Term
Patient History
Assessment |
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Definition
1- cheif complaint
2- history present illness
3- past medical history
4- social history
5- family history
6- reproductive history
7- review os systems(patient view) |
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Term
when doing physical assessment
you need to |
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Definition
observe,auscalate (listen),
palpation (feel),percusion (tap)
olfaction ( smell) |
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Term
| WHen observing you do what? |
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Definition
your are looking skin color, deformities
appearence, weekness, movement, rashes, scars, lesions |
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Term
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Definition
feeling for muscle spasms,pain,
swelling, growth,movement, temp,
reaction from them |
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Term
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Definition
| elasticity and presence of edema |
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Term
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Definition
| when skin pinched stays up usually in elderly |
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Term
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Definition
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Term
| when doing percussion what are you doing |
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Definition
| take your hand tap with finger by movement of wrist and listen for sound |
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Term
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Definition
appearence, height & weight, vital signs,
head & neck, EENT, heart, lungs, abdomen,
Genital, skin, neuro, muscularskeletal |
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Term
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Definition
P= pupal
E= equal
R= round
RLA= react to light |
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Term
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Definition
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Term
| basic needs assessment order of importance |
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Definition
rest and activity
nutrition needs
safety & security
hygiene & grooming
o2 circulation
Psycological needs- support system
elimination/voiding |
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Term
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Definition
activities of daily living
example bathing,walking,eatting |
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Term
| what id definition of cynosis? |
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Definition
| a bluish tingle to nail beds indicating lack of o2 |
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Term
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Definition
| blue, purplish path on the skin none as bruising |
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Term
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Definition
| yellowness of skin, sclera, resulting from hyperbilirubinemia and blue pigment |
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Term
| describe LETHARGY a level of caunsiousness |
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Definition
| abnormal drowsiness or Stupor |
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Term
| what do you ask a patient to deside there level of ORIENTATION |
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Definition
awareness of one’s environment with reference to place, time, and people
ok to all three do x3 if two of them x2 if one do x1 |
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Term
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Definition
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Term
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Definition
| pinpoint, round, purplish red spots that are not raised usually blood disorder |
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Term
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Definition
| a mark remaining after the healing of a wound |
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Term
| what does sign mean in medical field? |
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Definition
| objective evidence of disease or dysfunction you can see |
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Term
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Definition
| a noise in the ear such as ringing, buzzing, or roaring |
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Term
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Definition
| a sensation of rotation or whirling movement: dizziness not lighheadness |
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Term
| describe wheezing sound in the lungs? |
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Definition
| a high pitched Whistling sound indicates narrow airways often with asthma |
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Term
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Definition
| bodily injury caused by physical disruption of skin |
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Term
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Definition
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Term
| when ausculating the heart listening where and names of? |
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Definition
Aortic area-right side chest by sternum 3 rib down
Pulmonic area- left side by sternum 2nd rib down
Tricuspid area- between 4th and 5th rib by sternum
Mitral area- between 4th and 5th rib midline |
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Term
| AUSCULTATION OF LUNGS in the front |
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Definition
1)above colier bone below neck 2-4)between 3,4,5 rib by sternum 5)between
6th and 7th rib out side by patients side |
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Term
| ausculate of lungs in the back? |
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Definition
Move from bottom neck outside torward should then move down mid back then out
Like a tree torward love handles |
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Term
| describe Rhonchi sounds in the lungs |
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Definition
| Low-pitched rattling sound cause by secretions in larger air ways |
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Term
| describe Crackles sounds in the lungs |
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Definition
| similar to sound of hair being rubbed through fingers by ear |
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Term
| describe Pleural friction sounds in the lungs |
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Definition
| grating or scratchy sound like opening a squeaky door |
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Term
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Definition
| restrict time is less than 3 seconds checked by pushing nail bed |
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Term
| how do you assess pittling edema |
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Definition
Checking for edema by pressing index finger in good place to check is in ankles. Stay in
Trace minimal edema
+1 2mm edema
+2 4mm edema
+3 6mm edema
+4 8mm of edema |
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Term
| *Learn the 4 equal quadrants |
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Definition
Right upper- liver, transverse colon
Right Lower- ascending colon
Left Upper- stomach, small intestine
Left Lower – descending colon, sigmoid colon
LOOK,ASUCALTAE,PALPATE |
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Term
| what are Indicators of pain that need to be asked if pain present |
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Definition
1)Location
2)Intensity (how severe)
3)Duration ( continues come and go)
4)Onset (start)
5)Precipitating factors ( what brings on the pain and makes it worse)
6)Alleviating the factors (treatment) |
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Term
| what is the Supine position? |
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Definition
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Term
| what is the Prone position? |
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Definition
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Term
| what is Dorsal recumbent position? |
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Definition
| on back knee’s up feet on table |
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Term
| what is the Lithotomy postion? |
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Definition
| Pelvic exam position first make sure bladder empty |
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Term
| what is the Sims position? |
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Definition
| on side arm on bottom put to back top leg over further |
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Term
| describe the Knee chest position |
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Definition
| back in arm knees pulled toward chest like baby |
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Term
| DESCRIBE LEVEL CONSCIOUSNESS |
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Definition
Alert- follows commands in timely fashion
Lethargic-appears dowsey, drifts off to sleep
Stuporous- takes a lot of effort to respond
Comatose- does not respond to verbal commands or physical stimuli |
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Term
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Definition
Temporal (tempal of head), Carotid (side of neck), Apical (midline cervical 5th rib) Brachial (inside elbow), Radial (wrist), Femoral (groin), Popliteal (back knee),
Posterior Tibial (ankle), Dorsalis Pedis (top foot) |
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