Chp. 4 - Diagnostic Procedures and Therapeutic Interventions Flashcards
Normal Range
when the body is in a healthy state, it functions normally, and the physical and chemical characteristics of the body substances are generally within a certain acceptable range…WNL
Symptom (Sx)
a change (subjective evidence) that is perceived by the patient, which may or may not be confirmed by the examiner
Ex: Headache, Itching, Pain
Sign
objective, or definitive, evidence of an illness or disordered function that is perceived by an examiner
Ex: Fever, Rash, evidence established by radiologic or laboratory testing
Diagnosis (Dx)
identification of a disease or condition by a scientific evaluation of physical signs, symptoms, history, tests, and procedures
Prognosis
predicted outcome of a disease
Acute (describing disease)
having a short and relatively severe course
Chronic (describing disease)
exists over a long time
Specimen
small sample or part taken from the body to represent the nature of the whole
Vital Signs
measurements of pulse rate, respiration rate, and body temperature
Pulse (P)
rhythmic expansion of an artery that occurs as the heart beats
results from the expansion and contraction of an artery as blood is forced from the heart
may be felt with a finger or measured electronically
Pulse Rate
count of heartbeats per minute
Normal/Resting State: 60-100 bpm
Respiration (R)
refers either to the exchange of oxygen and carbon dioxide within the body or to breathing
Respiratory Rate
number of breaths per minute
Tympanic Thermometer
has a specially designed probe tip that is placed at the external opening of the ear canal
Blood Pressure (BP)
pressure exerted by the circulating volume of blood on the walls of the arteries and veins and on the chambers of the heart
readings generally consist of two numbers expressed as a fraction: first number represents the maximum pressure on the artery, second number represents the amount of pressure that still exists when the heart is relaxed
standard unit of measurement is millimeters of mercury (mm Hg)
Systolic Pressure
higher reading of blood pressure
Diastolic Pressure
lower reading of blood pressure
History
a record of past events and factors that may have a bearing on one’s present condition
History of Present Illness
obtained by the medical professional from the patient regarding the onset, duration, and character of the present illness
Four Techniques of Physical Examination
Inspection, Palpation, Percussion, Auscultation
Inspection
examiner uses the eyes and ears to observe and listen to the patient
Palpation
examiner feels the texture, size, consistency, and location of certain body parts with the hands
Percussion
examiner taps the body with the fingertips or fist to evaluate the size, borders, and consistency of internal organs and to determine the amount of fluid in a body cavity
Auscultation
examiner listens for sounds within the body to evaluate the heart, blood vessels, lungs, intestines, or other organs, or to detect the fetal heart sound
performed most frequently with a stethoscope
Stethoscope
an instrument consisting of two earpieces connected by flexible tubing
the diaphragm is placed against the patient’s skin to hear sounds within the body