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Nsg fund class
nursing - terms, assessment, body sys
| Question | Answer |
|---|---|
| bruit | sign comprising an abnormal swishing sound |
| dyspnea | difficulty breathing |
| normal capillary refill | less than 3 seconds; more than 3 sec= sluggish digital circulation; 5 seconds is abnormal; |
| capillary refill | also blanch - test by pressing firmly for 5 sec on area and estimating speed at which blood returns |
| what conditions identified with delay in capillary refill | poor cardiac function, dehydration, PVD |
| LOC | level of consciousness; meas of neurolog assessment; x1=person, x2= person and place, x3 = person, place, and time, x4 = person, place, time, and purpose |
| PERRLA | pupils equal, round, reactive to light, and accomodation |
| Glascow coma scale | standardized, objective meas of consciousness; 3 areas - eye opening, verbal response, motor response; each has score and total the number; normal is 15;, score 8 or less indicates severe brain injury |
| abnormal skin color findings | pallor (white), cyanosis (dusky blue), jaundice (yellow), erythema (redness), ecchymosis |
| normal skin findings | warm, dry, smith, with good turgor |
| turgor | elasticity of the skin; caused by outward press of cells and interstitial fluid |
| normal corotid pulse sound | regualr and palpable without a thrill(vibrating sensation perceived as you palpate along the artery) |
| tachypnea | rapid rate of breathing; greater than 24 breaths/minute |
| bradypnea | slow breathing; less than 10 breaths/min |
| normal O2 saturation | 90% - 100% |
| normal respiration rate | 12-20/minute |
| normal BP | Systolic less than 120; Diastolic less than 80 |
| normal pulse/heart rate | 60-100 bpm |
| bowel sounds | normal rate is 4-32/minumte; occur q 15-60 sec; classified as active, hyperactive, or absent |
| normal mucous membrane findings | moist, pink, free of lesions; dry= dehydration |
| tachycardia | greater than 100 bpm |
| bradycardia | less than 60 bpm |
| pre-hypertension | Systolic = 121-139 OR Diastolic = 81-89 |
| hypertension | Systolic = 140 or greater OR Systolic = 90 or greater |
| hypotension | Systolic less than 90 |
| pulse pressure | difference between systolic and diastolic ; eg. 120/80 |
| sign | objective |
| symptom | subjective |
| strength of pulse noted as | 0 = absent, 1+ = thready, 2+ = weak, 3+ = normal, 4+ = bounding |
| bounding |
Created by:
MBuzzelli
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