Chapter 11 Patient Assessment: Vital Vocabulary Flashcards
Abnormal breath sounds, such as wheezing, rhonchi, crackles, stridor, and pleural friction rubs.
adventitious breath sounds
A determination made when assessing mental status by looking at whether the patient is oriented in four areas: person, place, time, and the event itself. Each element provides information about different aspects of the patient’s memory.
alert and oriented (A x O)
Unequal pupils with a greater than 1-mm difference.
anisocoria
The language impairment that affects the production or understanding of speech and the ability to read or write.
aphasia
An episode characterized by some combination of apnea (central or obstructive), color change (cyanotic, pallid, erythematous, or plethoric) change in muscle tone (usually diminished), and choking or gagging.
apparent life-threatening event (ALTE)
Abnormal accumulation of fluid in the peritoneal cavity; typically signals liver failure.
ascites
The entry of fluids or solids into the trachea, bronchi, and lungs; the act of drawing material in or out by suction.
aspiration
The act of using a stethoscope to listen to sounds within the body.
auscultation
A method of assessing mental status by determining whether a patient is Awake and alert, responsive to Verbal stimuli or Pain, or Unresponsive; used principally in the primary survey.
AVPU
Bruising over the mastoid process, which may indicate a basilar skull fracture; also known as retroauricular ecchymosis or raccoon eyes.
Battle sign
The combination of a narrowed pulse pressure, muffled heart tones, and jugular venous distention associated with cardiac tamponade; usually caused by penetrating chest trauma.
Beck triad
The measurement of the force exerted against the walls of the blood vessels as the heart contracts and relaxes; it is calculated as the product of cardiac output and peripheral vascular resistance.
blood pressure (BP)
Hollow, tubular, lower-pitched sounds heard over the trachea.
bronchial sounds
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.
bronchophony
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 the scapulae.
bronchovesicular sounds
An abnormal whooshing sound of turbulent blood flow moving through a narrowed artery; usually heard in the carotid arteries.
bruit
The use of a 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 electrocardiogram.
capnography
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.
capnometry
Ear wax
cerumen
The reason the patient is seeking help.
chief complaint
Wet rattling, bubbling, or crackling lung sounds indicative of fluid in the small airways; also known as rales.
crackles
A crackling, grating, or grinding sound often heard when fragments of broken bones rub together.
crepitus
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.
current health status
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.
Cushing reflex
A blue-gray skin color that is caused by inadequate levels of oxygen in the blood.
cyanosis
An acute confusional state characterized by global impairment of thinking, perception, judgment, and memory.
delirium
The gradual and pervasive deterioration or loss of cognitive cortical functions.
dementia
Excessive sweating; it is often associated with shock.
diaphoresis
The result of residual pressure in the circulatory system while the left ventricle is relaxing (ie, in diastole).
diastolic pressure
The process of weighing the probability of 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.
differential diagnosis
Double vision
diplopia
Localized bruising or collection of blood within or under the skin.
ecchymosis
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;” and “A” sound indicates lung consolidation.
egophony
A field conclusion of the patient’s problem based on the clinical presentation and the exclusion of other possible causes through considering the differential diagnoses.
field impression
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.
focused exam
A systematic head-to-toe exam performed during the secondary assessment of a patient who has sustained a significant mechanism of injury, is unresponsive, or is in critical condition.
full-body exam
The overall initial impression that determines the priority of patient care; based on the patient’s surroundings, the mechanism of injury, sign and symptoms, and the other chief complaint.
general impression
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.
Glasgow Coma Scale (GCS)
Contraction of the abdominal muscles indicating peritoneal irritation.
guarding
The perception that the heart is beating very strongly; felt upon palpitation of the chest wall, this finding suggests hypertrophy; also called a lift.
heave
A narrative detail of the symptoms that a patient is experiencing, usually obtained using the OPQRST mnemonic.
history of the present illness
Related to a side effect or complication of medications or other medical treatment.
iatrogenic
Looking at the patient, either in general or at a specific area (i.e., a patient’s overall appearance from the doorway, versus looking specifically at the chest wall for abnormalities/ deformities).
inspection
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.
jugular venous distention (JVD)
Sounds related to blood pressure measurement that are heard by stethoscope.
Korotkoff sounds
Outward curve of the thoracic spine.
kyphosis
Localized areas of the skin that do not resemble the area surrounding it.
lesions
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
The series of events that result in traumatic injuries; the forces that act on the body to cause injury.
mechanism of injury (MOI)
A blotchy pattern on the skin; a typical finding in states of severe protracted hypoperfusion and shock.
mottling
An abnormal whooshing sound heard over the heart that indicates turbulent blood flow around a cardiac valve.
murmur
The general type of illness a patient is apparently experiencing
nature of illness (NOI)
An instrument used to examine a patient’s 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.
ophthalmoscope
Multiple sets of vital signs taken from the patient in different positions. (for example, in the supine and sitting or standing positions) to determine the degree of hypovolemia; also called a tilt test.
orthostatic vital signs
An instrument used to examine the ears of a patient; consists of a head and a handle. The head contains an electric light source and a low-power magnifying lens.
otoscope
Paleness
pallor
Physical touching for the purpose of obtaining information (for example, to detect tenderness).
palpitation
Tingling feeling or sensory change.
paresthesias
Information obtained during the history-taking process, such as the patient’s general state of health, childhood and adult disease, surgeries and hospitalizations, psychiatric and mental illnesses, or traumatic injuries, which may relate to the patient’s current condition.
past medical history
A fracture that occurs when normal forces are applied to abnormal bone structures.
pathologic fracture
Information about the patient’s chief complaint, present symptoms, and previous illnesses.
patient history
Gently striking the surface of the body, typically overlying various body cavities, to detect changes in the densities of the underlying structures.
percussion
The circulation of oxygenated blood through the body tissues and vessels.
perfusion
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.
pertinent negatives
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.
pleural friction rubs
The part of the assessment process that focuses on identifying immediate or potential life-threatening conditions so you can initiate lifesaving care.
primary survey
Reflex reactions such as Babinski, grasping, and sucking signs normally found in infants.
primitive reflexes
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 perception of the position and movement of the body or limbs.
proprioception
The wave of pressure created as the heart contracts and forces blood out the left ventricle and into the major arteries; palpated at a point where an artery passes close to a bone.
pulse
An assessment tool used to measure oxygen saturation of hemoglobin in the capillary beds.
pulse oximetry
A 60 to 90 second nonsystematic review and palpation of the patient’s body to identify injuries that must be managed or protected immediately; also called the rapid full-body sweep.
rapid full-body scan
The portion of the assessment process in which a patient’s condition is reevaluated and responses to treatment is assessed.
reassessment
Involuntary motor responses to specific sensory stimuli, such as a tap on the knee or stroking the eyelash.
reflexes
Coarse, low-pitched breath sounds heard in patients with chronic mucus in the upper airways.
rhonchi
A clinically important sign characterized by marked peritoneal irritation and guarding, indicating an injury or illness for which urgent surgical intervention may be required.
rigidity
Redness; one of the classic signs of inflammation.
rubor
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.
scene size-up
Sideways curvature of the spine.
scoliosis
The process by which more detailed, quantifiable, objective information is obtained from the patient about his or her overall state of health.
secondary assessment
Objective observations that can be seen, heard, felt, smelled, or measured.
signs
A subsection of the patient history that provides valuable information regarding the patient’s overall health status and helps to identify risk factors for various disease processes; includes items such as tobacco use, alcohol and drug use, sexual behavior, diet, travel history, living environment, and occupation.
social history
A blood pressure cuff
sphygmomanometer
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.
splitting
A harsh, high-pitched respiratory sound produced as air moves past an obstruction within or immediately above the glottic opening; associated with severe upper airway obstruction.
stridor
Subjective information the patient feels, such as pain, discomfort, or other abnormality.
symptoms
Blood pressure created by the left ventricle as it contracts (that is, in systole).
systolic pressure
A condition in which the skin slowly retracts after being pinched and pulled away slightly from the body; a sign of dehydration.
tenting
A humming vibration that can be palpated through the chest wall, suggesting an underlying bruit or murmur.
thrill
A fracture that occurs when abnormal forces are applied to normal bone structures.
traumatic fracture
Loss of skin elasticity
turgor
Narrowing of the diameter of a blood vessel.
vasoconstriction
Widening of the diameter of a blood vessel.
vasodilation
Normal breath sounds made by air moving in and out of the alveoli.
vesicular sounds
Determined by the ability or inability to see, and by how far.
visual acuity
A high-pitched whistling sound that may be heard on inspiration, expiration, or both, indicating air movement through a constricted lower airway, as in asthma.
wheezing
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.
whispered pectoriloquy
The one diagnosis from a differential list used to bas the patient’s treatment plan.
working diagnosis
