results in a structural change in an organ that interferes with its functioning.
often appear to be those of organic disease, but careful fails to reveal evidence of structural or physiologic abnormalities.
a pathologic condition of the body. Any disturbance of a structure of function of the body.
means there has been a potential or complete disappearance of clinical and subjective characteristics of a disease.
develops slowly and exist over a long period, often foe a person's life.
caused by an invasion of microorganisms , such as bacteria, viruses, fungi, or parasites, that produce tissue damage.
protective response of body tissues to irritation, injury or invasion by disease producing organisms
SUBJECTIVE indications of illness that the pt. percieves
OBJECTIVE DATA perceived by the examiner (you)
a relative measure of heat or cold norm. 98.6 range 97-99.6
an instrument that is placed against the pt. chest or back to hear heart and lung sounds
am abnormal pattern of respiration characterized by alternating periods of apnea and deep rapid breathing
listening for sounds within the body to elevate the condition of, heart, lungs, pleura, intestines, or other organs or to detect fatal heart tones
when body temperature is abnormally high above 105
when body temperature is abnormally low below 93.2
represents the actual beating of the heart infants
the difference between radial and apical rates
blood pressure below
occurs when elevated blood pressure is sustained above 140/90
the pressure exerted by the circulating volume of blood on the arterial walls, veins, and chambers of the heart norm 120/80
a rhythmic beating or vibrating movement norm 60-100
anatomic site for apical pulse measurements heartbeat
5th intercostal space at the mid-clavicular line
any disturbance or abnormality in a normal rhythmic pattern.
represents the pressure within the artery between beats, that is, between contractions of the atria or the ventricles, when blood enters the relaxed chambers from the systemic circulation and lungs (the lower number of the reading)
indication of body functioning
rapid respiratory rate; exercise and fever increase respiratory rate
a slow respiratory rate below 10/min
heart rate of more than 100/min
pulse lower than 60/min
the higher number that represents the ventricles contracting, forcing blood into the aorta and the pulmonary atery
the taking in of oxygen, its utilization in the tissues, and the giving off of carbon dioxide, the act of breathing, i.e inhaling and exhaling
listening to the pulsating sounds of the brachial artery with a stethoscope (4 phases)
breathing with difficulty
a device for measuring the arterial blood pressure
a drop of blood pressure when a person moves from a lying to a sitting or from a sitting to a standing position
begins abruptly with marked intensity of severe signs and symptoms and then often subsides after a period of treatment
use the hands and sense of touch to gather data
sounds produced by the movement of air through narrowed passages in the tracheobronchial tree/
musical noise sounding like a squeak
Trace-a barely perceptible pit(2mm)
Mid- a deeper pit (4mm) 10-15 sec.
Moderate- (6mm) 30 sec to 1 min
Severe-an even deeper pit (8mm) severe edema 2 to 5 min
lack of oxygen to the tissues,often caused by narrowing of the tissue.
produced by fluid in the bronchial and alveoli, are short , discrete,interrupted, crackling, or bubbling sounds that are most commonly heard during inspiration.
an evaluation or apraisal of the pt. condition
What position improves exposure to the rectal area?
What steps does the nurse take for an abdominal assessment?
productivity, quality, religion, severity, timing/treatment
appropriate response, oriented to time, place, person and purpose.
inappropriate responses to simple commands
drowsiness or increased sleep time, responds appropriately, able to be aroused
fainting, loss of consciousness
health care record
the process of adding written information in the chart is called...
charting, documenting and recording
people appointed to examine pt charts and heath records to access quality of care
an apraisal by professional co-workers of equal status
a system that classifies pt by age, diagnosis, and surgical procedure, using 300 different categories to predict the use of hospital resources including length of stay
the form on the pt chart on which nurses record their observations, the care given, and the pt responses
all documents should have the correct pt .....
name, date and time if appropriate
risk factors for disease
genetic, physiological, age, environment, and lifestyle
conditions causing alterations in blood pressure
hemorrhage, acute pain, exercise and smoking
factors influencing respiration
medications, exercise, acute pain, age, fever, sex, stress body position
apical pulse site
no apparent cause is known
transmitted genetically from parents to children.
appears at birth or shortly after but are not caused by genetic abnormalities
abnormal growth of new tissues
result from invasions of microorganisms into the body
airway, breathing, circulation
whats going in, whats going out