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48 Cards in this Set

  • Front
  • Back
Physical Examination
is a systematic, orderly process by which the nurse collects objective data about the client's body, mind and spirit.
It is a critical investigation and evaluation of client's present status.
Validation
Comparing data with another source
Inspection
Visual examination, to observe, to look, to smell
Palpation
using the sense of touch; to feel, to stroke the surface of an area to detect its characteristics such as temperature, vibration, turgor, texture, masses, etc.
Auscultation
listening to sounds produced in the body, usually aided by a stethoscope
Dyspnea
difficulty in breathing
Hemoptysis
Bloody sputum
Cyanotic
blue, blue-gray
Mottled
patchy areas of blue
Pallor
pale
Flushed
reddish hue
Diaphoretic
skin moist with perspiration
Level of Consciousness (LOC)
the client's awareness of his surroundings
Complaint
statement of any symptom or problem
Adjunct equipment
includes any medical equipment or devices in use
Dysphasia
difficulty with speech or understanding the spoken word
Jaundice
yellowish- orange skin, sclera, mm

in darked skin: assess hard palate

excess bilirubin; liver or hemolytic disease
Erythema
red

increased blood flow

inflammation

rashes
Senile Lentigo
brown age spots due to sun exposure
Diaphoresis
perspiration
Edema (Effusion)
the abnormal presence of fluid in the body
Periorbital
edema around the eyes
Ascites
edema in the abdominal cavity
Anasarca
all over edema
Lesions
any abnormal area of the skin

ex.: wound, cyst, rash, boil, tumor
Myopia
nearsightedness
Hyperopia
farsightedness
Presbyopia
lens is unable to change shape to accommodate close vision
Ptosis
drooping of the eyelid
Arcus senilis
bilateral gray ring around the iris due to lipid deposits
Cataracts
cloudiness of the lens
PERRLA
Pupils are equal, round, react to light, and accommodate
Mydriasis
dilation for distant
Miosis
pinpoint constriction for close
Cerumen
ear wax
Edentulous
no teeth, or a number of them missing
FROM
Full Range of Motion
Bronchial sounds
over trachea

harsh, loud

duration of I<E
Bronchovesicular sounds
1-2 ICS, SB and posteriorly between the scapulae

I=E
Vesicular sounds
very quiet

I>E
Adventitious sounds
unequal sounds or if the incorrect sound is heard in a location
Body temperature
the heat of the body determined by the balance of heat produced and heat lost
Core temperature
reflects temperature of the core body tissues (vital organs)

ex.: tympanic and rectal
Surface temperature
temperature varies according to site used

lower than core

Oral and axillary
Hypothermia
subnormal, temp less than 96.8 F or 36 C
Fever (Pyrexia)
temp is above 100.4 F or 38 C
pulse pressure
difference in systolic and diatolic BP
Respiration
act of breathing for 1 min.