation)

A portable, nonpharmacologic pain management intervention utilizing electronic stimulation that can be used outside the hospital setting.

Opioid Tolerance

An expected physiologic adaptation to long-term opioid therapy requiring increased medication doses to achieve pain relief, distinct from addiction.

Standard Physical Assessment Order

The standard physical examination sequence: Inspection \rightarrow Palpation \rightarrow Percussion \rightarrow Auscultation.

Abdominal Physical Assessment Order

The specific physical examination sequence used for abdominal assessment: Inspection \rightarrow Auscultation \rightarrow Percussion \rightarrow Palpation.

GCS Eye Opening Response

Glasgow Coma Scale sub-score: $4$ (spontaneous), $3$ (to verbal stimuli), $2$ (to pain), $1$ (none).

GCS Verbal Response

Glasgow Coma Scale sub-score: $5$ (oriented), $4$ (confused), $3$ (inappropriate words), $2$ (incoherent), $1$ (none).

GCS Motor Response

Glasgow Coma Scale sub-score: $6$ (obeys commands), $5$ (localizes pain), $4$ (withdraws from pain), $3$ (flexes to pain/decorticate), $2$ (extends to pain/decerebrate), $1$ (none).