Patient Care I

Subjective Data

Interpretation-based data that is less objective and reliable.

Objective Data

Measurable and observable data collected during physical examination, including vital signs and diagnostic test results.

Inspection

Quick visual examination of the patient's body to detect obvious physical indicators.

Palpation

Physical touching to assess tenderness, deformities, crepitus, masses, and pulsations.

Auscultation

Listening with a stethoscope to assess internal body sounds, such as heartbeats and lung sounds.

Percussion

Gently striking the body surface to assess underlying structures by producing sound waves.

Blood Pressure (BP)

Measurement of the force of blood against arterial walls, commonly measured in $mmHg$.

Systolic Pressure

Force against arterial walls when the ventricles contract.

Diastolic Pressure

Pressure in the arteries when the heart is at rest between beats.

Normotension

Systolic BP $\text{≥} 100 \text{ mmHg}$, ideally $115/75 \text{ mmHg}$ to $120/80 \text{ mmHg}$.

Hypertension

Systolic BP greater than $140 \text{ mmHg}$.

Hypotension

Systolic BP less than $90 \text{ mmHg}$.

Cardiac Output (CO)

The volume of blood the heart pumps per minute, calculated as $CO = SV \times HR$.

Stroke Volume (SV)

Amount of blood leaving the heart per beat.

Heart Rate (HR)

Number of heartbeats per minute.

Pulse Definition

The pulsing of arteries each time the heart pumps blood.

Perfusion

Delivery of oxygen and nutrients to tissues, assessed via skin color, temperature, and capillary refill time.

Normal Pulse Rate

60–100 beats per minute (bpm).

Tachycardia

Heart rate greater than 100 bpm.

Bradycardia

Heart rate less than 60 bpm.

Normal Respiratory Rate

12–20 breaths per minute.

Bradypnea

Respiratory rate less than 12 breaths per minute.

Tachypnea

Respiratory rate greater than 20 breaths per minute.

Normal Body Temperature

36–37.3 $^\text{C}$.

Hypothermia

Body temperature less than 36 $^\text{C}$.

Hyperthermia

Body temperature greater than or equal to 37.4 $^\text{C}$.

Pulse Oximetry (SpO2)

Measures the percentage of hemoglobin saturated with oxygen in arterial blood.

Normal SpO2 Range

Typically between 92% and 96% saturation.

Patient Assessment

A systematic process in which healthcare providers determine patient health status through various evaluation methods.

Focused Physical Examination

Concentrates on specific findings related to patient presentation rather than a full head-to-toe assessment.

AVPU Scale

A rapid method for assessing the level of consciousness based on Alertness, Verbal response, Painful response, and Unresponsive.

Continuous Reassessment

Required to adapt to changes in a patient's condition.