Nursing Fundamentals: Vital Signs, Critical Thinking & Documentation, and Infection Control

Comprehensive vocabulary flashcards covering vital signs measurement and interpretation, the clinical decision-making process and documentation formats, and principles of medical and surgical asepsis with isolation precautions.

Vital Signs

Objective clinical measurements—including temperature, pulse, respirations, blood pressure, and oxygen saturation ($\text{SpO}_2$)—used to assess client physiological status, perfusion, thermoregulation, and oxygenation.

Pyrexia

An elevated body temperature or fever, defined in lecture notes as mild when exceeding $102.2^\circ\text{F}$, with a low-grade fever beginning at $100.4^\circ\text{F}$.

Hypothermia

A core body temperature falling below $95^\circ\text{F}$ ($35^\circ\text{C}$), which may present with shivering and a slowed metabolic rate.

Hyperthermia

An extreme, potentially life-threatening elevation in core body temperature exceeding $105^\circ\text{F}$.

Apical Pulse

The central pulse auscultated at the apex of the heart using the diaphragm of a stethoscope, positioned at the fifth intercostal space (ICS) along the left midclavicular line (MCL) in adults.

Radial Pulse

A peripheral pulse palpated over the radial artery on the thumb side of the wrist; routinely counted for $30\,\text{seconds}$ and multiplied by $2$, or counted for a full minute if irregular.

Pulse Deficit

The mathematical difference between the apical pulse rate and the radial pulse rate when both are counted simultaneously for one full minute; a difference greater than zero indicates suboptimal cardiac contractions.

Tachycardia

An adult heart rate exceeding $100\,\text{bpm}$, commonly triggered by fever, physical exertion, pain, anxiety, hypovolemia, or certain medications.

Bradycardia

An adult heart rate dropping below $60\,\text{bpm}$, seen physiologically in conditioned athletes or pathologically from hypothermia and medications.

Dysrhythmia

An irregular heart rhythm reflecting an underlying abnormality in the heart's electrical conduction system.

Pulse Strength Scale

A grading scale quantifying arterial pulse amplitude: $0$ is absent (requires Doppler validation), $1+$ is diminished (weak, thready), $2+$ is normal/moderate, and $3+$ is increased (bounding).

Peripheral Pulse Sites

Anatomical locations where superficial arteries cross solid bony structures: temporal, carotid, apical, brachial, radial, femoral, popliteal, posterior tibial, and dorsalis pedis.

Stage 1 Hypertension

A blood pressure category defined by a systolic reading of $130\text{--}139\,\text{mmHg}$ or a diastolic reading of $80\text{--}89\,\text{mmHg}$.

Stage 2 Hypertension

A blood pressure category defined by a systolic reading greater than $140\,\text{mmHg}$ or a diastolic reading greater than $90\,\text{mmHg}$, with values exceeding $180/110\,\text{mmHg}$ requiring immediate intervention.

Hypotension

A blood pressure level marked by a systolic measurement less than $90\,\text{mmHg}$, commonly linked to dehydration, hemorrhage, medications, or malnutrition.

Orthostatic Hypotension

A postural drop in blood pressure defined by a systolic decrease of $\ge 20\,\text{mmHg}$ or a diastolic decrease of $\ge 10\,\text{mmHg}$, typically with a $10\%\text{--}20\%$ rise in heart rate upon standing, posing a major fall risk.

Bradypnea

An abnormally slow breathing rate of less than $12\,\text{breaths/min}$ in an adult, occurring with normal respiratory depth.

Tachypnea

An abnormally elevated breathing rate greater than $20\,\text{breaths/min}$ in an adult, occurring with regular respiratory depth.

Apnea

The complete cessation of respiratory effort, requiring immediate emergency intervention to assess airway, breathing, and circulation (ABCs).

Cheyne-Stokes Respirations

An abnormal respiratory pattern characterized by alternating intervals of hyperventilation and apnea.

Kussmaul Respirations

Deep, rapid, and labored respirations classically observed in states of severe metabolic acidosis.

Oxygen Saturation ($\text{SpO}_2$)

An indirect pulse oximetry assessment measuring the fraction of hemoglobin saturated with oxygen; normal adult baseline is $95\%\text{--}100\%$, while chronic respiratory disease (COPD) may exhibit an expected baseline of $88\%\text{--}92\%$.

Clinical Decision-Making

A six-step cognitive process aligned with the nursing process: recognizing cues, analyzing cues, prioritizing hypotheses, generating solutions, taking action, and evaluating outcomes.

Concept Mapping

A visual, non-linear representation demonstrating connections between client problems, assessment cues, nursing diagnoses, health needs, interventions, and evaluation criteria.

Reflective Journaling

A professional learning strategy where nurses articulate and analyze their clinical experiences in their own words to strengthen critical thinking competence.

Subjective Data

Information conveyed verbally by the patient, including reported symptoms, feelings, perceptions, and past health history (e.g., statements like 'I don't feel good' or pain ratings).

Objective Data

Directly observable, measurable clinical findings obtained by physical assessment, laboratory values, vital signs monitoring, and diagnostic imaging.

Electronic Health Record (EHR)

A comprehensive digital health record capturing data over time across multiple patient care encounters, supporting interprofessional coordination and ongoing standard-of-care audits.

Electronic Medical Record (EMR)

A digital record detailing clinical information collected during a single healthcare encounter, such as an urgent care visit, outpatient encounter, or single hospital admission.

Charting by Exception (CBE)

A streamlined documentation method that records only significant deviations or abnormal findings from standardized clinical parameters, minimizing repetitive charting.

Narrative Notes

A paragraph-style, chronological documentation method used to detail significant events, adverse occurrences, acute deteriorations, and complex multidimensional patient care.

SOAP Note

A structured format for nursing progress notes divided into Subjective (patient quotes/symptoms), Objective (vitals/exam data), Assessment (nursing diagnosis/problems), and Plan (interventions/monitoring).

Incubation Period

The initial stage of infection spanning from the introduction of the pathogen into the body until the earliest appearance of non-specific, vague symptoms.

Prodromal Stage

The stage of an infection marked by non-specific manifestations where pathogen replication is elevated and the individual is at their most infectious.

Illness Stage

The active disease phase when overt, recognizable clinical signs and symptoms—either localized or systemic—are clearly evident.

Convalescence

The final recovery phase of an infectious process during which symptoms resolve and the patient returns toward health.

Iatrogenic Infection

A type of healthcare-associated infection (HAI) resulting directly from a therapeutic or diagnostic healthcare procedure.

Exogenous Infection

An infection produced by microorganisms that originate from outside the human host rather than from normal resident microflora.

Endogenous Infection

An infection that emerges when an individual's normal resident microflora is disturbed, resulting in opportunistic overgrowth.

Localized Infection

An infection restricted to a single body area, presenting clinically with local redness, erythema, edema, warmth, pain, and tenderness.

Systemic Infection

An infection that has spread throughout the body, presenting with generalized manifestations including fever, chills, malaise, and gastrointestinal disturbances.

Medical Asepsis

Also called 'clean technique'; procedures and practices aimed at reducing the total number of organisms present and curbing their transmission, with hand hygiene as the primary intervention.

Surgical Asepsis

Also called 'sterile technique'; practices that achieve the complete elimination of all microbial life and spores, mandated for dressing changes, catheterizations, and surgical procedures.

Disinfection

A cleaning process that destroys or eliminates nearly all pathogenic microorganisms on inanimate surfaces, excluding bacterial endospores.

Sterilization

The definitive process resulting in the total destruction and eradication of all microbial life forms, including bacterial endospores.

Standard Precautions

Universal infection control principles applied to all patient encounters, comprising thorough hand hygiene and the targeted use of PPE (gloves, gown, mask, eye protection, face shield).

Contact Precautions

Transmission-based isolation protocols for organisms spread via physical contact (e.g., MRSA, Clostridium difficile, open wound drainage); requires a private room, gown, and gloves.

Droplet Precautions

Transmission-based precautions for large-droplet pathogens (e.g., pertussis, influenza, mumps, rubella); requires a private room, dedicated equipment, and wearing a mask when within $3\,\text{feet}$ of the client.

Airborne Precautions

Isolation precautions for aerosolized pathogens (e.g., Measles, Tuberculosis, Varicella); requires a negative-pressure private room ($6\text{--}12\,\text{air exchanges/hr}$) and an N95 respirator.

Neutropenic Isolation

Protective environmental precautions implemented for severely immunocompromised patients, mandating PPE, strict hand hygiene, dedicated equipment, and prohibiting fresh fruits, vegetables, and live flowers.

PPE Donning Sequence

The correct order for putting on personal protective equipment: 1. Gown, 2. Mask or Respirator, 3. Goggles or Face Shield, and 4. Gloves.

PPE Doffing Sequence

The standardized protocol for safely removing personal protective equipment (Example 1): 1. Gloves, 2. Goggles or Face Shield, 3. Gown, and 4. Mask or Respirator, followed immediately by Hand Hygiene.