chapter 17 - patient assessment Flashcards
what are the tools used to enhance a patient assessment?
stethoscope, otoscope, sphygmomanometer (bp cuff), ophthalmoscope, thermometer, penlights
what tool is used to auscultate sound and vibrations
stethoscope
what tool is used to visualize the inner ear and tympanic membrane (eardrum). Also good way to assess for cerebrospinal fluid in the ear and nose after trauma
otoscope
used to assess blood pressure, manually
sphygmomanometer
the three key parts of the sphygmomanometer are what?
the bulb, the cuff, and the manometer (carefully calibrated scale)
what tool is used to examine the inside of an eye
opthalmoscope
what is the blurring of the optic disc, as a result of increased intracranial pressure
papilledema
another word for farsighted is what
hyperopic
another name for nearsighted is what
pyopic
what tool measures a patient’s core body temperature in either degrees of celsius or degrees of fahrenheit
thermometer
what tool allows you to assess pupillary response and illuminate openings such as the ear nasopharynx, and oropharynx to inspect for fluids
penlights
antegrade amnesia
the inability to remember short term memory information after an event during which the head was struck
auscultation
the process of listening to body noises with a stethoscope
AVPU
mnemonic for Awake Verbal Pain Unresponsive, used to evaluate a patients mental status
battle signs
significant bruising around the mastoid process (behind the ears)
borborygmus
hyperactivity of bowel sounds
bowel sounds
the noises made by the intestinal smooth muscles as they spueeze fluids and food products through the digestive tract
bradycardia
heart rate slower than 60 beats/min (from brady, meaning slow)
bradypnea
a respiratory rate less than 12 breaths/min
bruit
the blowing or swishing sound created by the turbulence within a blood vessel
carotid bruit
the noise made when blood in the carotid arteries passes over plaque buildups
core body temperature
the measured body temperature within the core of the body; generally measured with an esophageal probe; normal is 98.6 F
CSM
Circulation, Sensation, and Movement
cullen’s sign
yellow-blue ecchymosis surrounding the umbilicus
cyanosis
a bluish coloration of the skin as a result of hypoxemia, or deoxygenation of hemoglobin
diastole
the period when the ventricles are relaxed and filling with blood
diastolic blood pressure
the pressure exerted against the walls of the large arteries during ventricular relaxation
ecchymosis
collection of blood within the skin that appears blue-black, eventually fading to a greenish-brown and yellow, commonly called a bruise
fluctuance
a wavelike motion felt between two fingertips when palpating a fluid filled structure such as a subcutaneous abscess
gasping
inhaling and exhaling with quick, difficult breaths
grey-turners sign
bruising along the flanks that may indicate pancreatitis or intraabdominal hemorrhage
grunting
a short low pitched sound heard at the end of exhalation that represents an attempt to generate positive end expiratory pressure by exhaling against a closed glottis, prolonging the period of oxygen and carbon dioxide exchange across the alveolar capillary membrane
gurgling
abnormal respiratory sounds associated with collection of liquid or semisolid material in the patients upper airway
head bobbing
indicator of increased work of breathing in infants; the head falls forward with exhalation and comes up with expansion of the chest on inhalation
hypertension
elevated blood pressure
hyperthermia
a core temperature greater than 98.6 F
hypotension
low blood pressure significant enough to cause inadequate perfusion
hypothermia
a core body temperature below 95 F
induration
hardened mass within the tissue typically associated with inflammation
Korotkoff sounds
the noise made by blood under pressure tumbling through the arteries
lesions
a wound injury or pathologic change in body tissue; any visible, local abnormality of the tissues of the skin, such as a wound, sore, rash, or boil
life threatening conditions
a problem of the circulatory, respiratory, or nervous system that will kill a patient within minutes if not properly managed
minute volume
the amount of air moved in and out of the lungs in 1 minute; determined by multiplying the tidal volume by the respiratory rate
nasal flaring
widening of the nostrils on inhalation; an attempt to increase the size of the airway and increase the amount of available oxygen
nysagmus
involuntary rapid movement of the eyes in the horizontal, vertical, or rotary planes of the eyeball
painful stimulus
any stimulus that causes discomfort to the patient, triggering some sort of response
palpation
the process of applying pressure against the body with the intent of gathering information
percussion
a diagnostic technique that uses tapping on the body to differentiate air, solids, and fluids
photosensitivity
a condition in which the patient’s eyes are sensitive or feel pain when exposed to bright light
pleural friction rub
noise made when the visceral and parietal pleural rub together
point of maximum impulses
PMI - tha apical impulse; the site where the heartbeat is most strongly felt
pulse oximetry
a measure percent of saturated hemoglobin
pulse pressure
the difference between the systolic and diastolic blood pressures
raccoon eyes
bruising around the orbits of the eyes
range of motion
the full and natural range of a joints movement
rapid medical assessment
a quick head to toe assessment of a medical patient who is unresponsive or has an altered mental status
rapid trauma assessment
a quick head to toe assessment of a trauma patient with a significant mechanism of injury
rebound tenderness
discomfort experienced by the patient that occurs when the pressure from palpation is released
retractions
sinking in of the soft tissues above the sternum of clavicle or between or below the ribs during inhalation
retrograde amnesia
the inability to remember events or recall memories from before an event in which the head was struck
S1
the sound of the tricuspid and mitral valves closing
S2
the sound of the closing of the pulmonary and aortic valves
signs and symptoms
signs are a medical or trauma condition of the patient that can be seen, heard, smelled, measured, or felt during the examination; symptoms are conditions described by the patient, such as shortness of breath, or pieces of information bystanders tell you about the patients chief complaint
shock
inadequate systemic perfusion
skin turgor
the elasticity of the skin; good skin turgor returns the skins natural shape within 2 seconds
sniffing position
neck flexing at the 5th and 6th cervical vertebrae, with the head extended at the frist and second cervical vertebrae. this position aligns the axes of the mouth, pharynx, and trachea, opening the airway and increasing airflow
snoring
noisy breathing through the mouth and nose during sleep; caused by air passing through a narrowed upper airway
stridor
a harsh, high pitched sound heard on inspiration associated with upper airway obstruction; often described as a high pitched crowing or seal bark sound
systole
the period when the ventricles are contracting
systolic blood pressure
the pressure exerted against the walls of the large arteries at the peak of ventricular contraction
tachycardia
a heart rate greater than 100 beats/min
tachypnea
an increased respiratory rate, usually greater than 30 beats/min
tidal volume
the volume of air moved into or out of the lungs during a normal breath; can be indirectly evaluated by observing the rise and fall of the patients chest and abdomen
tripod position
position used to maintain an open airway that involves sitting upright and leaning forward with the neck slightly extended, chin projected, and mouth open and supported by the arms
verbal stimulus
any noise that elicits some sort of response from the patient
visual acuity card
a standardized board used to test vision
voluntary guarding
conscious contraction of the abdominal muscles in an attempt to prevent painful palpation
wheezes
high pitched whistling sounds produced by air moving through narrowed airway passages
