Chapter 11 - Patient Assessment Flashcards
Differential diagnosis
possible diagnoses based on assessment findings.
Working diagnosis
diagnosis you are basing treatment plan on
Field Impression
Initial summary of pts condition after findings
Delirium
Sudden change in mental status
anisocoria
Unequal pupils with a greater than 1-mm difference
aphasia
The language impairment that affects the production or understanding of speech and the ability to read or write
Ascites
Abnormal accumulation of fluid in the peritoneal cavity; typically signals liver failure.
Battle sign
bruising over mastoid bone behind the ear, may indicate a basilar skull fracture, also called retroauricular ecchymosis or raccoon eyes
Beck triad
The combination of a narrowed pulse pressure, muffled heart tones, and jugular venous distention associated with cardiac tamponade; usually caused by penetrating chest trauma.
Bronchial sounds
Hollow, tubular, lower-pitched sounds heard over the trachea.
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 sound indicates lung consolidation.
Egophony
A test of decreased breath sounds performed by placing the diaphragm of the stethoscope over the area in question while the patient saying a drawn-out “ee;” an “A” sound indicates lung consolidation.
Bruit
An abnormal whooshing sound of turbulent blood flow moving through a narrowed artery; usually heard in the carotid arteries.
Cerumen
Term for ear wax
Crackles
The breath sounds produced as fluid-filled alveoli pop open under increasing inspiratory pressure; can be fine or coarse; formerly called
Cushing Reflex
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.
The result of residual pressure in the circulatory system while the left ventricle is relaxing (ie, in diastole)
Diastolic Pressure
Double vision
Diplopia
Ecchymosis
Localized bruising or collection of blood within or under the skin.
Contraction of the abdominal muscles indicating peritoneal irritation.
Guarding
Define Heave
The perception that the heart is beating very strongly; felt upon palpation of the chest wall, this finding suggests hypertrophy; also called a lift.
Iatrogenic
Related to a side effect or complication of medications or other medical treatment.
Sounds related to blood pressure measurement that are heard by stethoscope.
Korotkoff sounds
A sensation felt upon palpation of the chest wall, in which the heart beats extremely strongly; suggests hypertrophy; also called a heave.
Lift
A sensation felt upon palpation of the chest wall, in which the heart beats extremely strongly; suggests hypertrophy; also called a heave.
Lift
Inward curve of the lumbar spine just above the buttocks. An exaggerated form results in the condition known as swayback.
Lordosis
whooshing sound heard over the heart that indicates turbulent blood flow around a cardiac valve.
Murmur
An instrument used to examine the inside of the ears; consists of a head and a handle. The head contains an electric light source and a low-power magnifying lens.
Otoscope
An abnormal sensation such as burning, numbness, or tingling.
Paresthesia
A fracture that occurs when normal forces are applied to abnormal bone structures, such as a weakened bone.
Pathologic fracture
The 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.
Pronator drift
The ability to perceive the position and movement of one’s body or limbs.
Proprioception
Rubor
Redness; one of the classic signs of inflammation.
Blood pressure created by the left ventricle as it contracts
Systolic pressure
A humming vibration that can be palpated through the chest wall, suggesting an underlying bruit or murmur.
Thrill
Adventitious breath sounds include:
- Wheezing: High-pitched whistling
- Crackles (also called rales): Wet breath sounds
- Rhonchi: Congested breath sounds with a lower pitch and rattling
- Stridor: Brassy, crowing sound
- Pleural friction rubs: Squeaking or grating sounds
Calculate MAP
MAP (average arterial pressure throughout one cardiac cycle, systole, and diastole)
* MAP = DP + 1/3(SP–DP) or MAP = DP + 1/3(PP)
Pulse pressure
The top number (systolic) minus the bottom number (diastolic)
