Ultimate study guide for ALL HESI Exams. Good Luck!! Basic Nursing Skills – Vital Signs – Chapter 30 • BP cuff size (review what happens with wrong cuff size) False-high diastolic readings on BP cuff Deflating cuff to slowly, inflating to slowly False-low readings on BP Cuff to wide, arm above heart level False-high readings on BP Cuff to narrow/short, cuff to loose or uneven, arm not supported  Technique for palpating systolic BP  (When arterial pulsations too weak to detect Korotkoff sounds or to identify auscultatory gap). Box 30-9, p. 508. Palpate radial pulse. Inflate cuff 30 mmHg above point at which you can no longer palpate the pulse. Slowly release valve and deflate cuff… See documentation guidelines, as well.  Technique for taking BP in the leg –  Popliteal artery. ▪ SBP usually 10-40 mmHg higher than using brachial. • DBP remains same. Ch. 30, p. 508.  Orthostatic BP readings –  orthostatic hypotension also called postural hypotension; • obtain supine, sitting, and standing (1-3 minutes between each); • observe pt. for dizziness, fainting, lightheadedness. • Record pts. position with each reading (remember pt. safety); • don’t delegate this. • Note when you should take postural hypotension readings.  Know normal vital signs – techniques, ranges, assessment, etc. Findings on respiratory assessment? o RR: 12-20 o BP:<120/<80 o HR: 60-100 o Temp: 98.6F or 37C o Pain 5 th vital sign Vital Signs – Guidelines • Nurse ultimately responsible for vitals but can be delegated instable patients, • RN to interpret their significance and make decision about interventions; • Determine equipment functional and appropriate; o Know pt normal vitals; • Know history, therapies and meds that could affect vitals; • Control environmental factor that could affect vitals; o Be organized and use systematic approach to ensure accuracy; o Use vitals to determine indications for med administration; • Analyze measurements; communicate changes to HCP; • Advise pt and or pt family of results.  What is a pulse deficit? What do you do if you detect a pulse deficit during your assessment?  See Clinical Decision (If pulse is irregular do an apical/radical pulse assessment to detect a pulse deficit. Count apical pulse help patient to supine position or sitting position move aside bed linen and gown to expose sternum and let side of chest. While a colleague counts radial pulse begin apical pulse count out load to simultaneously assess pulses. If pulse differs by more than 2 a pulse deficit exists which sometimes indicates alternation in cardiac output.).  What if pulse deficit is in lower extremities? Pedal pulse weak on one side? ▪ Assess next pulse up, e.g., posterior tibial. ▪ If that pulse is weak, move up to popliteal, etc. ▪ Compare one extremity to the other.  Apical pulse is taken for a full minute;  PMI (point of maximal impulse) located at 4 th or 5 th intercostal space (ICS), just medial or left of the midclavicular line (MCL).  Elevated BP? Pt c/o headache? What may this indicate? What do you do?  Reassess using other arm.  Do not keep taking BP on same extremity.  Reassess  May even need a manual cuff. Pain and Sleep  Exercise and Sleep – • Exercise 2 hrs before bedtime allows cool down period and fatigue that promotes relaxation (see Sleep Hygiene Habits, Box 43-9, p. 1006). • Should not exercise closer to bedtime. • See Factors Affecting Sleep, pp. 998-999.  Sleep problems; • Altered sleep – pain. • Treat pain first. • See Box 43-5 Nursing Asses