Ch. 11 Patient Assessment Flashcards

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1
Q

Adventitious breath sounds

A

Abnormal breath sounds, such as wheezing, rhonchi, crackles, strider, and pleural friction rubs.

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2
Q

Alert and oriented (A X O)

A

A determination made when assessing mental status by looking at whether the patient is oriented in four areas: person, place, time, and event.

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3
Q

Anisocoria

A

Unequal pupils with a greater than 1-mm difference

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4
Q

Aphasia

A

The language impairment that affects the production or understanding of speech and the ability to read or write.

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5
Q

Apparent life-threatening event (ALTE)

A

An episode characterized by some combination of apnea (central or obstructive), color change (cyanosis, pallid, erythematous, or plethoric) change in muscle tone, and choking or gagging.

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6
Q

Ascites

A

Abnormal accumulation of fluid in the peritoneal cavity; typicallly signals liver failure.

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7
Q

Aspiration

A

The entry of fluids or solids into the trachea, bronchi, and lungs; the act of drawing material in or out by suction.

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8
Q

Auscultation

A

The act of using a stethoscope to listen to sounds within the body

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9
Q

AVPU

A

Method of assessing mental status by determining whether a patient is Awake and alert, responsive to Verbal stimuli or Pain, or Unresponsive.

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10
Q

Battle signs

A

Bruising over the mastoid process, which may indicate a basilar skull fracture; also known as a retroauricular ecchymosis or raccoon eyes.

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11
Q

Beck triad

A

The combination of a narrowed pulse pressure, muffled heart tones, and jugular venous distention associated with cardiac tamponade; usually caused by penetrating chest trauma.

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12
Q

Blood pressure (BP)

A

Measurement of the force exerted against the walls of the blood vessels as the product of cardiac output and peripheral vascular resistance.

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13
Q

Bronchial sounds

A

Hollow, tubular, lower-pitched sounds heard over the trachea.

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14
Q

Bronchophony

A

Test of decreased breath sounds performed by placing the diaphragm of the stethoscope over the area in question while the patient says “ninety-nine” a loud, clear sounds indicates lug consolidation

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15
Q

Bronchovesicular sounds

A

A combination of the tracheal and vesicular breath sounds; heard where airways and alveoli are found, in the upper part of the sternum and between scapulae.

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16
Q

Bruit

A

An abnormal whooshing sound of turbulent blood flow moving through a narrowed artery; usually heard in the carotid arteries.

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17
Q

Capnography

A

The use of noninvasive diagnostic tool that can quickly and efficiently provide information on a patient’s ventilatory and circulatory status with a graphic and digital depiction similar to an electrocardiograph.

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18
Q

Capnometry

A

The use of a capnometer, which is a monitoring device used to measure the amount of expired carbon dioxide. The reading is usually given as a digital reading.

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19
Q

Cerumen

A

Ear wax

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20
Q

Chief complaint

A

The reason the patient is seeking help.

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21
Q

Crackles

A

Wet rattling, bubbling, or crackling lung sounds indicative of fluid in the small airways; also known as rails

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22
Q

Crepitus

A

A crackling, grating, or grinding sound often heard when fragments of broken bones rub together.

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23
Q

Current health status

A

A composite picture of a number of factors in a patient’s life, such as dietary habits, current medications, allergies, exercise, alcohol or tobacco use, recreational drug use, sleep patterns and disorders, and immunizations.

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24
Q

Crushing reflex (triad)

A

The combination of a slowing pulse, rising blood pressure, and an erratic respiratory pattern; a grave sign for patients with head trauma or cerebrovascular accident.

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25
Q

Cyanosis

A

A blue-gray skin color that is caused by invadequate levels of oxygen in the blood.

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26
Q

Delirium

A

An acute confusion also state characterized by global impairment of thinking, perception, judgment, and memory.

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27
Q

Dementia

A

the gradual and pervasive deterioration or losss of cognitive cortical functions

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28
Q

Diaphoresis

A

Excessive sweating; it is often associated with shock.

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29
Q

Diastolic pressure

A

The result of residual pressure In the circulatory system while the left ventricle is relaxing

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30
Q

Differential diagnosis

A

Process of comparing one disease versus other diseases by comparing clinical findings that could account for a patient’s illness; also refers to the list of possible conditions considered based on the patient’s signs and symptoms.

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31
Q

Diplopia

A

Doubled vision

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32
Q

Ecchymosis

A

Localized bruising or collection of blood within or under the skin

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33
Q

Egophony

A

A test of decreased breath sounds performed by placing the diaphragm of the stethoscope over the area in question while the patient says a drawn out “eye;” an “A” sound indicates lung consolidation.

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34
Q

Field impression

A

Field conclusion on the patients problem based on the clinical presentation and the exclusion of other possible causes through considering the differential diagnoses.

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35
Q

Focused exam

A

Type of physical exam that is typically performed on responsive patients who have sustained an isolated injury.
This type of exam is based on the chief complaint and focuses on one body system or part.

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36
Q

Full-body exam

A

A systematic head-to-toe exam performed during the secondary assessment of a patient who has sustained a significant MOI, is unresponsive, or is in critical condition.

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37
Q

General impression

A

Overall initial impression that determines the priority of patient care; based on the patient’s surroundings, the mechanism of injury, signs and symptoms, and the chief complaint.

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38
Q

Glasgow Coma Scale (GCS)

A

An evaluation tool used to determine level of consciousness by evaluating and assigning point values (scores) for eye opening, verbal response, and motor response, which are then totaled; effective in helping predict patient outcomes.

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39
Q

Guarding

A

Contraction of the abdominal muscles indicating peritoneal irritation

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40
Q

Heave

A

The perception that the heat is beating very strongly; felt upon palpating of the chest wall, this finding suggests hypertrophy; also called a lift.

41
Q

History of the present illness

A

A narrative detail of the symptoms that a patient is experiencing, usually obtained using the OPQRST mnemonic.

42
Q

Iatrogenic

A

Related to a side effect or complication of medications or other medical treatment.

43
Q

Inspection

A

Looking at the patient, either in general or at a specific area

44
Q

Jugular vein distention (JVD)

A

The visible bulging of the jugular veins when a patient is in semi-Fowler or full Fowler position; indicates inadequate blood movement through the heart and/or lungs

45
Q

Korotkoff sounds

A

Sounds related to blood pressure measurement that are heard by stethoscope.

46
Q

Kyphosis

A

Outward curve of the thoracic spine

47
Q

Lesions

A

Localized areas of the skin that do not resemble the area surrounding it.

48
Q

Lift

A

A sensation felt upon palpating of the chest wall, in which the heart beats extremely strongly; suggests hypertrophy; also called a heave

49
Q

Lordosis

A

Inward curve of the lumbar spine just above the button. An exaggerated form results in the condition known as swayback.

50
Q

Mechanism of injure (MOI)

A

The series of events that result in traumatic injuries; the forces that act on the body to cause injury.

51
Q

Mottling

A

A blotchy patter on the skin; a typical finding in states of severe protracted hypoperfusion and shock

52
Q

Murmur

A

An abnormal whooshing sound heard over the heart that indicates turbulent blood flow around a cardiac valve.

53
Q

Nature of illness (NOI)

A

The general type of illness a patient is apparently experiencing.

54
Q

Ophthalmoscope

A

An instrument used to examine a patients eyes and view the retina and aqueous fluid; consists of a concave mirror and a battery-powered light that is usually contained in the handle.

55
Q

Orthostatic vital signs

A

Multiple sets of vital signs taken from the patient in different positions. (Supine, sitting, standing) to determine the degree of hypovolemia; also called a tilt test.

56
Q

Otoscope

A

An instrument used to examine the ears of a patient; consists of a head and handle,, the head contains an electric light source and a low powered magnifying lense

57
Q

Pallor

A

Paleness

58
Q

Palpating

A

Physical touching for the purpose of obtaining information

59
Q

Paresthesias

A

Tingling feeling or sensory change

60
Q

Past medical history

A

Information obtained during the history taking process, such as the patient’s general state of health, childhood and adult diseases, surgeries and hospitalizations, psychiatric and mental illness, or traumatic injuries, which may relate to the patient’s current condition.

61
Q

Pathologic fracture

A

A fracture that occurs when normal forces are applied to abnormal bone structures

62
Q

Patient history

A

Information about the patient’s chief complaint, present symptoms, and previous illnesses.

63
Q

Percussion

A

Gently striking the surface of the body, typically overlying various body cavities, to detect changes in the densities of the underlying structures.

64
Q

Perfusion

A

The circulation of oxygenated blood through the body tissues and vessels.

65
Q

Pertinent negatives

A

The absence of certain signs and symptoms normally expected of specific illnesses or conditions; these findings warrant no medical care or intervention, but demonstrate the thoroughness of the patient exam and history.

66
Q

Pleural friction rubs

A

Squeaking or grating sounds that occur when the pleural linings rub together, which may be heard on inspiration, expiration, or both;
Commonly caused by inflammation of the pleura.

67
Q

Primary survey

A

The part of the assessment process that focuses on identifying immediate or potential life threatening conditions so you can initiate lifesaving care.

68
Q

Primitive reflexes

A

Reflex reactions such as babinski, gasping, and sucking signs normally found in infants

69
Q

Pronator drifts

A

Drifting of one arm downward toward a patient’s feet while he or she holds out his or her arms, palm side up, with his or her eyes shut; can be a sign of a stroke.

70
Q

Proprioception

A

The perception of the position and movement of the body or limbs

71
Q

Pulse

A

The wave of pressure created as the heart contracts and forces blood out of the left ventricle and into the major arteries; palpated at a point where an artery passes close to a bone

72
Q

Pulse oximitry

A

An assessment tool used to measure oxygen saturation of hemoglobin in the capillary beds.

73
Q

Rapid full body scan

A

A 60 to 90 second non systematic review and palpation of the patients body to identify injuries that must be managed or projected immediately;
Also called the rapid full body sweep

74
Q

Reassessment

A

Portion of the assessment process in which a patient’s condition is reevaluated and responses to treatment is assessed.

75
Q

Reflexes

A

Involuntary motor responses to specific sensory stimuli, such as a tap on the knee or stroking the eyelash.

76
Q

Rhonchi

A

Coarse, low-pitched breath sounds heard in patients with chronic mucus in the upper airways.

77
Q

Rigidity

A

A clinically important sign characterized by marked peritoneal irritation and guarding, indicating an injury or illness for which urgent surgical intervention may be required.

78
Q

Rubor

A

Redness; one of the classic sgns of inflammation.

79
Q

Scene size up

A

A step in the patient assessment process involving a quick assessment of the scene and its surroundings to gather information about the overall safety and stability of the scene and the mechanism of injury or nature of illness
This process is carried out before you enter and begin patient care

80
Q

Scoliosis

A

Sideways curvature of the spine

81
Q

Secondary assessment

A

The process by which more detailed, quantifiable, objective information is obtained from the patient about his or her overall state of health.

82
Q

Signs

A

Objective observations that can be seen, heard, felt, smelled, or measured.

83
Q

Social history

A

A subsection of the patient history that provides valuable information regarding the patient’s overall health status ad helps to identify risks factors for various disease processes; included items such as Tabasco use, alcohol and drug use, sexual behavior, diet, travel history, living environment, and occupation.

84
Q

Sphygmomanometer

A

A blood pressure cuff

85
Q

Spitting

A

In the context of heart sounds, a situation in which events on the right side of heart occur slightly later than those on the left side, and create two discernible sounds rather than one heart sound

86
Q

Strider

A

A harsh, high pitched respiratory sound produced as air moves past an obstruction within or immediately above the glottis opening; associated with severe upper airway obstruction.

87
Q

Symptoms

A

Subjective information the patient feels, such as pain, discomfort, or other abnormality.

88
Q

Systolic pressure

A

Blood pressure created by the left ventricle as it contracts

89
Q

Tenting

A

A condition in which the skin slowly retracts after being pinched and pulled away slightly from the body; a sign of dehydration,

90
Q

Thrill

A

Humming vibration that can be palpated through the chest wall, suggesting an underlying bruit or murmmur.

91
Q

Traumatic fracture

A

A fracture that occurs when abnormal forces are applied to normal bone structures

92
Q

Turf or

A

Loss of skin elasticity

93
Q

Vasoconstriction

A

Narrowing of the diameter of the blood vessel

94
Q

Vasodilation

A

Widening of the diameter of the blood vessel

95
Q

Vesicular sounds

A

Normal breath sounds made by air moving in and out of the alveoli

96
Q

Visual acuity

A

Determined by the ability or inability to see, and by how far.

97
Q

Wheezing

A

High pitched whistling sound that may be heard on inspiration, expiration, or both , indicating air movement through constricted lower airways, as in asthma

98
Q

Whispered pectoriloquy

A

A test of decreased breath sounds performed by placing the diaphragm of the stethoscope over the area in question as the patient whispers “ninety nine” a loud, clear sound indicates lung consolidation.

99
Q

Working diagnosis

A

The one diagnosis from a differential list used to base a patient’s treatment plan.