GLOSSARY Assessment

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1

flank

Part of the body between the bottom of the ribs and the upper border of the ilium; it overlies the kidneys.

2

cachexia

Severe malnutrition and wasting of muscles associated with a chronic illness such as cancer.

3

angle of Louis

Visible and palpable angulation between the sternum and manubrium; also referred to as the manubriosternal junction.

4

confluent

Describes lesions that run together.

5

Effect

result of an action or force

6

affect

Emotional state or response

Observable behaviors that indicate an individual’s feelings or emotions.

7

Kernig’s sign

Diagnostic sign of meningeal irritation characterized by pain and inability of a supine patient to completely extend the leg when the knee and hip are flexed on the abdomen.

Diagnostic sign of meningeal irritation characterized by pain and inability of a supine patient to completely extend the leg when the knee and hip are flexed on the abdomen.

8

Romberg’s test

Test of cerebellar function that evaluates an individual’s ability to maintain a given position when standing erect with feet together and eyes closed. Observe for 20 second.

9

Homans’ sign

Calf pain associated with rapid dorsiflexion of the foot.

10

Cullen's sign

Superficial edema & bruising in subcutaneous fatty tissue around umbilicus.

11

Murphy’s sign

Pain elicited during abdominal palpation indicating gallbladder disease.

12

Obturator Sign

This is a test for appendicitis

  1. Raise the patient's right leg with the knee flexed.
  2. Rotate the leg internally at the hip.
  3. Increased abdominal pain indicates a positive obturator sign
13

Iliopsoas muscle test Psoas Sign

perform when acute abdominal pain of appendicities is suspected. supine, lift right leg, nurse push down on thigh, pt gives resistance no pain should be felt in RLQ.

This is a test for appendicitis

  1. Place your hand above the patient's right knee.
  2. Ask the patient to flex the right hip against resistance.
  3. Increased abdominal pain indicates a positive psoas sign.
14

carpal tunnel syndrome

Painful disorder of the wrist and hand induced by compression of the median nerve between the inelastic carpal ligament and other structures within the carpal tunnel.

15

point of maximum impulse (PMI)

Specific area of the chest where the heartbeat is palpated strongest; usually the apical impulse, located in the fourth or fifth intercostal space along the midclavicular line.

16

costal angle Costal

margin angle formed on the anterior chest wall at the base of the xiphoid process where the ribs separate.

17

hypoxia

Abnormal reduction of oxygen delivery to body tissue.

18

diastole

Period of time within the cardiac cycle in which ventricles are relaxed and filling with blood.

19

hypoxemia

Abnormal reduction of oxygen content in the arterial blood

20

emphysema

Chronic pulmonary disease characterized by permanent enlargement of air spaces caused by destruction of alveolar walls.

21

midclavicular line

Vertical line extending downward from the middle of the clavicle.

22

midaxillary line

Vertical line extending downward from the midaxillary fold; used in assessment as an anatomic reference point.

23

mediastinum

Space within the thoracic cavity positioned behind the sternum, in front of the vertebral column, and between the lungs.

24

heave

Palpable, diffuse, sustained lift of the chest wall or a portion of the wall.

25

palpitation

Sensation of pounding, fluttering, or racing of the heart; can be a normal phenomenon or caused by a disorder of the heart.

26

objective data

Data obtained from examination, measurements, or diagnostic tests; observable by the nurse.

27

infarct

Localized area of tissue necrosis caused by prolonged anoxia.

28

paroxysmal nocturnal dyspnea (PND)

Periodic acute attacks of shortness of breath that awaken a person, usually after several hours of sleep in a recumbent position.

29

obsessive-compulsive disorder

An anxiety disorder that develops when the patient tries to resist an obsession or compulsion.

30

depression

An abnormal mood state in which a person characteristically has a sense of sadness, hopelessness, helplessness, worthlessness, and despair resulting from some personal loss or tragedy.

31

dementia

Broad term that indicates impairment of intellectual functioning, memory, and judgment.

32

delusion

Persistent belief or perception that is illogical or improbable.

33

delirium

An acute, reversible organic mental disorder characterized by confusion, disorientation, restlessness, anxiety, and excitement.

34

compulsive

behavior Repetitive act that usually originates from an obsession.

35

Subjective symptom

indicator or sensation perceived by the patient.

36

subjective data

Data obtained from a health history or provided to the nurse by the patient.

37

sign

Objective finding perceived by the nurse.

38

osteoarthritis

Form of arthritis in which one or many of the joints undergo destruction of cartilage.

39

embolus

Foreign object (composed of air, fat, or clustered cellular elements) that circulates through the blood and usually lodges in a vessel, causing some degree of occlusion.

40

plaque

Solid, elevated, circumscribed, superficial lesion more than 1 cm in diameter.

41

prehypertension

An elevated blood pressure of 120 to 139 mm Hg systolic or 80 to 89 mm Hg diastolic on two or more readings taken at two or more visits.

42

hypotension

Refers to abnormally low blood pressure.

43

hypertension

Blood pressure above 120 mm Hg systolic or 80 mm Hg diastolic on two or more readings taken at two or more visits.

44

refraction

Deviation of light rays as they pass from one transparent medium into another of different density.

45

hyperplasia

Increase in the number of cells of a body part that results from an increased rate of cellular metabolism.

46

anesthesia

Partial or complete loss of sensation.

47

remission

Disappearance or diminishment of signs or symptoms

48

stridor

Shrill, harsh sound heard during inspiration.

49

Cheynes-Stokes

An abnormal breathing pattern characterized by intervals of apnea interspersed with a deep and rapid breathing pattern.

50

adventitious sounds

Breath sounds that are not normal.

51

air trapping

An abnormal respiratory pattern seen in patients with chronic obstructive pulmonary disease; characterized by rapid inspirations with prolonged forced expirations.

52

rhonchus

Loud, low-pitched, coarse sound similar to a snore heard on auscultation of an obstructed airway.

53

dysphasia

A neurologic condition in which language function is absent or severely impaired.

54

dyspnea

Breathing that is labored or difficult.

55

bradycardia

Abnormally slowed heart rate, usually under 60 beats/min.

56

tachycardia

Rapid heart rate (more than 100 beats/min).

57

bradypnea

Breathing that is abnormally slow.

Abnormally slow rate of respiration; usually less than 10 breathes per minute.

58

dysphagia

Difficulty swallowing.

59

tachypnea

Rapid breathing; a respiratory rate that is faster than 20 breaths/min.

60

orthopnea

Difficulty breathing in any position other than an upright one.

61

Apnea

Absence of spontaneous respiration (breathing).

Causes: Obstructive sleep apnea Seizures Cardiac Arrhythmias Brain injury Nervous system dysfunction

Drug overdose Prematurity Bronchospasm Encephalitis Choking

62

Eupnea

Normal breathing

63

empyema

accumulation of pus in the pleural cavity.

64

pulse pressure

Difference between systolic and diastolic pressures.

65

pulse deficit

Discrepancy between the ventricular rate auscultated over the heart and the arterial rate palpated over the radial artery.

66

Pulse

60-100bmp

Rate, rhythm, quality

67

Respiratory

12-20 bmp

Rate, rhythm, depth

68

Rectal Temperature

Use water soluble lubricant & insert probe 1 1/2 inches

69

Blood pressure

110-130mmg hg Systolic

60-79 mm hg diastolic

70

ischemia

Diminished supply of blood to a body organ or surface; characterized by pallor, coolness, and pain.

71

bruit

Audible murmur (a blowing sound) heard when auscultating over a peripheral vessel or an organ.

are lower pitched blowing sounds. Usually heard during systole indicate occlusion of the vessel. Occlusion of Coratid artery may impair perfussion of the brain & increase the risk for transient Ischemic attack (TIA)

72

hernia

Abnormal opening in a muscle wall or cavity that permits protrusion of its contents.

73

bronchovesicular breath sounds

Refers to breath sounds at a moderate pitch heard in the posterior chest over the outer center of the back on either side of the spine between the scapulae and in the anterior chest around the sternal border.

74

consolidation

Increasing density of lung tissue caused by pathologic engorgement.

75

hyperresonance

Sound elicited by percussion; very loud intensity and very low pitch with a booming quality; heard over lungs when air is trapped in emphysema.

76

hypovolemic

Pertaining to decreased blood volume; usually refers to a state of shock resulting from massive blood loss and inadequate tissue perfusion.

Poor blood volume prevents the heart from pumping enough blood to the body.
Causes: Trauma Diarrhea Burns GI Bleeding ( Hypovolemic shock)

77

gallop rhythm

Audible extra heart sound produced by an abnormal third or fourth heart sound.

78

Korotkoff sounds

Sounds heard during the taking of blood pressure.

79

Kussmaul respiration

Rapid deep respiration often associated with ketoacidosis.

80

respiratory stridor

A harsh, high pitched sound associated with breathing.

81

wheeze

High-pitched, musical noise that sounds like a squeak; heard during auscultation of a narrowed airway.

82

bronchial breath sounds

High-pitched breath sounds normally heard over the trachea and the area around the manubrium.

83

vesicular breath sounds

Expected breath sounds heard over most of the lungs.

84

systole

Period of time within the cardiac cycle in which the ventricles contract.

85

friction rub

Sound produced by the rubbing of the pleura around the lung or the pericardium around the heart.
G

86

tactile fremitus

Vibratory sensations of the spoken voice felt through the thoracic wall on palpation.

87

crackles

Abnormal respiratory sound heard during auscultation, characterized by discontinuous bubbling sounds; heard over distal bronchioles and alveoli that contain serous secretions; formerly called rales

88

vocal fremitus

Vibratory sensations of the spoken voice felt through the chest wall on palpation; also known as tactile fremitus.

89

Pleural Effusion

Fluid in the Chest.

causes of pleural effusions include:

  • congestive heart failure
  • cirrhosis, or poor liver function
  • pulmonary embolism, which is caused by a blood clot and is a blockage in the lung arteries
  • open heart surgery complications
  • pneumonia
  • severe kidney disease
90

bronchophony

An abnormality in vocal resonance. When lungs are auscultated, the patient says “ninety-nine” or “one, two, three” indicating lung consolidation.

91

Skene’s glands

(periurethral) Mucus-secreting glands that lie just inside the urethral orifice of women; not visible during examination.

92

shifting dullness

Change in the dull sounds heard with percussion; at first the dull sound is heard in one location and then in a different location.

93

rebound tenderness

Sign of inflammation in the peritoneum in which pain is elicited by a sudden withdrawal of a hand pressing on the abdomen.

94

gout

Metabolic disease associated with abnormal uric acid metabolism that is a form of acute arthritis; marked by inflammation of the joints

95

peristalsis

Alternating contraction and relaxation of the smooth muscles of the intestinal tract to propel contents forward.

96

presbycusis

Impairment of hearing in older adults.

97

erythematous

Redness (of the skin)

98

strabismus

Condition in which the eyes are not directed at the same object or point.

99

presbyopia

Loss of accommodation (ability to focus on near objects) associated with older adults.

100

nystagmus

Involuntary rhythmical movement of the eyes; oscillations may be horizontal, vertical, rotary, or mixed.

101

myopia

(nearsightedness) Refractive error in which light rays focus in front of the retina.

102

hyperopia

(farsightedness) Refractive error in which light rays focus behind the retina

103

goiter

Hypertrophy of the thyroid gland, usually evident as a pronounced increase in its size.

104

precordium

Area of the chest that overlies the heart and adjacent great vessels.

105

petechiae

Tiny, flat purple or red spots on the surface of the skin resulting from minute hemorrhages within the dermal or submucosal layers.

106

paronychia

Inflammation of the skinfold that adjoins the nail bed.

107

palpebral fissure

Opening between the upper and lower eyelids.

108

sebaceous glands

Secretory dermal structures that produce sebum, an oily substance.

109

eccrine sweat glands

Secretory dermal structures distributed over the body that secrete water and electrolytes and regulate body temperature.

110

subluxation

Partial or incomplete dislocation of a joint.

111

tophus/tophi

Calculus that contains sodium urate deposits; associated with gout.

is a deposit of uric acid crystals, in the form of monosodium urate crystals, in people with longstanding hyperuricemia (high levels of uric acid in the blood). Tophi are pathognomonic for the disease gout. Calculus that contains sodium urate deposits; associated with gout.

112

tympany

Low-pitched note heard on percussion of a hollow organ such as the stomach.

113

thrill

Palpable murmur.

114

thrombus

Blood clot attached to the inner wall of a vessel.

115

thrombophlebitis

Inflammation of a vein.

116

stereognosis

Ability to recognize objects by the sense of touch.

by Identification familiar object in hand

117

graphesthesia

Ability to recognize symbols, numbers, or letters traced on the skin.

by identification of # or letter drawn on hand, back, other area

118

two-point discrimination

Ability to identify being touched by two sharp objects simultaneously.

119

egophony

Abnormality in vocal resonance; when lungs are auscultated, the patient says “e-e-e,” but the nurse hears “a-a-a”; suggests pleural effusion.

120

hyperkinesis

Hyperactivity or excessive muscular activity.

121

dyskinesia

Refers to a reduced ability to perform voluntary movements.

122

turgor

Expected resiliency of the skin.

123

scoliosis

Lateral curvature of the spine.

124

kyphosis

Abnormal convexity of the posterior curve of the spine.

125

lordosis

Abnormal anterior concavity of the spine.

126

macule

Flat, circumscribed lesion of the skin or mucous membrane that is 1 cm or less in diameter.

127

ipsilateral

same side of the body

128

contralateral

opposite side

129

unilateral

Relating to or referring to one side.

130

scale

Small, thin flake of epithelial cells.

131

lesion

A pathologically or traumatically altered area of tissue.

132

nodule

Solid skin elevation that extends into the dermal layer and that is 1 to 2 cm in diameter.

133

patch

Flat, circumscribed lesion of the skin or mucous membrane that is more than 1 cm in diameter.

134

papule

Solid, elevated, circumscribed, superficial lesion 1 cm or less in diameter.

135

nevus (nevi)

Congenital pigmented area on the skin. Example: Mole, birthmark.

136

ecchymosis

Discoloration of skin or a mucous membrane caused by leakage of blood into the subcutaneous tissue; can also be a bruise.

137

xerostomia

Dryness of the mouth

138

wheal

Elevated, solid, transient lesion; often irregularly shaped but well demarcated; an edematous response

139

vestibule

Middle part of the inner ear located behind the cochlea and in front of the semicircular canals.

140

vesicle

Fluid-filled, elevated, superficial lesion 1 cm or less in diameter.

141

ulcer

Circumscribed crater on the surface of the skin or mucous membrane that results from necrosis.

142

tumor

Solid skin elevation that extends into the dermal layer and is more than 1 cm in diameter.

143

syncope

Sudden, temporary loss of consciousness; fainting.

144

lateral

Referring to the side; position away from the middle.

145

medial

Referring to the middle; the median plane of the body.

146

diarthrotic

joint Joint that permits relatively free movement; types of diarthrotic joints include hinge joints, pivot joints, condyloid joints, ball-and-socket joints, and gliding joints.

147

pleximeter

Finger placed on the skin surface to receive the taps from the percussion hammer or plexor; used in percussion.

148

circumvention

Circular movement of a limb.

149

dorsiflexion

Upward or backward bending or flexion of a joint.

150

extension

Movement that brings a joint into a straight position.

151

flexion

Movement that brings a joint into a bent position.

152

external rotation

Turning a limb outward or away from the midline of the body.

153

plantar

Referring to the bottom surface of the foot.

154

plantar flexion

A toe-down motion of the foot at the ankle.

155

inversion

Turning inside out or upside down.

156

hyperextension

Refers to the extension of a body part beyond normal limits of extension.

157

internal rotation

Inward turning of a limb.

158

abduction

Movement of a limb away from the body

159

adduction

Movement of a limb toward the body

160

pronate

To turn the forearm so the palm faces downward or to rotate the leg or foot inward.

161

supinate

To turn the forearm so the palm faces upward or to rotate the foot and leg outward.

162

posterior triangle (of neck)

Landmark area for palpating chains of lymph nodes located along the anterior border by the sternocleidomastoid muscle, the posterior border by the trapezius muscle, and the bottom by the clavicle.

163

eversion

Outward turning as with a foot, or an inside-out position as with an eyelid.

164

palmar

Relating to the palm of the hand.

165

striae

Streaks of linear scars that often result from rapidly developing tension in the skin; also called stretch marks.

166

vertigo

Sensation of moving around in space (whirling motion; subjective vertigo) or of objects moving about themselves (objective vertigo).

167

paresthesia

Abnormal sensation such as numbness or tingling.

168

hyperesthesia

Abnormally increased sensitivity to sensory stimuli such as touch or pain.

169

nociceptor

Free nerve endings that are located at the ends of nerve fibers and initiate an action potential.

170

perception of pain

The third phase in the pain process that occurs when the parietal lobe is stimulated, causing a conscious experience of pain.

171

kinesthetic sensation

Ability to detect muscle movement and position.

172

proprioception

Awareness of body posture, movement, and changes in equilibrium.

173

paresis

Motor weakness.

174

hallucination

Sensory perception that does not arise from an external stimulus; can be auditory, visual, tactile, gustatory, or olfactory.

175

paralysis

Loss of muscle function, loss of sensation, or both.

176

Transmission

Second step in pain process begin with stimulation of one of four types by Nociceptors end by closing or opening gate (substantia gelatinosa)

177

Transduction

First step in pain process involving conversion of mechanical, thermal, chemical, or electrical stimuli that damage tissues.

178

Stoma

General term that means opening or mouth.

179

retraction

Shortening or drawing the skin backward

180

ptosis

Drooping of the upper eyelid; can be unilateral or bilateral.

181

psychosis

Any major mental disorder characterized by greatly distorted perceptions and severe disorganization of the personality.

182

intermittent claudication

Pain in the legs that occurs while walking but that can be relieved by rest.

183

pruritus

Itching

184

jaundice

A yellow discoloration of the skin, mucous membrane, and sclera.

185

hordeolum (stye)

Infection of a sebaceous gland at the margin of the eyelid.

186

hemoptysis

Coughing up blood or referring to bloody sputum.

187

helix

Margin of the external ear.

188

guarding

Protective withdrawal or positioning of a body part during an injury.

189

ascites

Accumulation of serous fluid in the peritoneal cavity.

190

edema

Excessive accumulation of fluid within the interstitial space.

191

clubbing

Broadening and thickening of the fingernails or toenails associated with an increased angle of the nail greater than 180 degrees; associated with chronic hypoxia

192

angina pectoris

Paroxysmal chest pain often associated with myocardial ischemia; pain patterns and severity vary among individuals

193

Impetigo

A highly contagious skin infection that causes red sores on the face.

mainly affects infants and children. Also called: school sores