Outward display of emotions ( objective)
Affect
Inability to speak (caused by left hemisphere damage)
Aphasia
An acute , reversible organic disorder characterized by confusion disorientation, restlessness, anxiety and excitement.
Delirium
Impairment of intellectual functioning, memory and judgment. (Slower)
Dementia
Sweating
Diaphoresis
Period of time within the cardiac cycle in which ventricles are relaxed and filling with blood
Diastole
Difficulty swallowing
Dysphagia
Bruises
Ecchymosis
Insufficiency of oxygen in the body’s tissue
Hypoxia
Side of the body
Ipsilateral
Sound heard during the take off of blood pressure
Korotkoff pressure
Away from midline of body
Lateral
Abnormal blowing or swishing sound heard during auscultation of an artery or organ
Bruit
Average arterial pressure during a single cardiac cycle
Equation : (systolic + diastolic *2)/3
MAP mean arterial pressure
Objective data
Obtained from examination, measurements, or diagnostic test observable by nurse
Ophthalmoscope
Used to examine interior eye
Palpation
Touch
Sphygmomanometer
Measure blood pressure
Irregular cardiac rhythm in which the heart rate usually increases during inspiration and decreases during expiration , common in children and young adults
Sinus arrhythmia
Pulse found on the thumb side of risk
Radial pulse
Pulse pressure
The difference between systolic and diastolic pressure (30-40)
External monitor placed on the patients finger or ear lobe to measure the oxygen saturation level in blood ( 95 or greater )
Pulse oximeter
The difference b/w the apical and the radial pulse (get apical pulse with scope)
Pulse deficit
Subject data
What the client tells you
Sudden temporary loss of consciousness; fainting
Syncope
Period of time within the cardiac cycle in which ventricles contract and eject blood into the aorta and pulmonary arteries
Systole
Palpable murmur ; feels like the throat of a purring cat
Thrill
“Feel a thrill “
High pitched sound
Tympany
Over normal lung
Resonat
Normal over child’s lung abdominal in the adult , over lungs with increased amounts of air as in emphysema
Hyperresonant
Relatively dense organ as liver or spleen
Dull
When no air is present , over thigh muscles or bone or over tumor
Flat
the process by which the eye lens changes shape to focus near or far objects on the retina
accommodation
persistent blue or cyanotic discoloration of the extremities, mostly commonly occurring in the hands, although it also occurs in the feet and distal parts of face
acrocyanosis
extra breath sounds that are not normally heard, such as crackles, rhonchi, wheeze and pleural friction rub
adventitious sounds
the force or resistance against which the heart pumps
after load
abnormal hair loss
alopecia
chest pain that results when the heart does not get enough oxygen
angina pectoris
visible and palpable angulation between the sternum and manubrium; also referred to as manubriosternal junction
angle of louis
condition in which the pupils are unequal in size
anisocoria
absence of breathing
apnea
high- pitched breath sounds normally heard over the trachea and the area around the manubrium; considered abnormal if heard anywhere over the posterior or lateral chest
bronchial breath sounds
a large blister that is usually more than 1 cm in diameter, thin walled and ruptures easily
example: friction blister, pemphigus, burns contact dermatitis
bulla
skin lesion the color of coffee
cellulitis