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Objective data as perceived by the examiner?
Signs
-
Removal of fluids from a body cavity, wound, or other source of discharge by one or more methods?
Drainage
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Fluid, cells, or other substances that have been slowly discharged from cells or blood vessels through small pores or breaks in cell membrane, usually as a result of inflammation or injury?
Exudate
-
Subjective data as perceived by the patient?
Symptoms
-
What is pruritus?
Itching
-
It is any disturbance of a structure or function of the body; a pathological condition of the body?
Disease
-
This disease develops slowly and persists over a long period, often for a person's lifetime?
Chronic
-
This disease is partial or complete disappearance of clinical and subjective characteristics of a disease?
Remission
-
This disease begins abruptly with marked intensity of severe signs and symptoms and then often subsides after a period of treatment?
Acute
-
Results in structural change in an organ that interferes with its functioning?
Organic diseases
-
May be manifested as organic disease, but careful examination fails to reveal evidence of structural or physiologic abnormalities?
Functional disease
-
Caused by an invasion of microorganisms, such as bacteria, viruses, fungi, or parasites that produce tissue damage?
Infection
-
Protective response of the body tissues to irritation, injury, or invasion by disease-producing organisms?
Inflammation
-
What are the cardinal signs of infection and inflammation?
- Erythema
- Edema
- Heat
- Pain
- Purulent drainage
- Loss of function
-
The process of making an evaluation or appraisal of the patient's condition?
Assessment
-
What is the initial step in the assessment process?
Nursing Health History
-
High-pitched, drumlike sound produced over hollow organs (i.e. stomach)?
Tympany
-
Low-pitched, thudlike sound upon percussion of dense organ (i.e. liver)?
Dullness
-
Soft, highpitched flat sound produced by percussion over tissue (i.e. muscle)?
Flatness
-
What does the PQRST method stand for?
- P - provocative/palliative
- Q - quality/quantity
- R -
region/radiation- S
- severity- T
- timing
-
Concentration of attention on the part of the body where signs and symptoms are localized or most active in order to determine their significance?
Focused assessment
-
What is the purpose of the nursing physical assessment?
To determine the patient's state of health or illness
-
Elasticity of the skin caused by the outward pressure of the cells and interstitial fluid?
Turgor
-
Vibrating sensation along the artery?
Thrill
-
Abnormal "swishing" sounds heard over organs, glands, and arteries?
Bruits
-
Respiratory sounds produced by fluid in bronchioles and alveoli?
Crackles
-
Respiratory sounds produced by the movement of air through narrowed passages in the tracheobronchial tree?
Wheezes
-
High-pitched, loud rushing sound heard over abdomen?
Borborygmi
-
What is the pitting edema scale?
- 1+ - barely perceptible
- 2+ - mild (10-15 sec)
- 3+ - moderate (30sec-1min)
- 4+ severe (1-5min)
-
What is the order of which we assess the abdomen?
- 1. Inspect
- 2. Auscultate
- 3. Palpate
- 4. Percuss
-
What are the six steps of the Nursing Process?
- 1. Assessment
- 2. Diagnosis
- 3. Identify Outcome
- 4. Planning
- 5. Implementation
- 6. Evaluation
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