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Nsg fund class

nursing - terms, assessment, body sys

QuestionAnswer
bruit sign comprising an abnormal swishing sound
dyspnea difficulty breathing
normal capillary refill less than 3 seconds; more than 3 sec= sluggish digital circulation; 5 seconds is abnormal;
capillary refill also blanch - test by pressing firmly for 5 sec on area and estimating speed at which blood returns
what conditions identified with delay in capillary refill poor cardiac function, dehydration, PVD
LOC level of consciousness; meas of neurolog assessment; x1=person, x2= person and place, x3 = person, place, and time, x4 = person, place, time, and purpose
PERRLA pupils equal, round, reactive to light, and accomodation
Glascow coma scale standardized, objective meas of consciousness; 3 areas - eye opening, verbal response, motor response; each has score and total the number; normal is 15;, score 8 or less indicates severe brain injury
abnormal skin color findings pallor (white), cyanosis (dusky blue), jaundice (yellow), erythema (redness), ecchymosis
normal skin findings warm, dry, smith, with good turgor
turgor elasticity of the skin; caused by outward press of cells and interstitial fluid
normal corotid pulse sound regualr and palpable without a thrill(vibrating sensation perceived as you palpate along the artery)
tachypnea rapid rate of breathing; greater than 24 breaths/minute
bradypnea slow breathing; less than 10 breaths/min
normal O2 saturation 90% - 100%
normal respiration rate 12-20/minute
normal BP Systolic less than 120; Diastolic less than 80
normal pulse/heart rate 60-100 bpm
bowel sounds normal rate is 4-32/minumte; occur q 15-60 sec; classified as active, hyperactive, or absent
normal mucous membrane findings moist, pink, free of lesions; dry= dehydration
tachycardia greater than 100 bpm
bradycardia less than 60 bpm
pre-hypertension Systolic = 121-139 OR Diastolic = 81-89
hypertension Systolic = 140 or greater OR Systolic = 90 or greater
hypotension Systolic less than 90
pulse pressure difference between systolic and diastolic ; eg. 120/80
sign objective
symptom subjective
strength of pulse noted as 0 = absent, 1+ = thready, 2+ = weak, 3+ = normal, 4+ = bounding
bounding
Created by: MBuzzelli