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