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38 Cards in this Set
- Front
- Back
1. subjective data
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what the client reports
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2. objective data
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what the nurse records/reports/sees
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3. validation of data
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comparison of assessment data w/another source to determine accuracy
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4. signs/cues?
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information obtained through use of the senses i.e. noticing a patient crying
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5. clustering
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grouping cues together to assist in the diagnosis, i.e. grimace, arms at side, reported pain = pain
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6. data cluster
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a group of signs/symptoms gathered during assessment lumped in a logical way
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7. symptoms (assessing)
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assess: location, onset & duration, precipitating factors, relieving factors, quality, and severity
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8. temperature
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difference btwn heat produced and heat lost
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9. temperature norms
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adult po: 36-38ºC, 96.8-100.4ºF
child pr: 37-37.5ºC |
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10. purpose of temperature
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thermoregulation--keep the body systems in an acceptable range
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11. what controls temp?
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anterior hypothalamus-heat loss; posterior hypothalamus-heat produce
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12. how is heat lost?
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vasodilation, sweating, radiation, conduction, convection evaporation, and diaphoresis; skin acts as radiator for blood
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13. what are factors affecting temp?
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age, exercise, hormone, circadian rhythm, stress, environment, fever
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14. hypothermia
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mild:34-36ºC; moderate 30-34º; severe <30ºC
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15. conversion of Fº to Cº
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C=(F-32)x5/9
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16. conversion of Cº to Fº
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(9/5xCº) + 32
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17. pulse
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palpable bounding of blood floww
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18. normal HR
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infant: 120-160
toddler: 90-140 preschooler: 80-110 school-age: 75-100 adolescent: 60-90 adult: 60-100 |
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19. tachycardia
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abnormally elevated HR>100bpm
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20. bradycardia
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slow HR<60bpm
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21. pulse deficit
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inefficient heart contraction that fails to emit a pulse wave
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22. how is pulse deficit measured?
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apical HR-peripheral HR = deficit
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23. dysrhythmia
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early, late, or missed beat; regularly irregular or irregularly irregular
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24. strength of pulse
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bounding 4+, full/strong 3+, normal/expected 2+, diminished/barely palpable 1+, absent 0
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25. respiration
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gas exchange; CO2 from body O2 from environment
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26. ventilation
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gases in/out of lungs
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27. diffusion
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mvmnt of gases btwn alveoli and RBCs
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28. perfusion
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distribution of RBCs to/from pulmonary capillaries
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29. physiological control of respiration
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CO2, O2, and H+ (pH) levels in blood; brainstem and chemoreceptors in carotid and aortic arch control RR
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30. normal ranges of RR
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newborn: 35-40
infant (6mo): 3050 toddler (2yo): 25-32 child: 20-30 adolescent: 16-20 adult: 12-20 |
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31. pulse oximetry
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measures O2 saturation of blood (SaO2)
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32. BP
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the force exerted on the walls of an artery by pulsing blood under pressure from the heart
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33. systolic pressure
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peak of maximum pressure when ejection occurs
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34. diastolic
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the minimal pressure exerted against arterial walls at all times
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35. pulse pressure
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systolic - diastolic = pulse pressure
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36. BP reflects the interrelationships of ...
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cardiac output, peripheral vascular resistance (friction), blood volume, blood viscosity, artery elasticity
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37. optimal BP
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newborn: 40 (mean)
1mo: 85/54 1 yo: 95/65 6 yo: 105/65 10-13 yo: 110/65 14-17 yo: 119/75 18 yo+: <120/<80 |
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38. factors affecting BP
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age, stress, ethnicity, gender, daily variation, medications, activity and weight, and smoking
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