Term
|
Definition
| Collection of data about an individual's health state. |
|
|
Term
|
Definition
| Subjective data, objective data, patient record and lab results. |
|
|
Term
|
Definition
| Assessment, Diagnosis, Outcome Identification, Planning, Implementation, Evaluation (ADPIE) |
|
|
Term
| COMPLETE DATA BASE (TOTAL HEALTH HISTORY) |
|
Definition
| Health state, cultural beliefs, values, family, social, health behaviors. |
|
|
Term
|
Definition
| Protected Health Information (name, photo, DOB, SSN, admission date, address, phone #, health info) |
|
|
Term
|
Definition
Provocative/palliative
Quality/quantity
Region/radiation
Severity
Timing
Understanding (perception)
Location |
|
|
Term
| ASSESSMENT TECHNIQUES (4) |
|
Definition
| Inspection, Palpation, Percussion, Auscultation |
|
|
Term
|
Definition
| Careful observation of body as a whole, then each body area |
|
|
Term
|
Definition
Light: 1-2cm - surface tenderness; superficial masses; temperature.
Deep: > 2cm - Condition of organs; masses; tenderness.
PALPATE TENDER AREAS LAST. |
|
|
Term
|
Definition
| Strike body to emit sounds or determine tenderness |
|
|
Term
| PERCUSSION TONES - TYMPANY |
|
Definition
| Abdomen (stomach) - Hollow |
|
|
Term
| PERCUSSION TONES - HYPERRESONANCE |
|
Definition
|
|
Term
| PERCUSSION TONES - RESONANCE |
|
Definition
|
|
Term
| PERCUSSION TONES - DULLNESS |
|
Definition
| solid filled muscle, fluid filled organ |
|
|
Term
| PERCUSSION TONES - FLATNESS |
|
Definition
|
|
Term
|
Definition
| Listening to sounds from body (cardiac & respiratory) |
|
|
Term
|
Definition
Diaphragm - high pitched sounds (breath)
Bell - low pitched sounds (heart murmurs) |
|
|
Term
| ABCDEs: ASSESSMENT FOR MELANOMAS |
|
Definition
Asymmetry
Border
Color
Diameter
Elevation/Expansion |
|
|
Term
|
Definition
|
|
Term
| ERYTHEMA (air-uh-theme-uh) |
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
| Yellow color (bilirubin --> Liver) |
|
|
Term
|
Definition
| Patchy areas of decreased pigmentation (Michael Jackson) |
|
|
Term
|
Definition
| Swelling - look for indentation (pitting edema) |
|
|
Term
|
Definition
| Resiliency, elasticity, recoil |
|
|
Term
|
Definition
| Ends of fingers abnormally large (bulb-like). Nails smooth and shiny |
|
|
Term
|
Definition
| Growth of nail bed damaged or stopped (HORIZONTAL LINES) |
|
|
Term
|
Definition
Hypothyroidism: dry, brittle
Hyperthyroidism: abn. soft, silky |
|
|
Term
|
Definition
| < 1 cm, flat. Example: freckles, flat moles |
|
|
Term
|
Definition
|
|
Term
|
Definition
| < 1cm, elevated. Example: wart, elevated mole |
|
|
Term
|
Definition
|
|
Term
| PRIMARY LESION - VESICLE (BLISTER) |
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
| Varying size, purulent fluid |
|
|
Term
| PRIMARY LESION - WHEAL/URTICARIA |
|
Definition
| Hive/ multiple hives (allergic reaction or mosquito bite) |
|
|
Term
|
Definition
| Results from changes over time or from an existing lesion |
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
| SECONDARY LESION - FISSURE |
|
Definition
|
|
Term
| SECONDARY LESION - EROSION |
|
Definition
| Shallow depression, no bleeding, heals without scar (does not extend into dermis) |
|
|
Term
|
Definition
| Deeper depression extending into dermis |
|
|
Term
| SECONDARY LESION - EXCORIATION |
|
Definition
| Abrasion; superficial; sometimes crusted; scratches from intense itching |
|
|
Term
|
Definition
| A permanent fibrotic change |
|
|
Term
| SECONDARY LESION - ATROPHIC SCAR |
|
Definition
| Skin level depressed with loss of tissue |
|
|
Term
| SECONDARY LESION - KELOID |
|
Definition
|
|
Term
| SECONDARY LESION - LICHENIFICATION |
|
Definition
| Intense scratching, eventually thickens the skin |
|
|
Term
Skin turgor is assessed to determine:
A. Aging Skin
B. Edema
C. Circulation
D. Dehydration |
|
Definition
|
|
Term
Skin temperature is assessed by using:
A. Ventral surface of hands
B. Dorsal surface of hands
C. Fingertips
D. Palmar surface of hands |
|
Definition
|
|
Term
A client's capillary refill is 5 seconds. What should the nurse do?
A. Call the MD
B. Perform a more in depth assessment of circulation
C. Attempt to warm the client's hands
D. Check for edema |
|
Definition
|
|
Term
What is the correct part of the hand used to assess for vibrations?
A. Fingertips
B. Dorsal surface
C. Ulnar/Palmar surface
D. Radial surface |
|
Definition
|
|
Term
|
Definition
| Decrease in size or wasting away of a body part or tissue |
|
|
Term
|
Definition
| Confined to a limited area |
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
| Abnormal sweating/perspiration |
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
| Abnormal change in structure of an organ due to injury or disease. Anything that interrupts pigmentation |
|
|
Term
|
Definition
|
|
Term
|
Definition
| Minute hemorrhagic spots, pinpoint to pinhead size. Not blanched by pressure (occur during labor or excessive vomiting) |
|
|
Term
|
Definition
| Abnormal sensitivity to light, especially of the eyes |
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
| Change for near/far vision. Lens curves differently |
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
| Optic nerve pinched, peripheral vision affected |
|
|
Term
|
Definition
|
|
Term
| ASSESSING DISTANCE VISION |
|
Definition
| Snellen chart - 20/20 = normal |
|
|
Term
|
Definition
| Nearsightedness; can't see far away |
|
|
Term
|
Definition
| Decrease in vision because of aging process |
|
|
Term
|
Definition
| Farsightedness; Can't see close up |
|
|
Term
|
Definition
| Irregularity of the cornea |
|
|
Term
|
Definition
| Rough estimate for peripheral vision |
|
|
Term
|
Definition
CN 3, 4, 6.
3 tests:
Cardinal positions of gaze
Cover-Uncover
Corneal Light Reflex |
|
|
Term
|
Definition
| Jerking movement of the eyes |
|
|
Term
|
Definition
| @ least 12 inches away. Want light to be in the same spot |
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
| Clear, over sclera, with few injections |
|
|
Term
|
Definition
| Inside lids; clear, pink underlying tissue with few injections |
|
|
Term
| CORNEAL REFLEX (CN 5 & 7) |
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
| Eyelid turns outward (aging) |
|
|
Term
|
Definition
| Eyelid turns inward (eyelashes scratch eye) |
|
|
Term
|
Definition
Pupils Equal
Round
React to Light
Accommodation |
|
|
Term
|
Definition
|
|
Term
|
Definition
| Contraction of pupil (light room, sunlight) |
|
|
Term
|
Definition
| Dilation of pupil. Dark room |
|
|
Term
|
Definition
| Want to see red-possessed glow |
|
|
Term
|
Definition
| Too much pressure on/in the eye |
|
|
Term
|
Definition
| Some medicine affects inner ear (hearing and balance). Not reversible |
|
|
Term
|
Definition
| Ringing sensation in one or both ears |
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
R - 5 o'clock
L - 7 o'clock |
|
|
Term
|
Definition
|
|
Term
|
Definition
| Hearing loss due to aging |
|
|
Term
|
Definition
| External or middle ear disorders that prevent transmission of sound |
|
|
Term
| SENSORINEURAL HEARING LOSS |
|
Definition
| Disorders of the inner ear; 8th CN or brain |
|
|
Term
To assess for early jaundice, the nurse should assess which of the following?
A. Sclera and hard palate
B. Nailbeds
C. Lips
D. All visible skin surfaces |
|
Definition
|
|
Term
A client has multiple red injections over the sclera. Which structure is most likely involved?
A. Palpebral conjunctiva
B. Bulbar conjunctiva
C. Sclera
D. Iris |
|
Definition
|
|
Term
Sensorineural hearing loss may be related to:
A. Gradual nerve degeneration
B. Foreign bodies
C. Impacted cerumen
D. Perforated tympanic membrane |
|
Definition
|
|
Term
Which of the following client's would you be most concerned about?
A. A client with floaters
B. A client with sudden epiphora
C. A client with a sudden onset of visual changes
D. A client with photophobia |
|
Definition
|
|
Term
|
Definition
| Excessive watering of the eyes |
|
|
Term
|
Definition
| Increased sensitivity to light |
|
|
Term
The nurse is testing a patient's visual accommodation, which refers to:
A. Pupillary constriction when looking at a near object
B. Pupillary dilation when looking at a far object
C. Changes in peripheral vision in response to light
D. Involuntary blinking in the presence of a bright light |
|
Definition
|
|
Term
|
Definition
| Meeting of the upper and lower eyelids (corner) |
|
|
Term
|
Definition
|
|
Term
|
Definition
| Border of cornea and sclera |
|
|
Term
|
Definition
| Additional blind spot (middle of vision) |
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
Lice - crawl around
Nits - attach to hair shaft
Fast, but do not jump.
Children don't need to be excluded from school |
|
|
Term
|
Definition
| Muscle strength & sensation |
|
|
Term
|
Definition
|
|
Term
|
Definition
- I- Olfactory
- II- Optic
- III- Oculomotor
- IV- Trochlear
- V- Trigeminal
- VI- Abducens
- VII- Facial
- VIII- Acoustic (Vestibulocochlear)
- IX- Glossopharyngeal
- X- Vagus
- XI- Spinal Accessory
- XII- Hypoglossal
|
|
|
Term
|
Definition
| Fold of nose to the fold of mouth (laugh lines) |
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
| Stick out tongue (hypoglossal) |
|
|
Term
|
Definition
0 - Not visible
+1 - Just visible
+2 - Visible & slightly larger
+3 - Large, visible, extending beyond arches
+4 - Same as above, plus the tonsils may be touching |
|
|
Term
|
Definition
|
|
Term
|
Definition
| Progressive destruction of any kind (teeth). Poor oral hygiene, baby bottle tooth decay |
|
|
Term
|
Definition
| Crackling/popping sounds and sensations experienced under the skin and joints |
|
|
Term
|
Definition
|
|
Term
|
Definition
| Bloody nose (Dryness, HTN, decreased vitamin K, trauma) |
|
|
Term
|
Definition
| Fluid that leaks out of blood vessels to nearby tissues |
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
| Disease of the lymph nodes |
|
|
Term
|
Definition
| Anterior and posterior openings on either side of the nasal cavity (nostril) |
|
|
Term
|
Definition
| Nipple-like structure - taste bud |
|
|
Term
|
Definition
| State of being open, expanded or unblocked |
|
|
Term
|
Definition
| Utterance of sounds through the use of vocal cords |
|
|
Term
|
Definition
| Containing, discharging or causing the production of pus |
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
| Inflammation of the sinuses. Occurs with infection from virus, bacteria or fungus |
|
|
Term
|
Definition
|
|
Term
| LYMPH NODES - PREAURICULAR |
|
Definition
|
|
Term
| LYMPH NODES - POSTERIOR AURICULAR (MASTOID) |
|
Definition
| Superficial to the mastoid process |
|
|
Term
|
Definition
|
|
Term
|
Definition
| Midline, behind the tip of the mandible |
|
|
Term
| LYMPH NODES - SUBMANDIBULAR |
|
Definition
| Halfway between the angle and the tip of the mandible |
|
|
Term
| LYMPH NODES - TONSILLAR (JUGULODIGASTRIC) |
|
Definition
| Under the angle of the mandible |
|
|
Term
| LYMPH NODES - SUPERFICIAL CERVICAL |
|
Definition
| Overlying the sternomastoid muscle |
|
|
Term
| LYMPH NODES - DEEP CERVICAL |
|
Definition
| Deep under the sternomastoid muscle |
|
|
Term
| LYMPH NODES - POSTERIOR CERVICAL |
|
Definition
| In the posterior triangle along the edge of the trapezius muscle |
|
|
Term
| LYMPH NODES - SUPRACLAVICULAR |
|
Definition
| Just above and behind the clavicle, at the sternomastoid muscle |
|
|
