Holistic Nursing Assessment Flashcards
the first part of the physical examination
that begins the moment the nurse meets
the client.
General Survey
are the body’s indicators of health
also known as “cardinal signs”
VITAL SIGNS
rate of energy utilization in the body
required to maintain essential activities
Basal Metabolic Rate (BMR)
increases metabolic rate
using large muscles to make heat rather
than movement
Muscle Activity
plays an important role on the
maintenance of core body temperature
through thermoregulation processes.
Sympathetic Nervous System
transfer of heat from one molecule to a
molecule of lower temperature
Conduction
transfer of heat in the form of waves
and particles
Radiation
it is the dispersion of heat by air
currents
Convection
it is a continuous evaporation of
molecules from the respiratory tract and
from the mucosa of the mouth and from
the skin.
Vaporization/Evaporation
alternative at regular intervals between
periods of fever and periods of
normal/subnormal temperature
Intermittent
wide range of temperature fluctuations
of which are above normal
Remittent
short febrile periods of a few days are
interspersed with periods of 1 or 2 days
of normal temperature.
Relapsing
fluctuates minimally but always remain
above normal
Constant
a shock wave produced by the
contraction of the heart and forceful
pumping of blood out of the ventricles
into aorta
PULSE
condition in which the apical pulse rate is
greater that the radial pulse rate
Pulse Deficit
is the regularity of the heartbeat
there are regular intervals between
beats
Pulse Rhythm
arrhythmia
irregular heartbeat
Dysrhythmia
is a measurement of the strength or
amplitude of force exerted by the
ejected blood against the arterial wall
with each contraction.
Pulse Volume
artery feels straight, resilient, & springy
Arterial Elasticity
is a heart rate less than 60 bpm in an
adult
Bradycardia
is a heart rate in excess of 100 bpm in
adult
Tachycardia
the act of breathing
rate and character are additional clues to
the clients overall health status
RESPIRATIONS
overexpansion of the lungs, rapid deep
breaths
Hyperventilation
shrill harsh sound during inspiration -
laryngeal obstruction
Stridor
snoring or sonorous respiration - partial
obstruction of upper airway
Stertor
high pitched musical squeak on
expiration - narrowed/partially
obstructed airway (asthma)
Wheeze
It is the measure of pressure exerted as
blood flows through the artery
BLOOD PRESSURE
refers to client's level of cognitive functioning (thinking, knowledge, problem solving) and emotional functioning ( feelings, mood, behaviors, stability)
MENTAL STATUS
an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.
PAIN
perceived at the source of the pain
and extends to the nearby tissues
Radiating Pain
felt in a part of the body that is
considerably removed or far from the
tissues causing the pain
Referred Pain
a pain that contributes insomnia,
weight gain, constipation, etc.
Persistent Pain
an emergency situation deserving
attention and professional treatment
Severe Pain
excessive sensitivity to pain
Hyperalgesia
the amount of pain stimulation a
person requires before feeling pain
least level of pain that the patient is
able to detect
Pain Threshold/Sensation
maximum amount and duration of
pain that an individual is willing to
endure
Pain Tolerance
the point which the person becomes
aware of the pain
Pain Perception
pain due to a stimulus that does not
normally provoke pain
Allodynia
unpleasant abnormal sensation,
imitates the pathology of central
neuropathic pain disorder.
Dysesthesia
pain directly related to tissue damage
and may be somatic
Nociceptive Pain
an increased sensitivity of a receptor
after repeated activation by noxious
stimuli or nociceptor
Sensitization
