NURS 402 – Fundamentals of Nursing Practice Final Exam Study Sheet
Lectures 1-8
Lecture 2: Vital Signs
(Chapter 25)
Terminology:
• Vital signs: body temperature, pulse and respiratory rates, and blood pressure; synonym for cardinal signs
➢ Temperature:
• Afebrile: a condition in which the body temperature is not elevated (normal body temp)
• Febrile: condition in which the body temperature is elevated (having fever/pyrexia)
• Hyperthermia: high body temperature
• Hypothermia: low body temperature
➢ Respiration:
• Eupnea: normal respirations
• Apnea: absence of breathing
• Tachypnea: rapid rate of breathing
• Bradypnea: slow rate of breathing
• Dyspnea: difficult or labored breathing
• Orthopnea: type of dyspnea in which breathing is easier when the patient sits or stands
➢ Blood Pressure:
• Systolic pressure: highest point of pressure on arterial walls; ventricular contraction
• Diastolic pressure: least amount of pressure exerted on arterial walls; ventricular relaxation
• Hypertension: blood pressure elevated above the upper limit of normal
• Hypotension: blood pressure below the lower limit of normal
• Orthostatic hypotension: fall in blood pressure when assuming an upright position; aka postural hypotension
• Korotkoff Sounds: sounds that correspond to changes in blood flow through an artery as pressure is released
• Auscultatory gap: diminished/absent Korotkoff sounds during the manual measurement of blood pressure
➢ Heart Rate & Pulse
• Tachycardia: rapid heart rate
• Bradycardia: slow heart rate
• Dysrhythmia: an abnormal cardiac rhythm
• Pulse pressure: difference between systolic and diastolic pressures
• Pulse deficit: difference between the apical and radial pulse rates
Lecture 3: Health Assessments
(Chapter 26)
Health Assessment:
➢ Types of Assessments:
1. Comprehensive (Initial) Health Assessment: conducted when a pt first arrives to the unit in order to obtain a
baseline for later assessments
▪ Ongoing-Partial Assessment: aka follow-up assessment; identifies if there are positive or negative
changes regarding baseline data
2. Focused Assessment: conducted to assess a specific problem or highest priority concern for a pt
▪ Functional Assessment: assesses pts ability to perform ADLs and IADls (i.e., self-care)
3. Emergency Assessment: used to address a life-threatening or unstable situation
4. Time-Lapsed Assessment: ongoing over a period of time, (i.e assessing how a patient is doing in LTC facility)
➢ Body Positions for Assessment:
1. Sitting: vital signs and assessment of ant./post. thorax
2. Supine: relaxation of abdominal muscles → abdominal assessment
3. Dorsal Recumbent: for pts having difficulty with supine
4. Sim’s Position: assessment of rectum or vagina
5. Prone: assessment of hip joint and post. thorax
1
, 6. Lithotomy: assessment of female rectum or vagina
7. Knee-Chest: assessment of rectal area; brief period only
8. Standing: assessment of posture, gait, & balance
➢ Physical Assessment Techniques:
1. Inspection: assess size, color, shape, position, and symmetry
2. Palpation: assess temperature, turgor, texture, moisture, vibrations, and shape
3. Percussion: assess location, shape, size, and density of tissues
• Types of Sounds:
i. Flat: soft (e.g. thigh)
ii. Dull: medium (e.g. over the liver)
iii. Resonance: loud (e.g. normal lung)
iv. Hyper-resonance: very loud (e.g. emphysematous lung)
v. Tympany: loud (e.g. puffed out cheek)
4. Auscultation: assess the four characteristics of sound: pitch, loudness, quality, and duration
Assessment of the Thorax and Lungs:
1. Inspection:
• Tracheal deviation (can suggest of tension pneumothorax)
• Kyphosis: anteroposterior curvature of the spine
• Scoliosis: lateral curvature of the spine
• Barrel chest: chest wall increased anteroposterior (normal in
children; typical of hyperinflation seen in COPD)
2. Palpation:
• Palmar hands placed on ant and post landmarks
• Chest should expand symmetrically
• Skin should be warm and dry
3. Auscultation:
• Normal Breath Sounds:
1. Bronchial: trachea and mainstem; high-pitched & harsh; exp longer than insp
2. Bronchovesicular: mainstem bronchi; medium pitched; exp = insp
3. Vesicular: most lung fields; low-pitched whisper; insp longer than exp
o Diminished: reduced breathing; normal for obese patients
• Abnormal/Adventitious Breath sounds:
1. Wheeze: (sibilant)
▪ Quality: high-pitched, continuous, musical or squeaking sound
▪ Duration: heard during either insp or exp
▪ Indication: narrowing airway
2. Ronchi: (sonorous wheeze)
▪ Quality: low-pitched, continuous, snoring sound
▪ Duration: heard during either insp or exp
▪ Indication: secretions in the airway
3. Crackles: (fine or coarse)
▪ Quality: low-/high-pitched, discontinuous, bubbling/crackling sounds
▪ Duration: heard during insp
▪ Indication: fluid in the airway; congestive heart failure
4. Friction Rub:
▪ Quality: rubbing or grating sound
▪ Duration: heard during insp and exp
▪ Indication: inflamed pleura rubbing against chest wall
5. Stridor:
▪ Quality: high-pitched, loud, harsh sounds
▪ Duration: heard during insp only
▪ Indication: narrowing airway
2
Lectures 1-8
Lecture 2: Vital Signs
(Chapter 25)
Terminology:
• Vital signs: body temperature, pulse and respiratory rates, and blood pressure; synonym for cardinal signs
➢ Temperature:
• Afebrile: a condition in which the body temperature is not elevated (normal body temp)
• Febrile: condition in which the body temperature is elevated (having fever/pyrexia)
• Hyperthermia: high body temperature
• Hypothermia: low body temperature
➢ Respiration:
• Eupnea: normal respirations
• Apnea: absence of breathing
• Tachypnea: rapid rate of breathing
• Bradypnea: slow rate of breathing
• Dyspnea: difficult or labored breathing
• Orthopnea: type of dyspnea in which breathing is easier when the patient sits or stands
➢ Blood Pressure:
• Systolic pressure: highest point of pressure on arterial walls; ventricular contraction
• Diastolic pressure: least amount of pressure exerted on arterial walls; ventricular relaxation
• Hypertension: blood pressure elevated above the upper limit of normal
• Hypotension: blood pressure below the lower limit of normal
• Orthostatic hypotension: fall in blood pressure when assuming an upright position; aka postural hypotension
• Korotkoff Sounds: sounds that correspond to changes in blood flow through an artery as pressure is released
• Auscultatory gap: diminished/absent Korotkoff sounds during the manual measurement of blood pressure
➢ Heart Rate & Pulse
• Tachycardia: rapid heart rate
• Bradycardia: slow heart rate
• Dysrhythmia: an abnormal cardiac rhythm
• Pulse pressure: difference between systolic and diastolic pressures
• Pulse deficit: difference between the apical and radial pulse rates
Lecture 3: Health Assessments
(Chapter 26)
Health Assessment:
➢ Types of Assessments:
1. Comprehensive (Initial) Health Assessment: conducted when a pt first arrives to the unit in order to obtain a
baseline for later assessments
▪ Ongoing-Partial Assessment: aka follow-up assessment; identifies if there are positive or negative
changes regarding baseline data
2. Focused Assessment: conducted to assess a specific problem or highest priority concern for a pt
▪ Functional Assessment: assesses pts ability to perform ADLs and IADls (i.e., self-care)
3. Emergency Assessment: used to address a life-threatening or unstable situation
4. Time-Lapsed Assessment: ongoing over a period of time, (i.e assessing how a patient is doing in LTC facility)
➢ Body Positions for Assessment:
1. Sitting: vital signs and assessment of ant./post. thorax
2. Supine: relaxation of abdominal muscles → abdominal assessment
3. Dorsal Recumbent: for pts having difficulty with supine
4. Sim’s Position: assessment of rectum or vagina
5. Prone: assessment of hip joint and post. thorax
1
, 6. Lithotomy: assessment of female rectum or vagina
7. Knee-Chest: assessment of rectal area; brief period only
8. Standing: assessment of posture, gait, & balance
➢ Physical Assessment Techniques:
1. Inspection: assess size, color, shape, position, and symmetry
2. Palpation: assess temperature, turgor, texture, moisture, vibrations, and shape
3. Percussion: assess location, shape, size, and density of tissues
• Types of Sounds:
i. Flat: soft (e.g. thigh)
ii. Dull: medium (e.g. over the liver)
iii. Resonance: loud (e.g. normal lung)
iv. Hyper-resonance: very loud (e.g. emphysematous lung)
v. Tympany: loud (e.g. puffed out cheek)
4. Auscultation: assess the four characteristics of sound: pitch, loudness, quality, and duration
Assessment of the Thorax and Lungs:
1. Inspection:
• Tracheal deviation (can suggest of tension pneumothorax)
• Kyphosis: anteroposterior curvature of the spine
• Scoliosis: lateral curvature of the spine
• Barrel chest: chest wall increased anteroposterior (normal in
children; typical of hyperinflation seen in COPD)
2. Palpation:
• Palmar hands placed on ant and post landmarks
• Chest should expand symmetrically
• Skin should be warm and dry
3. Auscultation:
• Normal Breath Sounds:
1. Bronchial: trachea and mainstem; high-pitched & harsh; exp longer than insp
2. Bronchovesicular: mainstem bronchi; medium pitched; exp = insp
3. Vesicular: most lung fields; low-pitched whisper; insp longer than exp
o Diminished: reduced breathing; normal for obese patients
• Abnormal/Adventitious Breath sounds:
1. Wheeze: (sibilant)
▪ Quality: high-pitched, continuous, musical or squeaking sound
▪ Duration: heard during either insp or exp
▪ Indication: narrowing airway
2. Ronchi: (sonorous wheeze)
▪ Quality: low-pitched, continuous, snoring sound
▪ Duration: heard during either insp or exp
▪ Indication: secretions in the airway
3. Crackles: (fine or coarse)
▪ Quality: low-/high-pitched, discontinuous, bubbling/crackling sounds
▪ Duration: heard during insp
▪ Indication: fluid in the airway; congestive heart failure
4. Friction Rub:
▪ Quality: rubbing or grating sound
▪ Duration: heard during insp and exp
▪ Indication: inflamed pleura rubbing against chest wall
5. Stridor:
▪ Quality: high-pitched, loud, harsh sounds
▪ Duration: heard during insp only
▪ Indication: narrowing airway
2
