Term
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Definition
| COLOR, SENSATION, range of MOTION and equality of strength, TEMPERATURE |
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Term
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Definition
| Intermittent claudication, leg cramps, varicose veins, past clots in the veins |
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Term
| Posterior & Lateral Thorax |
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Definition
Assess skin - note color, check for lesions
Assess spine and other bony structures for shape, curvature, and symmetry
Inspect and palpate for symmetry and depth of respiration
Percussion of the posterior chest to determine position of diaphragm
Auscultate posterior and lateral lung fields in a systematic manner
Instruct client to breath through mouth, slightly deeper but not faster than normal- Warm stethoscope & provide support for client; Note type and location of breath sounds |
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Term
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Definition
| dorsum of the foot just lateral to the extensor tendon of the great toe, if not palpated proceed laterally |
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Term
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Definition
| 32 or 28 if wisdoms removed |
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Term
| 4 domains of Taxonomy of N. P. |
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Definition
Functional
Physiological
Psychosocial
Enviromental |
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Term
| ASSESSMENT/MUSCULE-SKELETAL |
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Definition
Determine range of motion note pain, limitation, crepitation, altered sensation.
Test muscle strength note general strength and symmetry.
• flexion upper and lower extremities
• extension upper and lower extremities
• grip for hands
Assess spine and other bony structures for
shape,
curvature,
and symmetry |
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Term
|
Definition
Inspect skin for color, moisture, lesions
Inspect umbilicus for cleanliness, inflammation, and herniation
Note general appearance - contour, symmetry, and obvious movements (peristalsis, pulsations)
Listen for bowel sounds with diaphragm of stethoscope
Palpate abdomen for consistency, tenderness, masses
Palpate bilateral femoral pulses for presence, strength, & symmetry |
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Term
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Definition
| ribs to hips, centered on imbilicus, 4 quadrants |
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Term
| Abdominal pulsation on which side? |
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Definition
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Term
|
Definition
Assess skin - note color, check for lesions
Observe respiratory pattern:
• rate, depth, symmetry and rhythm of respirations
Auscultate anterior lung fields systematically
• Stand to the side so client does not breathe in your face
• Provide support for client
Auscultate heart locate Apical/Point of Maximal Impulse at left 5th interspace just medial of mid-clavicular line
Count heart rate/rhythm (for a full minute if rhythm irregular) |
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Term
| Apical/Point of Maximal Impulse is at: |
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Definition
| the place where the apical pulse is palpated as strongest, often in the fifth intercostal space of the thorax, just medial to the left midclavicular line. |
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Term
| Assess spine and other bony structures for |
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Definition
| shape, curvature, and symmetry |
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Term
| Assess spine and other bony structures for ; |
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Definition
shape,
curvature,
and symmetry |
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Term
|
Definition
Inspect general symmetry and movement of head & neck
Inspection of Eyes
Check pupils for size, equality, shape
Reaction to light Direct
Consensual
Inspection of Ears
Inspection of Mouth
Explain the examination to client as appropriate for all aspects
Determine range of motion note pain, limitation, crepitation, altered sensation.
Test muscle strength note general strength and symmetry.
• flexion upper and lower extremities
• extension upper and lower extremities
• grip for hands |
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Term
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Definition
| the technical term for listening to the external sounds of the body, usually using a stethoscope; based on the Latin verb auscultare "to listen". |
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Term
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Definition
| Lumps, pain or discomfort, nipple discharge, self-examination |
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Term
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Definition
| is the term for the unusual sound that blood makes when it rushes past an obstruction (called turbulent flow) in an artery |
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Term
|
Definition
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Term
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Definition
| a clouding that develops in the crystalline lens of the eye or in its envelope, varying in degree from slight to complete opacity and obstructing the passage of light. |
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Term
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Definition
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Term
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Definition
| a medical term usually referring to impairment in walking |
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Term
| Components of Nursing Health History |
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Definition
biographical data
complaint
history of
clients perception of health status
past medical history
family history
meds
complementary/alternative modalities CAM
Review of body system & functional abilities |
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Term
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Definition
| refers to situations where noises are produced by the rubbing of parts one against the other, |
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Term
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Definition
| From about 1940 to 1970, DES was given to pregnant women under the mistaken belief it would reduce the risk of pregnancy complications and losses. In 1971, DES was shown to cause a rare vaginal tumor in girls and women who had been exposed to this drug in utero. |
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Term
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Definition
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Term
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Definition
| closed questions; y/n; who, what, when, where |
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Term
| Disability— Assess level of consciousness using the AVPU scale: |
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Definition
A—Is the patient alert?
V—Does the patient respond to voice?
P—Does the patient respond to painful stimulus?
U—The patient is unresponsive to painful stimulus. |
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Term
|
Definition
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Term
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Definition
| pain during menstruation that interferes with daily activities |
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Term
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Definition
| shortness of breath (SOB) |
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Term
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Definition
| after ABC, assess level of consciousness using the AVPU scale |
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Term
|
Definition
A—Is the patient alert?
V—Does the patient respond to voice?
P—Does the patient respond to painful stimulus?
U—The patient is unresponsive to painful stimulus. |
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Term
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Definition
| The initial rapid assessment of the patient is meant to identify life-threatening problems (airway, profuse bleeding, breathing, and circulation). |
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Term
| EMS/SECONDARY ASSESSMENT/E F G HH I |
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Definition
E Expose— remove clothing as necessary to examine
F Fahrenheit - Remember to keep victim warm
G Get - a set of vital signs Pulse, Respirations
H History- of injury and suspected injury followed by past medical history.
H Head to Toe Assessment systematic examination of victim
I Inspect posterior surfaces of victim with assistance
observe cervical spine precautions in trauma patients Soft tissue injury
Spinal tenderness Pain or tenderness |
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Term
|
Definition
E Expose— remove clothing as necessary to examine
F Fahrenheit - Remember to keep victim warm
G Get - a set of vital signs Pulse, Respirations
H History- of injury and suspected injury followed by past medical history. |
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Term
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Definition
| Hearing, tinnitus, vertigo, earaches, infection, discharge. If hearing is decreased, use of hearing aids |
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Term
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Definition
| a long-term, progressive disease of the lungs that primarily causes shortness of breath. In people with emphysema, the tissues necessary to support the physical shape and function of the lungs are destroyed. |
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Term
|
Definition
Palpate pulses for presence, strength, symmetry
• radial, and brachial pulses
• popliteal, (posterior knee with slight flexion, may have client rollover)
• dorsalis pedis, (dorsum of the foot just lateral
to the extensor tendon of the great toe, if not palpated proceed laterally)
• posterior tibial (behind and slightly below the medial ankle)
Determine range of motion note pain, limitation, crepitation.
Test muscle strength note general strength and symmetry.
• flexion upper and lower extremities
• extension upper and lower extremities
• grip for hands |
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Term
|
Definition
| Vision, glasses or contact lenses, last eye examination, pain, redness, excessive tearing, double vision, blurred vision, spots, specks, flashing lights, glaucoma, cataracts |
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Term
|
Definition
Face pt
Open, relaxed posture
Lean towards pt
Keep eye contact |
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Term
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Definition
| Usual weight, recent weight change, any clothes that fit tighter or looser than before. Weakness, fatigue, fever |
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Term
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Definition
| a swelling in the thyroid gland,[1] which can lead to a swelling of the neck or larynx (voice box). Goitre rarely occurs when the thyroid gland is functioning properly. |
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Term
| Gordon's Functional Health Patterns |
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Definition
| Describes common patterns of behavior and describes them as functional/dysfunctional |
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Term
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Definition
| Head Ears Eyes Nose Throat |
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Term
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Definition
Inspect general symmetry and movement
Palpate Temporal pulse Inspect jugular veins - note location when supine, distention while sitting, angle at which distention disappears
Palpate trachea - note position and ability to swallow
Palpate carotid pulses individually - note presence, strength, symmetry |
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Term
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Definition
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Term
| Health History/Include the following characteristics: |
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Definition
| Apparent state of health; signs of distress; stature (observed weight in relation to height and body build); posture; motor activity and gait; dress, grooming, and personal hygiene; odors; facial expression, manner, mood, and relationship to surroundings and people; speech; and state of awareness. |
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Term
|
Definition
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Term
|
Definition
note location when supine,
distention while sitting, angle at which distention disappears |
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Term
| Inspect posterior surfaces of victim with assistance |
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Definition
observe cervical spine precautions in trauma patients
Soft tissue injury
Spinal tenderness
Pain or tenderness |
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Term
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Definition
| cleanliness, inflammation, and herniation |
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Term
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Definition
| can best be described as "purposeful looking." |
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Term
| Internal and external shoulder rotation |
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Definition
| rotation toward and away from center of body |
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Term
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Definition
| is a restriction in blood supply, generally due to factors in the blood vessels, with resultant damage or dysfunction of tissue. |
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Term
|
Definition
|
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Term
|
Definition
| a yellowish pigmentation of the skin, the conjunctival membranes over the sclerae (whites of the eyes), and other mucous membranes caused by hyperbilirubinemia (increased levels of bilirubin in the blood). |
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Term
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Definition
| any learning technique that aids memory. |
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Term
| Mnemonic for Observing DHEPD |
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Definition
DO HELP EVERY PATIENT DELIBERATELY
DISTRESS
HAZARDS
EQUIPMENT
PEOPLE
DETAILS |
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Term
|
Definition
| Condition of teeth and gums, bleeding gums, dentures, if any, and how they fit, last dental examination, sore tongue, dry mouth, frequent sore throats, hoarseness |
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Term
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Definition
| Lumps, “swollen glands,” goiter, pain or stiffness in the neck |
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Term
| Neurologic/ROS/Extremities |
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Definition
| Fainting, blackouts, seizures, weakness, paralysis, numbness or loss of sensation, tingling or “pins and needles,” tremors or other involuntary movements |
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Term
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Definition
| the need to get up in the night to urinate, thus interrupting sleep. Its occurrence is more frequent in pregnant women and in the elderly. |
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Term
| Non-directive interviewing |
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Definition
| allow patient to control subject matter and tell the story. |
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Term
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Definition
| Frequent colds; nasal stuffiness, discharge, or itching; hay fever, nosebleeds, sinus trouble |
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Term
| Note general appearance of abdomen for- |
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Definition
| contour, symmetry, and obvious movements (peristalsis, pulsations) |
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Term
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Definition
| conceptualizes health as the ability to perform self care. |
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Term
|
Definition
| gathered through physical assessment or lab or tests |
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Term
|
Definition
Posterior Roof of Mouth. reaches from the Uvula to the level of the hyoid bone.
It opens anteriorly, through the isthmus faucium, into the mouth, while in its lateral wall, between the two palatine arches, is the palatine tonsil. |
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Term
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Definition
| is shortness of breath (dyspnea) which occurs when lying flat,[1] causing the person to have to sleep propped up in bed or sitting in a chair. It is the opposite of platypnea. |
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Term
| Other types of assessment |
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Definition
cultural
spiritual
psychosocial
wellness
family
community |
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Term
|
Definition
| Pupils Equal, Round, Reactive to Light, and Acommodation |
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Term
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Definition
| point of maximum impulse; is the furthermost point outwards (laterally) and downwards (inferiorly) from the sternum at which the cardiac impulse can be felt. |
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Term
| PQRST Method for Pain Assessment |
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Definition
PROVOKES: what?
QUALITY: describe it
RADIATES: from where to where?
SEVERITY: 1-10
TIME: starting and duration |
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Term
|
Definition
| Precipitates or Palliative, Quality, Region or Radiating, Severity, Time, Happened to U Before |
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Term
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Definition
| lighting, fluids on floor, people in room, patient awareness and mental state |
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Term
|
Definition
| consistency, tenderness, masses |
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Term
| Palpate pulses (extremities) for: |
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Definition
| presence, strength, symmetry |
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Term
| Paroxysmal nocturnal dyspnea |
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Definition
| shortness of breath at night |
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Term
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Definition
| involves light tapping of a body area usually for the purpose of determining the density of an underlying structure. |
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Term
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Definition
| Peristalsis is a radially symmetrical contraction and relaxation of muscles which propagates in a wave down the muscular tube, in an anterograde fashion. In humans, peristalsis is found in the contraction of smooth muscles to propel contents through the digestive tract. |
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Term
|
Definition
| an inflammation of the pleura,[1] the lining of the pleural cavity surrounding the lungs. Among other things, infections are the most common cause of pleurisy. |
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Term
|
Definition
| behind and slightly below the medial ankle |
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Term
|
Definition
| subj and obj data from client |
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Term
|
Definition
| taken posterior knee joint |
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Term
|
Definition
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Term
|
Definition
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Term
|
Definition
nspect umbilicus for cleanliness, inflammation, and herniation
Note general appearance - contour, symmetry, and obvious movements (peristalsis, pulsations)
Listen for bowel sounds with diaphragm of stethoscope
Palpate abdomen for consistency, tenderness, masses |
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Term
|
Definition
| Heart trouble, high blood pressure, rheumatic fever, heart murmurs; chest pain or discomfort, palpitations; dyspnea, orthopnea, paroxysmal nocturnal dyspnea, edema; past electrocardiogram or other heart test results |
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Term
|
Definition
| Thyroid trouble, heat or cold intolerance, excessive sweating; diabetes, excessive thirst or hunger, polyuria |
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Term
|
Definition
| Age at menarche; regularity, frequency, and duration of periods; amount of bleeding, bleeding between periods or after intercourse, last menstrual period; dysmenorrhea, premenstrual tension; age at menopause, menopausal symptoms, postmenopausal bleeding. If the patient was born before 1971, exposure to DES (diethylstilbestrol) from maternal use during pregnancy. Discharge, itching, sores, lumps, sexually transmitted diseases and their treatments. Number of pregnancies, number of deliveries, number of abortions (spontaneous and induced); complications of pregnancy; birth control methods. Sexual preference, interest, function, satisfaction; any problems, |
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Term
|
Definition
| Trouble swallowing, heartburn, appetite, nausea, vomiting, regurgitation, vomiting of blood, indigestion. Frequency of bowel movements, color and size of stools, change in bowel habits, rectal bleeding or black tarry stools, hemorrhoids, constipation, diarrhea. Abdominal pain, food intolerance, excessive belching or passing of gas. Jaundice, liver or gallbladder trouble, hepatitis |
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Term
|
Definition
| Frequency of urination, polyuria, nocturia, burning or pain on urination, hematuria, urgency, reduced caliber or force of the urinary stream, hesitancy, dribbling, incontinence; urinary infections, stones |
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Term
|
Definition
| Anemia, easy bruising or bleeding, past transfusions and any reactions to them |
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Term
|
Definition
| Hernias, discharge from or sores on the penis, testicular pain or masses, history of sexually transmitted diseases and their treatments. Sexual preference, interest, function, satisfaction, and problems |
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Term
|
Definition
| Muscle or joint pains, stiffness, arthritis, gout, backache. If present, describe location and symptoms (e.g., swelling, redness, pain, tenderness, stiffness, weakness, limitation of motion or activity). |
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Term
|
Definition
| Intermittent claudication, leg cramps, varicose veins, past clots in the veins |
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Term
|
Definition
| Nervousness, tension, mood including depression; memory |
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Term
|
Definition
| Cough, sputum (color, quantity), hemoptysis, wheezing, asthma, bronchitis, emphysema, pneumonia, tuberculosis, pleurisy; last chest x-ray film |
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Term
|
Definition
| Conceptualizes pts as adapting constantly to internal and external demands within a biological and psychosocial context. |
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Term
| S.A.M.P.L.E. Format for EMS Interview |
|
Definition
S Signs/Symptoms
A Allergies
M Medications
P Pertinent Past History
L Last oral intake: Solid or liquid
E Events leading to the injury or illness |
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Term
|
Definition
| obtained second hand; med record, colleague. |
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Term
|
Definition
A- Asymmetry:
Normal moles or freckles are completely symmetrical. If you were to draw a line through a normal spot, you would have two symmetrical halves. In cases of skin cancer, spots will not look the same on both sides.
B- Border:
A mole or spot with blurry and/or jagged edges.
C- Color:
A mole that is more than one hue is suspicious and needs to be evaluated by a doctor. Normal spots are usually one color. This can include lightening or darkening of the mole.
D- Diameter:
If it is larger than a pencil eraser (about 1/4 inch or 6mm), it needs to be examined by a doctor. This is includes areas that do not have any other abnormalities (color, border, asymmetry).
E- Elevation:
Elevation means the mole is raised above the surface and has an uneven surface. |
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Term
|
Definition
| Rashes, lumps, sores, itching, dryness, color change, changes in hair or nails, evaluated with each area. |
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Term
|
Definition
| info from client, family, community |
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Term
|
Definition
| the medical term for fainting |
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Term
|
Definition
| the practice and science of classification or the result of it. |
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Term
| Taxonomy of Nursing Practice (NANDA/NOC/NIC) |
|
Definition
| Intended as a model for categorizing nursing diagnoses, client outcomes, and nursing interventions. Has 4 domains & 28 classes. |
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Term
| The NANDA Nursing Diagnosis Taxonomy 2 |
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Definition
| Consists of functional patterns and is a modified version of the Gordon model. |
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Term
| The mnemonic D-O-T-S is helpful in remembering the signs of injury. |
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Definition
| Deformities, Open injuries, Tenderness & Swelling |
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Term
| Turbulent arterial blood flow |
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Definition
| partially obstructed, under unusual pressure (ausculation) |
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Term
|
Definition
initial
ongoing
comprehensive
focused
special needs
nutritional
pain
functional ability |
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Term
|
Definition
| Frequency of urination, polyuria, nocturia, burning or pain on urination, hematuria, urgency, reduced caliber or force of the urinary stream, hesitancy, dribbling, incontinence; urinary infections, stones |
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Term
|
Definition
subjective and objective data disagree.
pt contradicts themselves.
data extremely abnormal
factors interfere with accurate measurement. |
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Term
|
Definition
| Assessment of gait is considered part of the assessment of whole body coordination. |
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