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Flashcards in chapter 17 - patient assessment Deck (78):
1

what are the tools used to enhance a patient assessment?

stethoscope, otoscope, sphygmomanometer (bp cuff), ophthalmoscope, thermometer, penlights

2

what tool is used to auscultate sound and vibrations

stethoscope

3

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

4

used to assess blood pressure, manually

sphygmomanometer

5

the three key parts of the sphygmomanometer are what?

the bulb, the cuff, and the manometer (carefully calibrated scale)

6

what tool is used to examine the inside of an eye

opthalmoscope

7

what is the blurring of the optic disc, as a result of increased intracranial pressure

papilledema

8

another word for farsighted is what

hyperopic

9

another name for nearsighted is what

pyopic

10

what tool measures a patient's core body temperature in either degrees of celsius or degrees of fahrenheit

thermometer

11

what tool allows you to assess pupillary response and illuminate openings such as the ear nasopharynx, and oropharynx to inspect for fluids

penlights

12

antegrade amnesia

the inability to remember short term memory information after an event during which the head was struck

13

auscultation

the process of listening to body noises with a stethoscope

14

AVPU

mnemonic for Awake Verbal Pain Unresponsive, used to evaluate a patients mental status

15

battle signs

significant bruising around the mastoid process (behind the ears)

16

borborygmus

hyperactivity of bowel sounds

17

bowel sounds

the noises made by the intestinal smooth muscles as they spueeze fluids and food products through the digestive tract

18

bradycardia

heart rate slower than 60 beats/min (from brady, meaning slow)

19

bradypnea

a respiratory rate less than 12 breaths/min

20

bruit

the blowing or swishing sound created by the turbulence within a blood vessel

21

carotid bruit

the noise made when blood in the carotid arteries passes over plaque buildups

22

core body temperature

the measured body temperature within the core of the body; generally measured with an esophageal probe; normal is 98.6 F

23

CSM

Circulation, Sensation, and Movement

24

cullen's sign

yellow-blue ecchymosis surrounding the umbilicus

25

cyanosis

a bluish coloration of the skin as a result of hypoxemia, or deoxygenation of hemoglobin

26

diastole

the period when the ventricles are relaxed and filling with blood

27

diastolic blood pressure

the pressure exerted against the walls of the large arteries during ventricular relaxation

28

ecchymosis

collection of blood within the skin that appears blue-black, eventually fading to a greenish-brown and yellow, commonly called a bruise

29

fluctuance

a wavelike motion felt between two fingertips when palpating a fluid filled structure such as a subcutaneous abscess

30

gasping

inhaling and exhaling with quick, difficult breaths

31

grey-turners sign

bruising along the flanks that may indicate pancreatitis or intraabdominal hemorrhage

32

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

33

gurgling

abnormal respiratory sounds associated with collection of liquid or semisolid material in the patients upper airway

34

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

35

hypertension

elevated blood pressure

36

hyperthermia

a core temperature greater than 98.6 F

37

hypotension

low blood pressure significant enough to cause inadequate perfusion

38

hypothermia

a core body temperature below 95 F

39

induration

hardened mass within the tissue typically associated with inflammation

40

Korotkoff sounds

the noise made by blood under pressure tumbling through the arteries

41

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

42

life threatening conditions

a problem of the circulatory, respiratory, or nervous system that will kill a patient within minutes if not properly managed

43

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

44

nasal flaring

widening of the nostrils on inhalation; an attempt to increase the size of the airway and increase the amount of available oxygen

45

nysagmus

involuntary rapid movement of the eyes in the horizontal, vertical, or rotary planes of the eyeball

46

painful stimulus

any stimulus that causes discomfort to the patient, triggering some sort of response

47

palpation

the process of applying pressure against the body with the intent of gathering information

48

percussion

a diagnostic technique that uses tapping on the body to differentiate air, solids, and fluids

49

photosensitivity

a condition in which the patient's eyes are sensitive or feel pain when exposed to bright light

50

pleural friction rub

noise made when the visceral and parietal pleural rub together

51

point of maximum impulses

PMI - tha apical impulse; the site where the heartbeat is most strongly felt

52

pulse oximetry

a measure percent of saturated hemoglobin

53

pulse pressure

the difference between the systolic and diastolic blood pressures

54

raccoon eyes

bruising around the orbits of the eyes

55

range of motion

the full and natural range of a joints movement

56

rapid medical assessment

a quick head to toe assessment of a medical patient who is unresponsive or has an altered mental status

57

rapid trauma assessment

a quick head to toe assessment of a trauma patient with a significant mechanism of injury

58

rebound tenderness

discomfort experienced by the patient that occurs when the pressure from palpation is released

59

retractions

sinking in of the soft tissues above the sternum of clavicle or between or below the ribs during inhalation

60

retrograde amnesia

the inability to remember events or recall memories from before an event in which the head was struck

61

S1

the sound of the tricuspid and mitral valves closing

62

S2

the sound of the closing of the pulmonary and aortic valves

63

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

64

shock

inadequate systemic perfusion

65

skin turgor

the elasticity of the skin; good skin turgor returns the skins natural shape within 2 seconds

66

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

67

snoring

noisy breathing through the mouth and nose during sleep; caused by air passing through a narrowed upper airway

68

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

69

systole

the period when the ventricles are contracting

70

systolic blood pressure

the pressure exerted against the walls of the large arteries at the peak of ventricular contraction

71

tachycardia

a heart rate greater than 100 beats/min

72

tachypnea

an increased respiratory rate, usually greater than 30 beats/min

73

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

74

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

75

verbal stimulus

any noise that elicits some sort of response from the patient

76

visual acuity card

a standardized board used to test vision

77

voluntary guarding

conscious contraction of the abdominal muscles in an attempt to prevent painful palpation

78

wheezes

high pitched whistling sounds produced by air moving through narrowed airway passages