Term
|
Definition
range of motion
limited? describe limitations |
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Term
|
Definition
|
|
Term
| clinical measurements are analyzed according to |
|
Definition
| normal standards, previous and serial numbers, diagnosis |
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|
Term
|
Definition
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Term
|
Definition
overeating, decreased physical activity
hyperthyroidism
corticosteroid use
diabetes |
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Term
|
Definition
fluid volume excess
2.2 lb = 1 L fluid retention
2-3 lb weight gain weekly could be CHF |
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Term
|
Definition
| intentional, unintentional? cancer, anorexia, dehydration, increased metabolism, diabetes new onset or poor control |
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Term
|
Definition
regulated hypothalamus
febrile state= fever
afebrile=no fever
peak temp at 4pm lowest at 4am
menstrual cycle increases temp
children have higher temp
prolonged exposure to cold=hypothermia |
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Term
|
Definition
|
|
Term
| Oral Temperature normal limits |
|
Definition
use as the benchmark
98.6o F (range = 96.4 - 99.1)
37o C (range = 35.8 - 37.3)
5-6years old and older |
|
|
Term
| rectal temperature normal limits |
|
Definition
| 1o F or 0.5o C higher than oral |
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|
Term
| tympanic temperature normal limits |
|
Definition
| 1o F or 0.5o C higher than oral |
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|
Term
| axillary temperature normal limits |
|
Definition
1o F or 0.5o C lower than oral
least accurate |
|
|
Term
| oral temperature technique |
|
Definition
BLUE TIP! sublingual pocket
wait 15 min after eating
2 min after smoking |
|
|
Term
| anal temperature technique |
|
Definition
RED TIP!
1 inch insertion (use lubricant) |
|
|
Term
| axillary temperature technique |
|
Definition
|
|
Term
| tympanic temperature technique |
|
Definition
use the ear probe
unreliable with ear infection or local inflammation (tooth) |
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Term
|
Definition
palpate rate and rhythm
regular count for 30 x2
irregular count for 60 sec |
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|
Term
|
Definition
pulse increases with inspiration
decreases with expiration
common in children/young adults |
|
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Term
|
Definition
apical until age 2
after age 2 count radial for 1 min |
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|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
difference between apical pulse and radial pulse
healthy = same
A + cardiac arrythmia |
|
|
Term
|
Definition
0 non palpable
1+ weak & thready
2+ normal
3+ full
4+ bounding |
|
|
Term
|
Definition
asses:
rhythm, regular count 30 sec, irreg count 60 sec
rate
depth
character- thoracic women, abdominal men/ infants
pattern |
|
|
Term
|
Definition
always count 1 minute
age specific variations |
|
|
Term
|
Definition
10-20
bradypnea less than 10
tachypnea more than 10 |
|
|
Term
|
Definition
| maximum arterial pressure |
|
|
Term
|
Definition
| resting pressure btwn contraction |
|
|
Term
blood pressure standards
J&C |
|
Definition
Normal SBP< 120 DBP< 80
pre SBP 120-139 or DBP 80-89
Hype rtension SBP ≥140DBP ≥ 90 |
|
|
Term
|
Definition
| difference between systolic and diastolic pressure |
|
|
Term
|
Definition
| pressure forcing blood into tissues averaged over cardiac cycle |
|
|
Term
| factors determining blood pressure |
|
Definition
Cardiac Output
• Volume of Circulating Blood
• Blood Viscosity (increased pressure with thicker blood)
• Peripheral Vascular Resistance (PVR) - increased pressure is generated to pump against
constricted blood vessels |
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|
Term
|
Definition
|
|
Term
|
Definition
support bare arm at heart level
feet flat on floor
correct cuff (arm 40 width, 80% length)
palpate brachial
inflate +20-30 palpation |
|
|
Term
|
Definition
|
|
Term
|
Definition
unusually large gap between 1st and 2nd karakoff sounds
may miss the true systolic
falsely low BP |
|
|
Term
|
Definition
wrong size cuff
incorrect arm position
too loose or too tight
deflate too quickly
not inflating high enough
retaking too quickly |
|
|
Term
|
Definition
normal change in Systolic is 5mm between an inspiration and expiration IF
greater than 10 mm then paradoxical pulse
could be cardiac tapenade or emphysema |
|
|
Term
|
Definition
| significant drop in BP from lying to sitting to standing |
|
|
Term
| orthostatic hypotension causes |
|
Definition
hypovolemia
bedrest
medications- vasodilators |
|
|
Term
| testing orthostatic hypotension |
|
Definition
patient rest supine 2-3 min, take BP
patient sit up, check dizziness
patient rest 2-3 min, take BP sitting
patient stand, not dizziness
patient rest 2-3 min, take BP standing |
|
|
Term
| orthostatic hypotension determination |
|
Definition
Drop in systolic of 20
drop in diastolic of 10 |
|
|
Term
|
Definition
| do they look older or younger than stated age? |
|
|
Term
|
Definition
| are they developmentally appropriate to age |
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
well groomed, clean clothes
poor hygiene physical or mental illness |
|
|
Term
|
Definition
| height within standards or abnormally tall or short |
|
|
Term
|
Definition
| well developed well nourished, obese, overweight, underweight, cachectic |
|
|
Term
|
Definition
| hypertrophy, swelling, atrophy, symmetric |
|
|
Term
|
Definition
| erect, slumped (depression) |
|
|
Term
|
Definition
| relaxed, tense, fetal (abdominal pain, mental illness) |
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
completely subjective
establish the subjective database
help establish problem list
establish diagnosis |
|
|
Term
|
Definition
| name, address, age, birthday, race, marital status, etc. |
|
|
Term
|
Definition
wellness or illness (chief complaint)
BRIEF |
|
|
Term
present health status
HPI history present illness |
|
Definition
| describe state of health, or analysis of symptoms |
|
|
Term
|
Definition
| Onset, Location, Duration, character, aggravating factors, relieving factors, treatments used |
|
|
Term
|
Definition
| what are your concerns, what do you think is wrong, how is it affecting you |
|
|
Term
questions before symptoms analysis
(before oldcart) |
|
Definition
| had before? find out what wrong? what testing? what results? what treatment? was that treatment effective? |
|
|
Term
|
Definition
months ago, weeks ago
sudden or gradual |
|
|
Term
|
Definition
point location
is their radiation or only localized |
|
|
Term
|
Definition
frequency
constant
intermittent (completely subside or mostly subside?) |
|
|
Term
|
Definition
quality dull, throbbing, bright red, sticky etc.
quantity (objective measurements)
severity (0-10)
description by patient "quotation"
can they maintain ADL |
|
|
Term
|
Definition
makes it worse
movement, foods, |
|
|
Term
|
Definition
makes it better
ice, hot, position |
|
|
Term
|
Definition
| was it effective? we don't want to repeat |
|
|
Term
|
Definition
secondary symptoms
1st= pain
secondary= nausea |
|
|
Term
|
Definition
| important because can rule out certain illnesses |
|
|
Term
|
Definition
| date, nature of event/explanation, any resulting disability |
|
|
Term
|
Definition
gravita: number of pregnancies
para: carrying a baby to 20 weeks regardless of survival
stillbirth: loss after 20 weeks
abortion: loss before 20 weeks
spontaneous abortion/miscarriage SAB
Therapeutic abortion TAB
multiple births are 1 PARA |
|
|
Term
|
Definition
| list all dates and adverse reactions |
|
|
Term
|
Definition
every 10 years
TDAP should replace T/Dip once when under 65
65 and over, should get it |
|
|
Term
|
Definition
| to people who have not had these illnesses and not vaccinated |
|
|
Term
|
Definition
to those at risk
sexually transmitted |
|
|
Term
|
Definition
|
|
Term
|
Definition
| adults 60+ who have had chickenpox |
|
|
Term
|
Definition
hepatitis B (if not previously received)
Influenza – annual (ethical responsibility: protect your patients)
MMR if not immune
Varicella if not immune |
|
|
Term
|
Definition
Hep B, 3 shot series
1st dose, 1 month, 6 months |
|
|
Term
|
Definition
| DPT, Tdap, MMR, Polio, Hflu [HIB]), Varicella |
|
|
Term
|
Definition
if high risk, if not received in childhood
2 part
1st, then 6 months later |
|
|
Term
|
Definition
against bacterial meningitis
college dorms
military
spleenectomy |
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
| for immunities measles, mumps, rubella, for current disease, lead levels, tuberculosis PPD |
|
|
Term
|
Definition
|
|
Term
|
Definition
dates for
physical
GYN
PAP
prostate
eye
hearing
dental
mammogram
CXR
ECG
lipid panel |
|
|
Term
|
Definition
to meds especially!!!
type of reacations
allergic reactions involve a histamine reaction- lactose intolerance is not an allergy
NKA |
|
|
Term
|
Definition
Rx
OTC
viatmins
herbs
ANYTHING!
document the reasons they are taking,
be aware of drug drug interactions
patients can confuse generic and trade names, ibuprophen and advil are the same |
|
|
Term
|
Definition
peak bone mass by 25
if failing to reach peak bone mass than osteoporosis can occur earlier
adult 1000 mg per day 500x2
older 1500mg
1 milk= 300
take vitamin d 400 units/15min in order to absorb |
|
|
Term
|
Definition
assess risk for genetic disease and disorders
identify the age of family members, document age illness occurred, document alive and well or age of death and cause. |
|
|
Term
|
Definition
| tobacco, alchohol, drugs, sleep, housing, occupation, economic status |
|
|
Term
|
Definition
| pack year, number of packs per day for how many years? |
|
|
Term
|
Definition
amount, type, frequency, duration
NO SOCIAL DRINKER! |
|
|
Term
|
Definition
| type, amount, frequency, duration |
|
|
Term
|
Definition
| quantity, quality, problems |
|
|
Term
|
Definition
| type, frequency, duration |
|
|
Term
|
Definition
| SUBJECTIVE for each body system |
|
|
Term
|
Definition
| unexpected response to a problem. |
|
|
Term
|
Definition
epidermis
dermis
subcutaneous |
|
|
Term
|
Definition
| avascular, wont cut or bleed |
|
|
Term
|
Definition
| nerves, receptors, veins, eccrine glands,apocrine glands |
|
|
Term
|
Definition
| sweat, infants mature at 2 months |
|
|
Term
|
Definition
open into hair follicles, secrete fluid in response to stimuli,
activated in puberty,
hiar locations:
nipples, axilla, genital, eyelind, outer ear |
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|
