Assessment & Vs

Front 1

1. subjective data

Back 1

what the client reports

Front 2

2. objective data

Back 2

what the nurse records/reports/sees

Front 3

3. validation of data

Back 3

comparison of assessment data w/another source to determine accuracy

Front 4

4. signs/cues?

Back 4

information obtained through use of the senses i.e. noticing a patient crying

Front 5

5. clustering

Back 5

grouping cues together to assist in the diagnosis, i.e. grimace, arms at side, reported pain = pain

Front 6

6. data cluster

Back 6

a group of signs/symptoms gathered during assessment lumped in a logical way

Front 7

7. symptoms (assessing)

Back 7

assess: location, onset & duration, precipitating factors, relieving factors, quality, and severity

Front 8

8. temperature

Back 8

difference btwn heat produced and heat lost

Front 9

9. temperature norms

Back 9

adult po: 36-38ºC, 96.8-100.4ºF
child pr: 37-37.5ºC

Front 10

10. purpose of temperature

Back 10

thermoregulation--keep the body systems in an acceptable range

Front 11

11. what controls temp?

Back 11

anterior hypothalamus-heat loss; posterior hypothalamus-heat produce

Front 12

12. how is heat lost?

Back 12

vasodilation, sweating, radiation, conduction, convection evaporation, and diaphoresis; skin acts as radiator for blood

Front 13

13. what are factors affecting temp?

Back 13

age, exercise, hormone, circadian rhythm, stress, environment, fever

Front 14

14. hypothermia

Back 14

mild:34-36ºC; moderate 30-34º; severe <30ºC

Front 15

15. conversion of Fº to Cº

Back 15

C=(F-32)x5/9

Front 16

16. conversion of Cº to Fº

Back 16

(9/5xCº) + 32

Front 17

17. pulse

Back 17

palpable bounding of blood floww

Front 18

18. normal HR

Back 18

infant: 120-160
toddler: 90-140
preschooler: 80-110
school-age: 75-100
adolescent: 60-90
adult: 60-100

Front 19

19. tachycardia

Back 19

abnormally elevated HR>100bpm

Front 20

20. bradycardia

Back 20

slow HR<60bpm

Front 21

21. pulse deficit

Back 21

inefficient heart contraction that fails to emit a pulse wave

Front 22

22. how is pulse deficit measured?

Back 22

apical HR-peripheral HR = deficit

Front 23

23. dysrhythmia

Back 23

early, late, or missed beat; regularly irregular or irregularly irregular

Front 24

24. strength of pulse

Back 24

bounding 4+, full/strong 3+, normal/expected 2+, diminished/barely palpable 1+, absent 0

Front 25

25. respiration

Back 25

gas exchange; CO2 from body O2 from environment

Front 26

26. ventilation

Back 26

gases in/out of lungs

Front 27

27. diffusion

Back 27

mvmnt of gases btwn alveoli and RBCs

Front 28

28. perfusion

Back 28

distribution of RBCs to/from pulmonary capillaries

Front 29

29. physiological control of respiration

Back 29

CO2, O2, and H+ (pH) levels in blood; brainstem and chemoreceptors in carotid and aortic arch control RR

Front 30

30. normal ranges of RR

Back 30

newborn: 35-40
infant (6mo): 3050
toddler (2yo): 25-32
child: 20-30
adolescent: 16-20
adult: 12-20

Front 31

31. pulse oximetry

Back 31

measures O2 saturation of blood (SaO2)

Front 32

32. BP

Back 32

the force exerted on the walls of an artery by pulsing blood under pressure from the heart

Front 33

33. systolic pressure

Back 33

peak of maximum pressure when ejection occurs

Front 34

34. diastolic

Back 34

the minimal pressure exerted against arterial walls at all times

Front 35

35. pulse pressure

Back 35

systolic - diastolic = pulse pressure

Front 36

36. BP reflects the interrelationships of ...

Back 36

cardiac output, peripheral vascular resistance (friction), blood volume, blood viscosity, artery elasticity

Front 37

37. optimal BP

Back 37

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

Front 38

38. factors affecting BP

Back 38

age, stress, ethnicity, gender, daily variation, medications, activity and weight, and smoking