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41 Cards in this Set
- Front
- Back
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acute
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begins abruptly with intense signs and symptoms
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borborygmi
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high pitched, loud, rushing bowel sounds
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bruit
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abnormal swishing sound heard over arteries
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chronic
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develops slowly and persists over a long period of time
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dullness
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a thudlike sound heard with percussion
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erythema
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redness, result of dilation and congestion of superficial capillaries
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etiology
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refers to cause of disease
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exudate
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fluid, cells, or other debris that have been slowly discharged
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focused assessment
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concentration of attention on a specific area of the body
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functional disease
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failure of examination to reveal evidence of structural or physiological abnormalities
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thrill
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vibrating sensation along the arteries that can be palpated
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turgor
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the elasticity of the skin
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tympany
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high-pitched, drumlike sound heard with percussion
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wheeze
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sibilant or sonorous sound produced bu fluid in the bronchioles and alveoli
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inspection
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purposeful observation
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palpation
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sense of touch to gather data
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percussion
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tap on surface of body to produce a sound
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auscultation
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listening to sounds
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olfaction
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smelling
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ASSESSMENT TECHNIQUES
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Inspection
Palpation Percussion Auscultation Olfaction |
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Pulse Locations
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Temporal
Carotid Apical Brachial Radial Femoral Popliteal Dorsal Pedis Medial Malleolus |
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CTAB
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clear to auscultation bilaterally
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A & O
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Alert and Oriented
* person * place * time * situation |
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Adventitious
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Abnormal Sounds
* wheeze * Ronchi * Crackles |
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Subjective
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Say
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Objective
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See
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Glasgow Coma Scale
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Alertness
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Skin Color
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cyanosis - blue
jaundice - yellow pallor - pale/white |
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Skin
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Color, Temperature, Moisture, Texture, Turgor, Injury or lesion
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JVD
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Jugular Vein Distention @ 45*
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PERRLA
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Pupils Equal Round Reactive to Light Accomodation
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Homan's
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Dorsiflex - checking for tenderness in calf
DVT's |
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Wound Drainage
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Serous - clear, watery plasma
Purulent - pus, thick yellow, green, tan or brown Serosanguineous - Pale, red, watery mixture Sanguineous - Bright red indicates active bleedinf |
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Capillary Refill
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fingernails, toenails
Normal refill time 2 seconds |
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Echymosis
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Bruise
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Spine Assessment
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Scoliosis - lateral curve
Lordosis - sway back lumbar curve Kyphosis - humpback - cervical curve |
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Neuro Check
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Proprioception
Motor function sensory function LOC - level of consciousness Cranial Nerves I-XII |
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ROM
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Range of Motion
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Abdomen
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Bowel sounds
percussion auscultation |
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Heart Assessment
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Lubb-Dupp
sounds of heart is caused by the closure of the AV (atrioventricular) and semilunar valves |
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Heart
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0 - absent
1+ - thready 2 + - weak 3+ - normal 4+ - bounding |
