Term
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Definition
| initial, problem focused, emergency, time-lapsed reassessment |
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Term
| Difference between subjective and objective data |
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Definition
subjective- symptoms
objective- what you observe |
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Term
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Definition
primary-client
secondary- family, med recs, nursing knowledge, my experience |
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Term
| 8 holistic considerations |
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Definition
| physiological, psychological/emotional, sociocultural, intellectual, spiritual, sexual, occupational, environmental |
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Term
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Definition
inspection- observe, listen, smell, hear
palpation-surface or deep
percussion-touching, tapping
ascultation- hearing |
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Term
| changes in skin color (4) |
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Definition
| cyanosis, jaundice, erythema, pallor |
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Term
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Definition
test for elasticity and hydration
tenting= dehydration or malnutrition |
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Term
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Definition
assymetry of lesion
border irregularity
color variation
diamter greater than 6 mm
evolving-changes |
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Term
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Definition
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Term
| Snellen chart is testing for what? |
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Definition
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Term
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Definition
| drooping of the upper eyelid over portion of pupil- could be related to muscle weakness or excessive skin |
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Term
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Definition
| pupils equal round reactive light accomodation |
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Term
| What is accomodation and what are its 3 parts? |
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Definition
reaction to distance
-constriction w/close objects
-dilation w/ distant objects
-symmetrically convergent |
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Term
| When should a breast exam be done? |
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Definition
| every month, 1 week after menstrual cycle starts |
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Term
| What are the 3 types of normal breath sounds? Where do you listen to them? What should they sound like? |
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Definition
-bronchial: trachia down to bronchii; harsh, loud
-broncho-vesicular: out in branches of bronchii; moderate
-vesicular: out in vesicular tissue; swishy like wind |
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Term
| What is the cause/name/valve/location of the 2 heart sounds? |
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Definition
lub-closure of AV valve, loudest at apex, occurs at beginning of contraction
dub-open of AV valve, loudest over base, occurs at resting phase |
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Term
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Definition
| left 5th intercostal space at midclavicular line (right under the nipple) |
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Term
| What are the 4 ausculatory areas of heart sounds and where are they? |
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Definition
-aortic: R 2nd intercostal space
-pulmonic: L 2nd intercostal space
-tricuspid: L 5th intercostal space at sternal border
-mitral/apical: L 5th intercostal space at midclavicular line |
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Term
| What is sinus arrhythmia? |
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Definition
| a variance but not disease related in child or young adult where the rhythm of the heartrate varies w/inspiration and expiration |
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Term
| peripheral pulses and characteristics assessed |
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Definition
radial- strength and regularity
brachial- strength and regularity
posterior tibial- presence and strength
dorsalis pedis- presence and strength |
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Term
| Order of assessment in abdomen |
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Definition
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Term
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Definition
| audible or palpable crunching or grating sound that accompanies movement caused by roughened joint surfaces |
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Term
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Definition
-should be negative
-pt. stands hands at sides w/eyes closed and should not have to reach out for something to maintain balance |
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