Stage 1 Nursing Documents - Vital Signs, Assessments, and Medical Terminology

Vocabulary and clinical concept flashcards extracted from TAFE Queensland Gold Coast Stage 1 Nursing Documents.

Normal Temperature Range

36 – 37.5°C

Febrile

Body temperature between 37.5°C – 40°C.

Hyperthermia

Core temperature above 40°C.

Hypothermia

Core temperature below 36°C.

Normal Pulse Range

60 – 100 beats per minute (bpm)

Tachycardia

Pulse rate above 100 bpm.

Bradycardia

Pulse rate below 60 bpm.

Asystole

Absence of pulse.

Normal Respiratory Rate Range

Respiratory Rate (RR) of 12 – 20 breaths per minute

Tachypnoea

Respiratory Rate (RR) above 20 breaths per minute.

Bradypnoea

Respiratory Rate (RR) below 12 breaths per minute.

Dyspnoea

Difficulty breathing.

Orthopnoea

Difficulty breathing when lying flat – relieved by sitting up.

Apnoea

Absence of breathing.

Normal Oxygen Saturation Range

95 – 100% on room air (RA) OR O2 therapy

Hypoxaemia

Low oxygen in the blood.

Hypoxia

Low oxygen content in any tissue OR organ OR the body as a whole.

Normal Blood Pressure Range

Systolic: 100 – 140 mmHg (mm of mercury), Diastolic: 60 – 90 mmHg

Hypertension

Systolic blood pressure above 140 mmHg or Diastolic blood pressure above 90 mmHg.

Hypotension

Systolic blood pressure below 100 mmHg or Diastolic blood pressure below 60 mmHg.

Orthostatic or Postural Hypotension

Hypotension that occurs when moving to an upright position eg from lying to sitting or standing.

Normal Blood Glucose Level (BGL) Range

4 – 8 mmol/L (4 – 10 mmol/L after meals)

Hyperglycaemia

Blood Glucose Level (BGL) above 8 mmol/L.

Hypoglycaemia

Blood Glucose Level (BGL) below 4 mmol/L.

Rule of 15

Hypoglycaemia treatment: Administer 15 grams of fast acting carbohydrates. Wait 15 mins. Take BGL, if >4 mmol/L, administer 15 grams of slow acting carbohydrates. If <4 mmol/L, repeat process from the beginning.

First Korotkoff Sound

The very first pulsing/beating noise heard when slowly deflating a blood pressure cuff, which indicates systolic blood pressure.

Fifth Korotkoff Sound

The point where there are no more sounds heard when slowly deflating a blood pressure cuff, which indicates diastolic blood pressure.

PQRSTU - P

Provoking factors: What makes the pain better or worse?

PQRSTU - Q

Quality: Describe what the pain feels like?

PQRSTU - R

Region/ Radiate: Where is the pain and does it radiate?

PQRSTU - S

Severity: Can you rate your pain using a scale of 0-10, where zero is no pain and 10 is the worst pain you have ever felt.

PQRSTU - T

Time: When did the pain start? How long does it last?

PQRSTU - U

Understanding: What is your understanding of the pain, what treatments have you tried to relieve it?

Urinalysis pH

Indicates acid-base balance (normal range 4.5 – 8.0). Higher numbers indicate basic (alkaline) urine and lower numbers indicate acidic urine.

Urinalysis Specific Gravity (SpG)

Identifies the hydration of an individual by measuring the concentration of particles in urine (normal range 1.000 – 1.030). High SpG indicates dehydration; low SpG indicates well-hydrated.

Leukocytes (Urinalysis)

Normal reading is Negative to +. Usually associated with a urinary infection when present.

Nitrites (Urinalysis)

Normal reading is Negative. Presence may indicate a UTI, as some bacteria can convert nitrate into nitrite.

Protein (Urinalysis)

Normal reading is Negative. Indicates damage to the kidney caused by hypertension, kidney disease, or diabetes mellitus.

Ketones (Urinalysis)

Normal reading is Negative. Formed during abnormal breakdown of fat; may be present due to prolonged vomiting, fasting, starvation, and poorly controlled diabetes.

Bilirubin (Urinalysis)

May be an indicator that bilirubin has not been effectively removed by the liver, suggesting liver disease or a problem with drainage of bile into the gut, such as gall stones.

Haematuria

Blood in the urine (Negative to + normally). Indicative of kidney disease, UTI, cancer, kidney trauma, kidney stones, blood-clotting disorders, or side-effects of anticoagulant drugs.

GCS Eyes Open - Score 4

Spontaneous: Eyes open before stimulus.

GCS Eyes Open - Score 3

To speech: Eyes open after spoken or shouted request.

GCS Eyes Open - Score 2

To pressure: Eyes open after fingertip stimulus.

GCS Eyes Open - Score 1

None: No eye opening at any time, with no interfering factor.

GCS Best Verbal Response - Score 5

Orientated: Correctly gives name, place and month / year.

GCS Best Verbal Response - Score 4

Confused: Not orientated but communicating coherently.

GCS Best Verbal Response - Score 3

Inappropriate words: Intelligible single words.

GCS Best Verbal Response - Score 2

Incomprehensible sounds: Only moans or groans.

GCS Best Verbal Response - Score 1

Nil: Nil audible response, with no interfering factor.

GCS Best Motor Response - Score 6

Obeys commands: Obeys 2-part request (open your mouth and stick out your tongue).

GCS Best Motor Response - Score 5

Localising: Brings hand above clavicle stimulus on neck.

GCS Best Motor Response - Score 4

Normal Flexion: Bends arm at elbow rapidly but features not predominantly abnormal; limb is stimulated but does not specifically localise.

GCS Best Motor Response - Score 3

Abnormal Flexion: After painful stimulus of the finger tip, the arm bends at the elbow but does not achieve a localising response when stimulated at other sites.

GCS Best Motor Response - Score 2

Extension response: In response to stimulation, the elbows straighten.

GCS Best Motor Response - Score 1

Nil: No motor response.

TEDs

Graduated compression stockings.

SCDs

Intermittent Pneumatic Compression devices.