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50 Cards in this Set
- Front
- Back
Adventitious Breath Sounds
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Abnormal breath sound heard over the lungs.
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Auscultation
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Listening for sounds within the body.
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Bronchial Sounds
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those heard over the trachea; high in pitch and intensity, with expiration being longer than inspiration.
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Bronchovesicular Sounds
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normal breath sounds heard over the upper anterior chest and intercostal area.
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Bruits
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unusual sounds, usually abnormal, heard in auscultation.
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Comprehensive Assessment
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health history and complete physical examination, ussually conducted when a patient first enters a healthcare setting, provides a baseline for comparing later assessment.
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Cyanosis
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bluish coloring of the skin and mucous membranes
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Ecchymosis
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collection of blood in subcutaneous tissues that causes a purplish discoloration
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Edema
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accumulation of fluid in extracellular spaces
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Emergency Assessment
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rapid focused assessment conducted to determine potentially fatal situations.
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Erythema
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redness of the skin
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focused assessment
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assessment conducted to assess a specific problem; focuses on pertinent history and body regions.
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inspection
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purposeful and systematic observation
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jaundice
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yellow appearance of the skin
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ongoing partial assessment
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assessment that is conducted at regular intervals during care of the patient; concentrates on identified health problems to monitor positive or negative changes and evaluate the effectiveness of interventions
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pallor
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paleness of the skin
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palpation
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method of examining by feeling a part with the fingers or hand
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percussion
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act of striking one object against another for the purpose of producing a sound; used to assess the location, shape, size, and density of body tissues
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petechiae
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small, purplish hemorrhagic spots on the skin that do not blanch with applied pressure
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precordium
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anterior surface of the chest wall overlying the heart and its related structures
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turgor
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Tension of the skin determined by its hydration
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vesicular breath sounds
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normal sounds of espirations heard on auscultation over peripheral lung areas.
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Four types of Assessments
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Comprehensive, ongoing partial, focused and emergency.
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Six components of a Health History
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Biographical Data, Reason for Seeking Health Care, History of Present Health Concern, Medical History, Family History and Lifestyle
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Four Primary Assessment Techniques
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Inspection, Palpation, Percussion and Auscultation.
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What is the sequence of techniques for abdomen assessment?
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Inspection, Auscultation, Percussion and then Palpation.
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Four characteristics of sound are assessed by ausculation. They are
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Pitch, Loudness, Quality and Duration.
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The General Survey Consists of:
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Appearance and Behavior, Vital Signs, and Height and Weight.
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What are the Characteristics of Masses Determined by Palpation?
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Shape, Size, Consistency, Surface, Mobility, Tenderness and Pulsatile.
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What are the Tones of Percussion?
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Flat-Soft, Dull-Medium, Resonance-Loud, Hyperresonance-Very Loud, Tympany-Loud
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What are the possible changes in skin color?
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Erythemia, Cyanosis, Jaundice, and Pallor
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Where is Turgor usually assessed?
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On the sternum or under the clavicle.
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What is the pitting Edema scale?
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0-none, +1-trace, 2mm, +2-moderate, 4mm, +3-deep, 6mm, +4-very deep, 8mm,
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What is the normal angle between the nail and its base in the finger?
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160 degrees
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PERRLA
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Pupils, Equal, Round, Reactive, Light, and Accomodation
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Direct Auscultation
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unaided ear, such as respiratory wheezes or the creaking joint
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Indirect Auscultation
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aided, stethoscope which amplifies sounds inside the body, ie, bowel, heart and lung sounds.
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Barrel Chest
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An increased anteroposterior diameter as in COPD and emphysema.
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Crepitation
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Crackling, the quality of a fine bubbling sound, Bubble Wrap
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What are the four quadrants of the abdomen?
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right upper, right lower, left upper and left lower.
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Why is percussion and palpation done after auscultation of the abdomen?
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percussion and palpation stimulate bowel sounds.
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peristalsis
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The movement of the intestine. Waves of contraction and relaxation of the intestine by which the contents are propelled onward.
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What is the frequency of normal bowel sounds?
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These clicks and gurgles usually occur every 5 to 20 seconds.
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What part of the stethoscope is used to auscultate bowell sounds?
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Diaphragm
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What part of the stethoscope is used to auscultate the aorta, renal arteries, and iliac arteries for bruits?
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Bell
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What is the Glasgow Coma Scale?
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A standardized assessment tool that assesses the level of consciousness.
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What three levels of awareness are important to evaluate orientation?
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Time, Place, Person
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Expressive Aphasia
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The individual understands written and spoken words but cannot write or speak to communicate effectively.
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Receptive Aphasia
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The individual cannot understand written or spoken words.
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What are 4 purposes of documention?
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Identify actual and potential health problems, make nursing diagnoses, plan appropriate care, and evaluate the patient's responses to treatment.
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