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45 Cards in this Set
- Front
- Back
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Normal Adult Pulse Rate |
60 - 100 beats/min |
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Tachycardia (Associated Features) |
Increased pulse rate: 100 to 180 beats/min Associated Features: decreased BP, elevated temperature, pain, poor oxygenation, medications, exercise |
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Bradycardia (Associated Features) |
Pulse rates below 60 beats/min Associated Features: severe pain, intracranial pressure |
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Pulse Amplitude |
The quality of the pulse in terms of its fullness and reflects the strength of the left ventricular contraction. Felt via palpation. |
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Pulse deficit |
Difference between the apical and radial pulse. Indicates all the heartbeats are not reaching the peripheral arteries or are too weak to be palpated. |
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Normal Adult Respiratory Rate |
12 - 20 breaths/min |
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Eupnea |
Normal Breathing |
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Tachypnea (Associated Features) |
>24 breaths/min (Shallow) Associated Features: Fear, Anxiety, Exercise, Respiratory disorders. Occurs when a person has a fever. Increases 4 breaths/min with every 1°F. |
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Bradypnea |
<10 breaths/min (regular) Associated Features: Brain damage, depression of the respiratory center by medications, caused by opioids. |
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Normal Adult Blood Pressure |
Systolic <120 Diastolic <80 *Must be measured 2 or more times before determining if unacceptable. Measurement should be taken after the patient has rested for 5 minutes and no caffeine or smoking 30 minutes prior. |
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Prehypertension |
systolic 120 -139 mm Hg Diastolic 80-89 mm Hg |
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High Blood Pressure |
Systolic Stage 1: 140-159 mm Hg Stage 2: ≥160 mm Hg
Diastolic Stage 1: 90-99 mm Hg Stage 2: ≥100 mm Hg |
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Orthostatic Hypotension (Postural Hypotension) |
Decrease in systolic blood pressure of 20 mm Hg or a decrease in diastolic blood pressure of 10 mm Hg within 3 minutes of standing when compared with BP from the sitting or supine position. |
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Normal Adult Body Temperature |
96.7°F to 100.5°F |
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Circadian Rhythm |
Body Temperature is lower in the early morning. Peak elevation is in the afternoon and early evening between 4 and 8PM. |
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Newborn Normal Vital Signs |
Temperature: 96.7–98.5°F Pulse: 70–190 beats/min Respiration: 30–55 breaths/min BP: 73/55 mm Hg |
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Aged Adult Normal Vital Signs (65+ years) |
Temperature: 96.4–98.3°F Pulse: 40–100 beats/min Respiration: 16–24 breaths/min BP: 120/80 mm Hg |
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Afebirle |
Without Fever |
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Febrile |
A person with a fever(pyrexia). |
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Average Normal Temperatures for Healthy Adults at Various Sites |
Axillary: 97.7 °F Oral: 98.6°F Temporal Artery: 98.6°F Tympanic: 99.5°F Rectal: 99.5 °F |
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Physical Effects of Fever |
-Flushed face -Thirst -Fatigue -Respirations and pulse rate increase -Extremely high in children causes seizures -Extremely high in adults causes confusion and delirium |
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Physical Effects of Hypothermia |
-Stupor -Respiration increase -Weak, irregular pulse -Low BP -Hallucinations |
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Dysrhythmia |
irregular heartbeat |
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Sites of Assessing the Pulse |
-Temporal -Carotid (used in an emergency) -Brachial (used for infants in emergencies) -Radial (most commonly used) -Femoral -Popliteal -Posterior Tibial -Dorsalis Pedis |
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Factors Affecting Respiratory Rate |
-Age ↓ -Exercise ↑ -Acid-base balance (hyperventilation) ↑ -Increase altitude ↑ -Respiratory Diseases ↑ -Anemia ↑ -Acute Pain ↑ |
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Apnea |
Periods of no breathing |
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Dyspnea |
Difficult or labored breathing |
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Orthopnea |
Type of dyspnea in which breathing is easier when the patient sits or stands |
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Pulse Oximetry |
Measures the oxygen saturation (SaO2) of arterial blood Normal: 90-100% |
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Hyperventilation |
Increased rate & depth Associated features: extreme exercise, fear, diabetic ketoacidosis (Kussmaul's respirations) |
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Hypoventilation |
Decreased rate and depth; irregular Associated Factors: Overdose of narcotics or anesthetics |
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Factors Contributing to BP Variations in Healthy people |
- Age ↑ - Circadian Rhythm -Gender (women lower than men of the same age until menopause) -Food Intake (goes ↑ after eating) -Weight (higher in obese ppl) -Body position (lower in a prone or supine position -Race -Drugs/Medications -Emotional State |
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Incubation Stage of Infection (1st) |
Organisms growing and multiplying |
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Prodromal Stage of Infection (2nd) |
Person is most infectious, vague and non-specific signs of illness |
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Full Stage of Infection (3rd) |
presence of specific signs and symptoms |
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Convalescent Period (Final Stage of Infection) |
Recovery from the infection |
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4 Categories for HAIs |
1. Urinary Tract Infection 2. Surgical Wound Site 3. Bloodstream Infections 4. Pneumonia |
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Infectious Agents |
-Bacteria: most significant & most prevalent in hospitals -Virus: smallest of microorganisms
-Fungi: plant-like organism present in the soil, air and water |
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Nursing Interventions used to break the infection cycle |
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Factors that affect the risk for developing an infection |
-Integrity of the skin -general health status -immunizations -age -presence of invasive or indwelling medical device |
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Five moments for hand hygiene |
1.Before touching a pt 2.Before a clean or aseptic procedure 3.After body fluid exposure risk 4.After touching a pt 5.After touching pt surroundings |
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Presbycusis |
Difficulty hearing high-pitched sounds such as s,z,sh and ch. Background noise further aggravates hearing deficit. Has a gradual onset and is progressive and bilateral. |
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Cataract |
Clouding of the crystalline lens, presents as progressive vision lost. Can be bilateral or unilateral. |
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Macular Degeneration |
The most common cause of legal blindness in the elderly. Central vision loss. Risk factors include smoking and excessive sunlight exposure. |
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Glaucoma |
Peripheral vision loss, Intolerance to glare, decreased perception of contrast, decreased ability to adapt to the dark. |
