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Module 3
NUR101
| Term | Definition |
|---|---|
| Data Collection | is the gathering of information through signs and symptoms, patient history, and objective findings. |
| Subjective Data | only the patient can perceive i.e. pain, family history, and personal feelings |
| Objective Data | you (the nurse) can perceive or measure i.e. something you can hear, see, touch, or smell |
| Comprehensive health assessment | An in-depth assessment of the whole person (usually on admission or initial visit to clinic/office) |
| Focused assessment | Involves an examination and an interview regarding a specific body system |
| Initial head-to-toe shift assessment | Provides quick overall assessment. Establish a baseline to compare to later assessments |
| Active listening | give clients your undivided attention |
| Open-ended questions | encourages clients to tell their story in their own way |
| Clarifying | question clients in greater depth of specific details |
| Back channeling | use active listening phrases (“go on” “tell me more”) to convey interest and disclose more information |
| Probing | ask more open-ended questions (“What else would you like to add?”) |
| Close-ended questions | requires yes or no answers |
| Summarizing | validate the accuracy of the story |
| Inspection | The visual observation of anything about the body that you can see with the naked eye or with the assistance of other equipment. |
| Palpation | Application of your hands to the external surfaces of the body to detect abnormalities of the skin or tissues lying below the skin, that is, to examine by touch or feel |
| percussion | Involves striking body parts with the tips of the fingers to:Elicit sounds that can help locate and determine the size of structures beneath the surface Identify whether the structure is solid or hollow Detect areas containing air or fluid |
| Auscultation | Listening to sounds produced by the body |
| PERRLA | pupils equal round and reactive to accommodation |
| posterior fontanelle | closes by 6-8 weeks of age |
| anterior fontanelle | closes by 12-18 months of age |
| Jugular Vein Distention | gives information about the RIGHT side of the heart by reflecting the filling pressure and volume change |
| Vesicular | Soft, breezy, and low pitched, normal breath sound Inspiratory phase longer than expiratory Can be heard in almost all lung fields |
| Bronchial | Loud, high pitched with hollow quality Expiration last longer than inspiration Normal breath sound |
| Bronchovesicular | Inspiratory phase is equal to expiratory phase Normal breath sound |
| Crackles | Fine crackles are soft, high-pitched, and very brief (i.e. in CHF) Coarse crackles are louder, lower-pitched Also called rales Heard during inspiration Abnormal |
| Wheezing | High-pitch, continuous, musical, or whistling and often Abnormal |
| Rhonchi | Lower pitch snoring quality and suggest secretions in larger airways Described as snoring, rattling, gurgling, squeaking, and low Abnormal |
| Tachypnea | greater than 20 breaths per minute |
| Bradypnea | Less than 12 breaths per minute |
| Cheyne-Stokes respirations | Abnormal cycle of respiration beginning with slow, shallow respiration that become rapid –to slow -to Apnea then repeats |
| PMI | point of maximum impulse |
| pulse deficit | radial pulse is slower than the apical pulse |
| Skin turgor | grasp a fold of skin on the sternum or clavicle; On an infant use the abdomen. |
| minimum urine output per hour | 30 mL |
| pulse strength 0 | absent |
| pulse strength 1+ | thready/diminished |
| pulse strength 2+ | brisk, expected |
| pulse strength 3+ | increased, strong |
| pulse strength 4+ | bounding, full volume |
| capillary refill adult | < or =3 sec |
| capillary refill elderly | < or = 5 sec |
| diastolic pressure | the bottom number of the BP Measurement of the pressure exerted by the blood on the artery walls while the heart ventricles are not contracting |
| Systolic pressure | the top number of the BP Measurement of the pressure exerted by the blood on the artery walls while the heart ventricles are contracting |
| Hypertension | The systolic BP consistently over 130-139 mm Hg or the diastolic BP consistently over 80-89 mm Hg |
| Hypotension | The BP suddenly falls 20 mm Hg to 30 mm Hg below the patient’s normal BP or falls below the low normal of 90/60 mm Hg |
| Orthostatic hypotension or postural hypotension: | When the position changes, it results in a systolic pressure drop of 15 to 25 mm Hg or the diastolic pressure falls 10 mm Hg |
| Pulse pressure | Measurement of the difference between the systolic and diastolic pressures, normally a 30-50 point difference |
| Afebrile | Without fever |
| Febrile | Fever |
| Bradycardia | Heart rate below 60 bpm |
| Tachycardia | Heart rate above 100 bpm |
| Eupnea | Evenly spaced respiration of normal depth, between the rate of 12 and 20 breaths per minute |
| Apnea | Respirations cease or are absent |
| Dyspnea | Labored or difficult breathing |
| Hypoxemia | Decreased oxygen level in blood |
| Hypoxia | Decreased oxygen level in tissues |
| Orthopnea | Difficulty breathing unless in upright position |
| Stridor | An audible high-pitched crowing sound that results from partial obstruction of the airways |
| Normal BP | Systolic less than 120 and diastolic less than 80 |
| Prehypertension (Elevated) | Systolic 120-129 diastolic <80 |
| Hypertension Stage 1 | Systolic 130-139 Diastolic 80-89 |
| Hypertension Stage 2 | Systolic 140 or higher Diastolic 90 or higher |
| Hypertensive Crisis | Systolic Greater than180 Diastolic greater than 120 |
| Atelectasis | Partial or total collapse of a lung |
| Crepitus | Air in the subcutaneous tissue |
| Cyanosis | A decrease in oxygen levels in the tissues; lips take on a bluish color |
Created by:
Ms. A LPNI
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