Term
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Definition
| observation of client's general appearance, level of comfort, and mental status, and measurement of vital signs, height, and weight |
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Term
| Appearance and Mental Status |
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Definition
-signs of distress in posture or facial expression
-observe body build, in relation to age, lifestyle and health
-posture and gait, standing, sitting and walking
-obvious signs of illness or health
-attitude
-affect/mood
-quantity and quality of speech
-relevance and organization of thought |
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Term
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Definition
CMITT
Turgor
-inspection and palpatation and smell
-pallor- most evident in in areas with least pigmentation such as conjunctiva, oral mucous membranes, nail beds, palms of hand, and soles of feet
cyanosis
jaundice
erythemia
vitiligo-hypopigmented skin
edema
lesions
temperature |
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Term
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Definition
-evenness of growth over the scalp
-thickness or thinness
-texture and oiliness
-presence of infections or infestations
-amount of body hair |
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Term
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Definition
-inspect for nail plate shape, angle between the finger and nail bed, nail texture, nail bed color, intactness of tissue around the nails
-normal angle is 160 degrees
-cyanosis
-blanch test to test capillary refill (less than 2 seconds) |
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Term
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Definition
| angle between nail and nail bed is 180 degrees or greater, caused by long-term lack of oxygen |
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Term
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Definition
-examine the skull, face, eyes, ears, nose, sinuses, mouth and pharynx.
-inspect, palpate, and auscultate
-measurements more than two standard deviations from norm for age, sex and race are abnormal and should be reported to primary care giver.
-exophthalmos
-hypothyroidism or myedema-dry puffy face with dry skin and coarse features
moon face- increased adrenal hormone production
-inspect skull for size, shape, symmetry
-inspect eyes for edema or hallowness |
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Term
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Definition
| protrusion of the eyeballs with elevation of the upper eyelids, resulting in startled or staring expression |
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Term
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Definition
-assessment of external structures, visual acuity, ocular movement, and visual field
-inspect bulbar conjunctiva for color, texture, and presence of lesions
-inspect cornea for clarity, and texture
-inspect pupils for color, shape, and symmetry of size
-inspect pupil's direct and consensual reaction to light, to determine function of third (oculomotor) and fourth (trochlear) cranial nerves
- accomodation
-assess peripheral visual fields to determine function of the retina and neuronal visual pathways to the brain and second (optic) cranial nerve
-assess extraocular eye movements |
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Term
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Definition
| degree of detail the eye can discern in and image |
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Term
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Definition
| area an individual can see when looking straight ahead |
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Term
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Definition
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Term
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Definition
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Term
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Definition
loss of elasticity of the lens and thus loss of ability to see close objects
-begins about 45 years of age |
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Term
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Definition
| uneven curvature of the cornea that prevents horizontal and vertical rays from focusing on the retina, is a common problem that may occur in conjunction with myopia and hyperopia |
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Term
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Definition
| inflammation of the lacrimal sac |
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Term
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Definition
| redness, swelling, and tenderness of the hair follicle and glands that empty at the edge of the eyelid |
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Term
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Definition
opacity of the lens or its capsule, which blocks light rays
-usually over age 65 |
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Term
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Definition
| -normally black, equal in size (3-7 mm) |
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Term
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Definition
| enlarged pupils may indicate injury or glaucoma, or result from certain drugs (atropine, cocaine, amphetamines) |
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Term
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Definition
constricted pupils may indicate inflammation of the iris or result from drugs such as morphine/heroin and other narcotics, barbituates, or pilocarpine
-may also be age related |
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Term
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Definition
unequal pupils may result from a central nervous system disorder
-slight variations may be normal |
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Term
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Definition
| pupils equally round and react to light and accomadation |
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Term
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Definition
| direct inspection and palpation of the external ear, inspection of internal parts by otoscope, and determination of auditory acuity |
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Term
| Ossicles (bones of transmission) |
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Definition
malleus (hammer)
incus (anvil)
stapes (stirrups) |
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Term
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Definition
result of interrupted transmission of sojund waves through the outer and middle ear structures
-possible causes are tear in tympanic membrane or an obstruction, due to swelling or other causes in auditory canal |
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Term
| sensorineural hearing loss |
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Definition
| result of damage to the inner ear, the auditory nerve, or the hearing center in the brain |
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Term
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Definition
1) sound stimulus enters external canal and reaches the tympanic membrane
2) sound waves vibrate the tympanic membrane and reach the ossicles
3) sound waves travel from ossicles to the opening in the inner ear (oval window)
4) cochlea receives sound vibrations
5) stimulus travels to the auditory nerve (eighth cranial nerve) and the cerebral cortex |
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Term
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Definition
| tip client's head away from you, and straighten the ear canal. For adults, pull the pinna up and back. Insert tip of otoscope into ear canal. Inspect tympanic membrane for color and gloss |
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Term
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Definition
| pearly gray color, semitransparent |
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Term
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Definition
Weber's-to assess bone conduction by examining the lateralization (sideward transmission) of sounds.
-place vibrating fork on top of client's head and ask where the client hears the noise
Rinne test-compare air conduction to bone conduction
-hold activated tuning fork on the mastoid process of one ear until client states vibration can no longer be heard, then move fork in front of client's ear canal and ask if can now hear sound, |
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Term
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Definition
-inspect externally for any deviations in shape, size or color and flaring or discharge from nares
-palpate external for tenderness, masses, displacement of bone or cartilage
-patency of both nasal cavities
-inspect floor of nose, anterior portion of septum, middle meatus, and middle turbinates
-observe for redness, swelling, growths, and discharge
-palpate maxillary and frontal sinuses for tenderness |
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Term
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Definition
-inspect outer lips for symmetry, color, texture
-inspect and palpate inner lips and buccal mucosa for color , moisture, texture, and presence of lesions
-inspect teeth and gums,
-inspect tongue for position, color and texture, tongue movement
-inspect uvula for position and mobility
-inspect hard and soft palate for color, shape and texture, and presence of bony prominences
-inspect oropharynx
-inspect tonsils |
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Term
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Definition
| muscles, lymph nodes, trachea, thyroid gland, carotid arteries, and jugular viens |
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Term
| Head and Neck Lymph Nodes |
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Definition
Occipital
Preauricular
Postauricular
Submanidubular
Submental
anterior cervical chain
posterior cervical chain
supraclavicular |
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Term
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Definition
-chest shape and size (normal oval-anterioposterior diameter is half its transverse diameter)
abnormal-pigeon chest, funnel chest, barrel chest
-breath sounds |
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Term
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Definition
| junction between the body of the sternum and the manubrium |
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Term
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Definition
color
moisture
intact
temperature
texture |
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Term
| Cardiovascular and peripheral vascular system |
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Definition
inspection, palpation, and auscultation
- APe To Man (Aortic, Pulmonic, Tricuspid, Mitral)
-S1 and S2 sounds
-palpate and auscultate carotid for bruit ( a blowing or swishing sound)
-inspect jugular veins for distention
-palpate peripheral pulses
-signs of phlebitis
-peripheral perfusion |
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Term
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Definition
| blowing or swishing sound created by turbulence of blood flow due either to a narrowed arterial lumen or a condition, such as anemeia or hyperthyroidism that elevates cardiac output |
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Term
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Definition
right upper
left upper
right lower
right lower |
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Term
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Definition
right hypochondriac
epigastric
right lumbar
umbilical
left lumbar
right inguinal
hypogastic
left inguinal
left hypochondriac
umbilical |
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Term
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Definition
-used to assess level of consciousness
-tests 3 major areas: eye response, motor response and verbal response
-assessment of 15 indicates the client is alert and completely oriented
-comatose client scores 7 or less |
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Term
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Definition
client stand with feet together and arms resting at the sides, first with eyes open, then closed.
-Negative Romberg: may sway slightly but is able to maintain upright posture and foot stance
-Positive Romberg: cannot maintain foot stance; moves feet apart to maintain stance
-if client cannot maintain balance with eyes shut may have sensory ataxia
-if no balance with eyes open or shut may have cerebellar ataxia |
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Term
| Plantar (Babinski) Reflex |
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Definition
| using moderately sharp object stroke the lateral border of the sole of the client's foot, starting at the heel, continuing to the ball of the foot, and then proceeding across the ball of the foot toward the big toe.observe response. Normally all five toes bend downward, this is negative Babinski. In an abnormal (positive) Babinski response toes, spread outward and big toe moves upward |
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Term
| Position of Kinesthetic Sensation |
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Definition
| middle fingers and large toes tested for the sense of position |
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