Term
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Definition
Total assessment, usually completed when a patient first presents to the healthcare setting.
*Most information provides a baseline for future comparison |
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Term
| Ongoing partial assessment |
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Definition
Conducted at regular intervals during care
Ex: shifts of nursing |
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Term
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Definition
Assesses a specific problem
Ex: A prenatal visit - focus is on gyn health/breast/OB |
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Term
| Common cardiovascular and peripheral vascular variations in older adults |
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Definition
- Apical pulse can be difficult to palpate
- Distal arteries can be difficult to palpate
- Dilated proximal arteries
- Varicosities common
- Increased systolic BP/ increased diastolic BP
- Widened pulse pressure
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Term
| Normal breast changes - infants/children |
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Definition
- 2 weeks - breast enlargement
- 10-11 years - female breast growth
- Pubescent boys - temporary enlargement of breasts (gynecomastia)
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Term
| Order of assessment techniques for abdomen |
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Definition
- Inspection
- Auscultation
- Percussion
- Palpation
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Term
| Unusual abdominal findings (inspection) |
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Definition
- Swelling/distention
- Abdominal masses
- Unusual pulsation
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Term
| Common abdominal variatins in infants/children |
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Definition
- 1st few weeks - umbilical cord dries/falls off
- < 5 years - "pot belly"
- Easily palpated liver/spleen
- Visible peristaltic waves
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Term
| Common abdominal variations in older adults |
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Definition
- Decreased bowel sounds
- Decreased abdominal tone
- Liver border palpated more easily
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Term
| Abdominal genitalia findings (male) |
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Definition
- Lesions
- Redness/swelling
- Pain
- Dysuria
- Discharge
- Displacement of meatus
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Term
| Normal genitalia variations of infants/children |
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Definition
- Development of pubic hair @ puberty
- Puberty - spontaneous nocturnal emission
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Term
| Common genitalia variations in older adults |
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Definition
- Decreased penis size
- Decreased pubic hair
- Decreased size/firmness of testes
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Term
| Abnormal anal assessment findings |
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Definition
- Relaxed tone
- Cracks
- Nodules
- Hemorrhoids
- Bleeding
- Hard/abnormal stools
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Term
| Normal rectal/anal variations in older adults |
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Definition
- Men:
- Anus darker in color
- Hemorrhoids often present
- Prostate may be enlarged
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Term
| Common musculoskeletal variations in older children |
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Definition
- C-shaped spinal curve
- Lordosis
- 12-30 months - pronation of feet
- 1 year after learning to walk - bowleg
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Term
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Definition
- Fully awake
- Oriented to person, place, time
- Responds to all stimuli (verbal commands)
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Term
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Definition
- Appears drowsy/asleep
- Can be aroused by gentle shaking/repeating name
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Term
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Definition
- Unconscious most of the time
- No spontaneous movement
- Shout/shake to arouse
- Can make verbal responses but less likely to be appropriate
- Responds to pain
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Term
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Definition
- Cannot be aroused, even with pain
- May have some reflex activity
- If no reflexes present
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Term
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Definition
- Balance
- Gait
- Coordination
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Term
| Sensory function assessment |
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Definition
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Term
| Common neurologic variations - infants/children |
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Definition
- Positive Babinski reflex (12-24 months)
- Birth - grasp reflex
- Motor control - head, neck, trunk, extremities
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Term
| Common neurologic variations in older adults |
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Definition
- Slower thought processes/verbal responses
- Decreased sensory ability
- Slower coordination/voluntary movements
- Decreased reflex responds
- Confusion in unfamiliar surroundings
- Slow gait
- Diminished deep tendon reflexes
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