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the collection of data about an individual's health
assessment
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the western european/north american tradition that views health as the absence of disease
biomedical model
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a complete health history and full pxy exam
complete database
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simultaneously problem-solving while self employing one's own thinking ability
critical thinking
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a method of collecting and analyzing clinical info w/ the following components:
1- attending to initially available cues
2- formulating diagnostic hypotheses
3- gathering data relative to the tentative hypotheses
4- evaluating each hypothesis with the new data collected
5- arriving at a final diagnosis
diagnostic reasoning
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rapid collection of the database, often compiled concurrently with lifesaving measures
emergency database
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the total of all conditions and elements that make up the surroundings and influence the development of a person
environment
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a systematic approach emphasizing the best reseach evidence, the clinitian's experience, patient preferences and values, pxy exam, and assessment
evidence-based practice
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one used for a limited or short-term problem; concerns mainly one problem, one cue complex, or one body system
focused database
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used in all settings to monitor progress on short-term or chronic health problems
follow-up database
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the view that the mind, body, and spirit are interdepenedent and function as a whole within the environment
holistic health
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used to evaluate the cause and etiology of disease; focus is on the function or malfunction of a specific organ system
medical diagnosis
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used to evaluate the response of the whole person to actual or potential health problems
nursing diagnosis
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a method of collecting and analyzing clinical info with the following components:
1- assessment
2- diagnosis
3- outcome identification
4- planning
5- implementation
6- evaluation
nursing process
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what the health professional obeserves by inspecting, palpating, percussion, and auscultating during the pxy exam
objective data
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an action directed toward promoting health and preventing the occurrence of disease
prevention
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what the person says about himself or herself during history taking
subjective data
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a dynamic process and view of health; a move toward optimal functioning
wellness
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situation towards the front of the body
anterior
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situated at or toward the hind of the body
posterior
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situated next to or near the point of attachment or origin or a central point
proximal
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situated away from the point of attachment or origin or a central point
distal
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lying or extending toward the median axis of the body
medial
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lying at or extending toward the right or left side; lying away from the median axis of the body
lateral
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situated toward the head and further away from the feet than another and especially another similar part of an upright body especially of a human being
superior
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situated below and closer to the feet than another and especially another similar part of an upright body especially of a human being
inferior
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meeting between the examiner and patient with the goal of gathering a complete health history
interview
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using medical vocab with patient in an exclusionary and paternalistic way
jargon
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the use of impersonal speech to put space between the self and a threat
distancing
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viewing the world from the other person's inner frame of reference while remaining yourself; recognizing and accepting the other person's feelings without criticism
empathy
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pondering a deeper meaning beyond the concrete and literal
abstract reasoning
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concentration, ability to focus on one specific thing
attention
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being aware of one's own existence, feelings, and thoughts and being aware of the environment
consciousness
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an acute confusional change or loss of consciousness and perceptual disturbance, may accompany acute illness, and usual resolves when the underlying cause is treated
delirium
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a gradual progressive process, causing decreased cognitive function even though the person is fully conscious and awake, and is not reversible
dementia
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using the voice to communicate one's thoughts and feelings
language
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ability to lay down and store experiences and perceptions for later recall
memory
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prolonged display of a person's feelings
mood
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awareness of the objective world in relation to the self
orientation
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awareness of objects through any of the five senses
perceptions
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what the person thinks- specific ideas, beliefs, the use of words
thought content
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the way a person thinks, the logical train of thought
thought process
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(or intensity) how loud or soft a sound is
amplitude
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the length of time a note lingers
duration
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an infection aquired during hospitalization
nosocomial infection
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an instrument that illuminates the interal eye structures, enabling the examiner to look through the pupil at the fundus (background) of the eye
ophthalmoscope
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an instrument that illuminates the ear canal, enabling the examiner to look at the ear canal and tympanic membrane
otoscope
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(or frequency) the number of vibrations (or cycles) per second of a note
pitch
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(or timbre) a subjective difference in a sound due to the sound's distinctive overtones
quality
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a brief period of time when Korotkoff sounds disappear during auscultation of blood pressure; common with hypertension
auscultatory gap
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heart rate <50 beats per min in the adult
bradycardia
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instrument for measuring arterial blood pressure
sphygmomanometer
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amount of blood pumped out of the heart eith each heart beat
stroke volume
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heart rate of >90 beats per min in the adult
tachycardia
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(baldness) hair loss
alopecia
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dusky blue color to skin or mucous membranes due to increased amount of unoxygenated hemoglobin
cyanosis
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the escape of blood into the tissues from ruptured blood vessels marked by a livid black-and-blue or purple spot or area
ecchymosis
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intense redness of the skin due to excess blood in dilated superficial capillaries, as in fever or inflammation
erythema
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self-inflicted abrasion on skin due to scratching
excoriation
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linear crack in skin extending into dermis
fissure
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yellow color to skin, palate, and sclera due to excess bilirubin in the blood
juandice
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hypertrophic scar, elevated beyond site of orginial injury
keloid
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an abnormal change in structure of an organ or part due to injury or disease ; especially : one that is circumscribed and well defined
lesion
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(mole) circumscribed skin lesion due to excess melanocytes
nevus
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excessively pale, whitish pink color to lightly pigmented skin
pallor
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a minute reddish or purplish spot containing blood that appears in skin or mucous membrane as a result of localized hemorrhage
petechia
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red-purple skin lesion due to blood in tissues from breaks in blood vessels
purpura
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skin lesion due to permanently enlarged and dilated blood vessels that are visible
telangiectasis
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sloughing of nectrotic inflammatory tissue that causes a deep depression in skin, extending into the dermis
ulcer
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profuse sweating
diaphoresis
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(liver spots) small, flat, brown macules. circumscribed areas are clusters of melanocytes that appear after extensive sun exposure.
senile lentigines
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elevated cavity containing thick, turbid fluid
pustule
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elevated cavity containing free fluid up to 1cm diameter
vesicle
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