NCM 101- Midterms

Vital Signs and Validation and Documentation of Data Study in the Book - General Survey

4 Major Vital Signs

Body Temperature, Respiratory rate, Pulse Rate, Blood Pressure

Body Temperature

heat produced and Heat lost metabolism

Core Temperature

deep tissues, oral, rectal

Surface Temperature

Skin

Radiation

transfer of heat from the surface of one object to the surface of another without contact

Conduction

transfer of heat from one surface to another, direct transfer by conduct Example: cloth and fever

Convection

dissipation of heat by air currents. Example: exposure of skin towards the electric fan

Evaporation

vaporization of moisture from the skin

Pyrexia

body temperature above normal range

Hyperpyrexia

Very high fever 41degrees C above

Hypothermia

subnormal core body below 36 degree C

Fibril

with fever

Intermittent fever

temperature fluctuates (normal/subnormal)

Remittent Fever

within a wide range over a 24 hrs period remains above normal range (always high/low)

Relapsing

elevated for a few days ( days where in you are sick or not)

Constant/ Continuous

constantly high

Oral

most accessible and convenient, allow 15 mins to elapse. Under the tongue

Rectal

most accurate measurement (core temp). Insert by 0.5 to 1.5 inches. 2-5 mins

Axillary

Safest and non-invasive method

Tympanic

useful for toddlers, core temperature

Forehead

less accurate, use infrared sensor to pick up infrared radiation that the body produce.

Pulse Rate

a wave of blood created by contraction of the left ventricle of the heart

Bradycardia

slow pulse

Tachycardia

fast pulse

Rhythm

pattern interval of beats

Volume (Amplitude)

strength of pulse

Respiration

act of breathing, inhalation, or inspiration, exhalation, expiration

Diffusion

exchange of Gas

Delfusion

flow of blood for transport gases

Ventilation

movement of gases in and out of the lungs

Normal Respiratory Rate Newborn

30-60 bpm

Normal Respiratory Rate Adult

12-20 bpm

Eupnea

normal respiratory rate

Tachypnea

quick respiratory rate

bradypnea

slow respiratory rate

Apnea

cessation

Dyspnea

difficult and labored breathing

Orthopnea

ability to only breathe in a upright position

Blood Pressure

measure of the pressure, every blood flow through the arteries

Systolic

pressure of blood contraction of ventricles

Diastolic

pressure of the ventricles when at rest

Pulse Pressure

difference between the systolic and diastolic pressure

Hypertension

abnormally high blood pressure over 140 mmHg systolic and above 90 mmHg diastolic

Hypotension

Abnormally low below 100/60 mmHg

Orthostatic Hypotension

a drop in systolic pressure

Korotkoff Sound

the sound you hear in taking Blood pressure

Oxygen Saturation

value to the percent of all hemoglobin in blood

Pulse Oximeter

non invasive device

Validation of Data

the process of confirming or verifying that the subjective and objective data you have collected are reliable and accurate

Cues

are subjective and objective data that can be directly observed by the nurse.

Inferences

nurses’ interpretation or conclusion based on the cues

Documentation

process of preparing a record reflecting the assessment data and both the client’s health status and response to care.

Health Information Technology

the use of communication and information technology healthcare to improve the effectiveness and efficiency of health services

Health Information Systems

to integrate data collection, processing, reporting, and use of information in public health facilities.

Narrative

requires documentation of all activities surrounding the care provided and the clients response to the procedures

S.O.A.P.

use an interdisciplinary approach, problems are identified and listed. Each member of the team then charts relevant information about each problem.

S.O.A.P.I.E

problems can be quickly identified. The members share in the interventions, implementation, and evaluation of outcomes. Team collaboration.

Focus

identifies the conduct or purpose of the narrative a condition, nursing diagnosis, behavior, signs of symptoms, an acute change.

FDAR

includes all wellness aspects