Nursing Assessment and Vital Signs Practice

Summary of vocabulary and key concepts from nursing lecture notes on assessment, physical examination techniques, and vital signs across the lifespan.

Assessment

The first step in the nursing process used to establish a baseline for patient care.

Patient Interview

A formal, structured discussion aimed at obtaining demographic information, health history, and medical and surgical backgrounds.

Orientation Phase

The introductory phase of an interview focused on establishing trust and determining the patient's preferred name.

Working Phase

The phase of the interview dedicated to gathering information, staying focused on the purpose of the interaction, and active listening.

Termination Phase

The concluding part of the interview where key findings are summarized and the nurse explains the next steps.

Review of Systems

A collection of subjective, patient-reported data gathered by asking brief questions about the normal function of each body system.

Inspection

The use of vision, hearing, and smell to scrutinize the physical characteristics of a person and their body systems.

Palpation

The use of touch to assess organ location, skin texture, temperature, moisture, turgor, and tenderness.

Percussion

Tapping the skin with short, sharp strokes to produce vibrations used to determine the size, shape, and borders of organs.

Auscultation

The technique of listening to sounds made by body organs, such as the heart and lungs, with the assistance of a stethoscope.

Comprehensive Assessment

A thorough systematic evaluation including an extensive head-to-toe assessment and health history, often performed on admission.

Focused Assessment

A brief individualized physical examination conducted at the beginning of a shift or in response to a specific patient concern.

Emergency Assessment

A rapid physical examination performed when time is a factor, focusing on airway, breathing, and circulation ($ABC$).

Triage

The classification of patients according to treatment priority based on the urgency of their condition.

Emergency Severity Index (ESI)

A five-tier triage system used to classify patients from Level 1 (Resuscitation) to Level 5 (Non-urgent).

Primary Data

Information obtained directly from the patient, considered the best source of information regarding their feelings and condition.

Secondary Data

Information collected from family members, medical records, or other health care team members.

Subjective Data

Spoken information or symptoms shared by the patient that are typically difficult to validate.

Objective Data

Also known as signs, this data can be measured or observed using the nurse's senses or diagnostic tools.

Cue

A hint or indication of a potential disease process or concern discovered during assessment.

Inference

A conclusion or interpretation of patient data that determines the direction of care.

Gordon's Functional Health Patterns

A holistic framework for organizing assessment data into areas of function, such as nutrition-metabolic or activity-exercise.

Vital Signs

Physiological measurements including body temperature ($T$), pulse ($P$), respirations ($R$), and blood pressure ($BP$).

Afebrile

The state of maintaining a normal body temperature within the range of $36.4^\circ$ to $37.6^\circ \text{C}$ ($97.6^\circ$ to $99.6^\circ \text{F}$).

Core Temperature

The temperature of deep body tissues, which typically remains relatively constant.

Hypothermia

A low body temperature resulting from exposure to extreme cold or inefficient thermoregulation.

Hyperthermia

A high body temperature resulting from prolonged heat exposure or environmental factors.

Radiation

The transfer of heat as waves or particles of energy without actual contact between objects.

Conduction

The transfer of heat through direct contact with a cooler object, such as an ice pack.

Convection

The transfer of heat by the movement or circulation of warm matter like air or water.

Evaporation

The process by which liquid is changed to vapor through heat, effectively lowering body temperature through diaphoresis.

Tachycardia

An excessively fast heart rate exceeding $100\text{ bpm}$ in an adult.

Bradycardia

A slow heart rate of less than $60\text{ bpm}$ in an adult.

Apical Pulse

A central pulse auscultated over the apex of the heart at the point of maximal impulse ($PMI$).

Pulse Deficit

A condition where the radial pulse rate is slower than the apical pulse rate due to weak cardiac contractions.

Eupnea

Normal respiration characterized by a normal rate and depth for the patient’s age.

Tachypnea

An increase in respiratory rate to more than $24\text{ BPM}$ in an adult.

Bradypnea

A decrease in respiratory rate to less than $10\text{ BPM}$ in an adult.

Apnea

An absence of breathing; brain damage can occur after $4$ to $6$ minutes of this state.

Dyspnea

Difficult or labored breathing, usually associated with a rapid, shallow pattern and anxiety.

Pulse Oximetry

A noninvasive measurement of the percentage of hemoglobin that combines with oxygen ($SpO_2$).

Cyanosis

A bluish discoloration of the skin and mucous membranes resulting from decreased oxygen levels in the blood.

Systolic Pressure

The peak of the pressure wave against arterial walls that occurs during ventricular contraction.

Diastolic Pressure

The lowest pressure exerted on arterial walls when the heart is in its resting phase.

Pulse Pressure

The numerical difference between the systolic and diastolic blood pressure readings.

Hypotension

A systolic blood pressure of less than $90\text{ mm Hg}$ or a diastolic pressure of $60\text{ mm Hg}$ or less.

Orthostatic Hypotension

A sudden drop of $20\text{ mm Hg}$ in systolic or $10\text{ mm Hg}$ in diastolic pressure when moving from lying to standing.

Korotkoff Sounds

The specific sounds for which a nurse listens when manually assessing blood pressure.

Auscultatory Gap

The absence of Korotkoff sounds noted in some patients after the initial systolic pressure.

Albinism

A congenital loss of pigmentation characterized by a lack of melanin in the eyes, skin, and hair.

Vitiligo

A loss of skin pigment, often resulting from an autoimmune response, presenting as depigmented patches.

Erythema

Skin redness caused by congestion or dilation of superficial blood vessels.

Petechiae

Tiny, dark red spots that indicate hemorrhage under the skin.

Turgor

The skin's elasticity or ability to resist deformity after being displaced.

Pitting Edema

Swelling that leaves an indentation in the tissue for some time after pressure is released.

Hirsutism

Excessive hair growth on the face or body, often associated with hormone imbalances.

Alopecia

The medical term for permanent or temporary hair loss.

Strabismus

A disorder known as 'crossed eyes' where one or both eyes deviate from alignment due to muscle weakness.

Nystagmus

Rapid, shaking, involuntary movement of the eyes.

Snellen Chart

A standardized chart with increasingly smaller lines of letters used to test distant visual acuity.

Tinnitus

A sensation of ringing, buzzing, or roaring in the ears.

Weber Test

A hearing assessment using a tuning fork to determine if sound is detected equally in both ears or lateralized.

Rinne Test

A hearing test that compares air conduction ($AC$) to bone conduction ($BC$).

Romberg Test

An assessment of equilibrium where a patient stands with eyes closed to check for vestibular balance.

Epistaxis

The clinical term for a nosebleed.

Atelectasis

A condition involving the collapse of lung tissue.

Hydrocephalus

Enlargement of the skull due to the accumulation of cerebrospinal fluid in the brain's ventricles.

Anthropometrics

The measurement of the human body, including weight, height, and head circumference.