Chief Complaint Definition - ANS The reason why the patient came to see the physician.
Chief Complaint Abbreviation - ANS CC
History of Present Illness Abbreviation - ANS HPI
History of Present Illness Definition - ANS This is an explanation of the CC to determine
the onset of the illness; associated symptoms; what the patient has done to treat the
condition, etc.
Past, Family and Social History Abbreviation - ANS PFSH
Past Medical History Definition - ANS Includes all health problems, major illnesses,
surgeries the patient has had, current medications complete with reasons for taking
them, and allergies.
Family History Definition - ANS Summary of health problems of siblings, parents, and
other blood relatives that could alert the physician to hereditary and/or familial disease.
Social History Definition - ANS Includes marital status, occupation, educational
attainment, hobbies, use of alcohol, tobacco, drugs, and lifestyles.
Review of Systems Abbreviation - ANS ROS
Review of Systems Definition - ANS This is an orderly and systematic check of each
organ and system of the body by questions. Both positive and pertinent negative
findings are documented.
3 Body Processes Necessary for life are: - ANS Body Temperature, Respiration, Heart
Function
4 Vital Signs of Body Function are: - ANS Temperature, Pulse, Respiration, Blood
Pressure
Define Body Temperature - ANS Is a balance between heart production and heart loss
in conjunction with each other, maintained and regulated by the hypothalamus.
,Thermometers - ANS Are used to measure temperature using the Fahrenheit and
Centigrade or Celsius scale.
Temperature Sites - ANS Mouth, Rectum, Ear (Tympanic Membrane), and the axilla
(underarm).
Normal Temperature Range for Rectal - ANS 98.6F to 100.6F
37.0C to 38.1C
Normal Temperature Range for Oral - ANS 97.6F to 99.6F
36.5C to 37.5C
Normal Temperature Range for Axillary - ANS 96.6F to 98.6F
35.9C to 37.0C
Normal Temperature Range for Tympanic Membrane - ANS 98.6 F
37 C
Define Febrile - ANS Presence of Fever
Define Afebrile - ANS Absence of Fever
Define Fever - ANS Elevated body temperature beyond normal range.
Intermittent Fever - ANS Fluctuating fever that returns to or below baseline then rises
again.
Remittent Fever - ANS Fluctuating fever that remains elevated; it does not return to
baseline temperature.
Continuous Fever - ANS A fever that remains constant above the baseline; it does not
fluctuate.
Oral Temperature - ANS Is the most common method of measurement.
Oral Temperature is not taken from what patients: - ANS -infants and children less than
six years old
-patients who has had surgery or facial, neck, nose, or mouth injury
-those receiving oxygen
,-those with nasogastric tubes
-patients with convulsive seizure
-hemiplegic patients
-patients with altered mental status
How long after a patient eats, smokes or drinks do you wait to take an oral
temperature? - ANS 30 minutes
When taking an oral temperature how long do you leave the thermometer in the
patient's mouth? - ANS 3-5 minutes
Rectal Temperature - ANS Is taken when oral temperature is not feasible.
Rectal Temperature is not taken from what patients: - ANS -patient's with heart disease
-patients with rectal disease or disorder or has had rectal surgery
-patients with diarrhea
Axillary Temperature - ANS Is the least accurate and is taken only when no other
temperature site can be used.
When taking an axillary temperature how long should the thermometer be held in place?
- ANS 5-10 minutes
Tympanic Temperature - ANS Is useful for children and confused patients because of
the speed of operation.
Tympanic Temperature is not taken from what patients: - ANS -patients with an ear
disorder or ear drainage
When taking a Tympanic Temperature: - ANS A covered probe is gently inserted into
the ear canal and temperature is measured with seconds (1-3 seconds).
What is the normal range for an adult pulse: - ANS 60 to 100 beats per minute
The site most commonly used for taking a pulse is: - ANS The radial artery (found in the
wrist on the same side as the thumb).
When taking a pulse at the radial artery it is felt with the: - ANS First two or three fingers
(never with the thumb) and usually taken for 30 seconds multiplied by two to get the rate
per minute.
, (Taking a pulse at the radial artery) If the rate is unusually fast or slow then: - ANS
Count it for 60 seconds
The _____ _____ is a more accurate measurement of the heart rate and it is taken over
the apex of the heart by auscultation using the stethoscope. - ANS Apical Pulse
Taking an apical pulse is used for patients with: - ANS Irregular heart rate and for infants
and small children.
Respiratory Characteristics - ANS Rate, Rhythm, and Depth
Respiratory Rate - ANS Is the number of respirations per minute.
Normal Adult Range of Respiratory Rate - ANS 12 to 20 per minute
What counts as one respirations: - ANS One inspiration (inhale) and One Expiration
(exhale).
How is a Respiratory Rate calculated: - ANS Count respirations for 30 seconds then
multiplied by two or count for a full minute.
Define Apnea - ANS This is a temporary complete absence of breathing which may by
result of a reduction in the stimuli to the respiratory centers of the brain.
Define Tachypnea - ANS This is a respiration rate of greater than 40/min. It is transient
in the newborn and maybe caused by the hysteria in the adult.
Define Bradypnea - ANS Decrease in numbers of respirations. This occurs during sleep.
It may also be due to certain diseases.
Define Respiratory Rhythm - ANS Refers to the pattern of breathing. It can vary with
age: infants have an irregular rhythm while adults have regular.
Define Cheyne-Stokes - ANS This is a regular pattern of irregular breathing rate.
Define Orthopnea - ANS This is difficulty or inability to breath unless in an upright
position.
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