Term
| assessment of skin reveals |
|
Definition
| pts health status related to: circulation, nutrition, local tissue damage, and hydration |
|
|
Term
| high risk skin impairment pts: outside factors |
|
Definition
| immobility, moisture, medications, incontinence |
|
|
Term
| high risk skin impairment pts: inside factors |
|
Definition
| diminished mental status, poor tissue oxygenation, low cardiac output, inadequate nutrition |
|
|
Term
| lung exam begins w/ pt sitting |
|
Definition
| posterior and lateral assessment |
|
|
Term
| lung exam begins w/ pt lying down for |
|
Definition
| anterior assessment of chest |
|
|
Term
|
Definition
| symmetrical, anteroposterior diameter 1/2 to 1/3 of the transverse diameter |
|
|
Term
| palpate posterior thorax for |
|
Definition
| lumps. masses. pulsations, or unusual movement |
|
|
Term
| use what part of stethoscope to assess breath sounds |
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
| anterior thorax, apical impulse |
|
|
Term
|
Definition
| 4th to 5th intercostal space just medial to the left clavicular line, aka PMI |
|
|
Term
|
Definition
| lub sound; ventricular contraction |
|
|
Term
|
Definition
| dub sound; ventricular relaxation |
|
|
Term
5 areas for listening to the heart:
All People Enjoy Time Magazine |
|
Definition
| aortic, pulmonic, erb's point, tricuspid, mitral |
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
| s1, s2- lt 3rd intercostal space |
|
|
Term
|
Definition
| lower lt sternal border, 4th intercostal space |
|
|
Term
|
Definition
| medial midclavicular line, 5th intercostal space |
|
|
Term
|
Definition
| too much fluid/ heart working hard |
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
| swishing sound- plaque has narrowed artery |
|
|
Term
|
Definition
| poor nutrition due to vascular insufficiency |
|
|
Term
|
Definition
|
|
Term
|
Definition
| rt side heart failure/ liver enlarged |
|
|
Term
|
Definition
| poor renal fx, cardiac problem |
|
|
Term
|
Definition
|
|
Term
| aloepecia in lower extremities |
|
Definition
|
|
Term
|
Definition
0-absent, not palpable
1-barely palpable
2-normal
3-increased pulse
4-bounding pulse |
|
|
Term
|
Definition
pain, pallor, paralysis, parathesis,
perfusin,
pulselessness,
polar |
|
|
Term
|
Definition
| temporal, carotid, apical, brachial, radial, ulnar, femoral, popliteal, dorsalis pedis, posterior tibial |
|
|
Term
| pain assessment- 10 questions to ask |
|
Definition
| location, radiation, quality, quantity,associated manifestations, aggravating factors,alleviating factors, setting, timing,meaning and impact |
|
|
Term
| assess cardiac sounds w/ what part of stethoscope |
|
Definition
|
|
Term
| 3 positions to assess heart sounds |
|
Definition
| sitting up, supine, left lateral recumbant |
|
|
Term
| listen at apical for how long? |
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
| assess jugular vein distention |
|
Definition
|
|
Term
|
Definition
| common in older adults, people who standing on feet for prolonged periods of time |
|
|
Term
|
Definition
| around the feet and ankles- venous insufficiency or rt sided heart failure |
|
|
Term
|
Definition
| inflammation of vein after infection, immobilization, and prolonged insertion of IV |
|
|
Term
| sign of venous and arterial insufficiency |
|
Definition
| decreased hair growth, thin shiny skin, thickened nails |
|
|
Term
|
Definition
| glaskow coma scale- assess LOC |
|
|
Term
|
Definition
| who are you? where are you? what did you have to eat for breakfast? |
|
|
Term
|
Definition
grade: 0-5
% normal: 0-100%
Lovett: O-zero, T-trace, P-poor, F-fair, G-good, N-normal |
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
