Axillary temperature: Temperature taken in the armpit using the same device as when taking an oral temperature. It can be as much as one degree lower than the oral temperature.
Blood pressure: The force of blood against the walls of the arteries as the heart pumps blood through the body reported in millimeters of mercury (mmHg). It is expressed as two numbers: systolic pressure and diastolic pressure.
Body mass index (BMI): A calculated measure of body fat based on a person’s height and weight.
Charting by exception (CBE): A common type of health care documentation where routine care is provided and notes are only written for abnormal findings or anything out of the ordinary. It is designed to keep documentation concise and reduce the amount of time required for documentation.
Daily weights: Client weight taken at the same time every day, on the same scale, in similar clothing, and before any food or fluids are consumed.
Diastole: The phase between each contraction of the heart when the ventricles are filling with blood.
Diastolic blood pressure: Resting pressure within the arteries during diastole.
Hypertension (HTN): Elevated blood pressure.
Hypotension: Low blood pressure.
Insensible losses: Fluid loss that cannot be measured, such as fluids lost through the respiratory system, sweat, and stool.
Intake and output (I&O): Fluid intake and output measured and documented every shift.
Oral temperature: Temperature taken in the mouth under the tongue.
Output: Fluids that leave the body, including urine output that is measured.
Oxygen saturation (SpO2): Oxygenation status by a pulse oximeter based on how much of hemoglobin in red blood cells is “saturated” with oxygen.
Pulse: The pressure wave that expands and recoils arteries when the left ventricle of the heart contracts. It can be palpated at many points throughout the body.
Rectal temperature: Temperature taken in the rectum. It provides the most accurate temperature measurement but is considered an invasive procedure.
Respirations: The movement of air into and out of the lungs. Inspiration refers to the process causing air to enter the lungs, and expiration refers to the process causing air to leave the lungs.
Respiratory distress: Problems breathing.
Systole: The phase of the heartbeat when the ventricles contract, causing the ejection of blood into the aorta and pulmonary arteries.
Systolic blood pressure: The maximum pressure within the arteries during systole.
Temporal temperature: Temperature taken by using a device placed on the forehead that measures the heat on the surface of the skin resulting from blood moving through the temporal artery in the forehead.
Tripod position: A position that people experiencing respiratory distress naturally assume by leaning forward and placing their arms or elbows on their knees or on a bedside table to help improve lung expansion.
Tympanic temperature: Temperature taken using a device placed in the ear. It is more accurate than oral or axillary measurement because the tympanic membrane in the ear shares the same artery that perfuses the hypothalamus (the part of the brain that regulates the body’s temperature).
Vital signs: Vital signs include temperature recorded in Celsius or Fahrenheit, pulse, respiratory rate, blood pressure, and oxygen saturation using a pulse oximeter.