Chapter 12 MSN Health Assesment
Terms
undefined, object
copy deck
- high-pitched, loud, rushing sounds produced by the movement of gass in the liquid contents of the intestine
- Borborygmi
- physical examination tecnique that uses the sense of touch to assess texture, temperature, moisture, organ location and size, vibrations and pulsations, swelling, masses, and tenderness
- Palpation
- hight-pitched harsh sound heard on inspiration when the trachea or larynx is obstructed
- Stridor
- bluish or dark purple discoloration of the lips, skin, or nail beds
- Cyanosis
- indirect measurement of cardiac output obtained by counting the number of prepheral pulse waves over a pulse point
- Pulse rate
- low-pitched grating sound on inhalation and exhalation
- Pleural Friction Rub
- respiratory rate greater than 24 breaths per minute
- Tachypnea
- abnormal, low-pitched breath sound, louder on exhalation
- Sonorous Wheeze
- abnormal breath sound
- Adventitous Breath Sound
- abnormal breath sounds that resembles a popping sound, heard in inhalation and exhalation, not cleared by coughing
- Crackle
- review of the client's functional health patterns prior to the current contact with the health care agency
- Health History
- physical examination technique that involves listening to sounds in the body that are created by movement of air or fluid
- Auscultation
- heart rate less than 60 beats per minute in an adult
- Bradycardia
- physical examination technique that uses short, tapping strokes on the surface of the skin to create vibrations of underlying organs
- Percussion
- condition in which the apical pulse rate is greater than the radial pulse rate
- Pulse Deficit
- regulartity of the heartbeat
- Pulse Rhythm
- chart containing various-sized letters with standardized numbers at the end of each line of letters
- Snellen Chart
- brief account of any recent signs or symptoms related to any body system
- Review of Systems
- medium-pitched and blowing sounds heard equally on inspiration and expiration from air moving through the large airways
- Bronchovesicular Sound
- easy respirations with a rate of breaths per minute that are age appropriate
- Eupnea
- outward expression of mood or emotions
- Affect
- respiratory rate of 10 or fewer breaths per minute
- Bradypnea
- physical examination technique thorough visual observation
- Inspection
- heart rate in excess of 100 beats per minute in an adult
- Tachycardia
- abnormal breath sound, hight pitched and whistlelike in nature, during inhalation and exhalation
- Sibilant Wheeze
- breathing characterized by shalow respirations
- Hypoventilation
- soft, breezy, low-pitched sound heard longer on inspiration than expiration that results from air moving through the smaller airways over the lung prephery, with the exeption of the scapular area
- Vesicular Sound
- measurment of the strength or force exerted by the ejected blood against the arterial wall with each contraction
- Pulse Amplitude
- difficulty breathing as observed by labored or forced respirations through the use of accssory muscles in the chest and neck
- Dyspnea
- loud, tubular, hollow-sounding breath sound normally heard over the sternum
- Bronchial Sound
- significant decrease in blood pressure that results in dizziness or lightheadedness when a person moves from a lying or sitting (supine) position to a standing position
- Orthostatic Hypotension
- breathing characterized by deep, rapid respirations
- Hyperventilation
- apical pulse
- AP
- blood pressure
- BP
- centimeter
- cm
- left lower quadrant
- LLQ
- level of conciousness
- LC
- left upper quadrant
- LUQ
- pulse
- P
- pupils equal, round, reacts to light and accomodation
- PERRLA
- respiration
- R
- temperature
- T
- right lower qaudrant
- RLQ
- review of systems
- ROS
- right upper quadrant
- RUQ
- determine if patient is functioning within the parameters expected for their age group ie. involved with family, involved with their children
- Developmental Level
- assessment of dimensions such as self-concept and self-esteem as well as usual sources of stress and the patient's ability to cope
- Psychosocial History
- inquiry about the home environment, family situation, and the client's role in the family. ie caffeine and alcohol intake
- Socioculture
-
location
character
intensity
timing
aggravating/alleviating factors - Review of systems
- demographic info, reason for seeking health care, perception of health status, previous illness, hospitaliations and surgeries, client/family medical history, immunizations/exposure to comunicable diseases, allergies, current meds, developmental level, p
- Health History
- inspection, palpation, percussion, auscultation
- Physical Examination
- general survey, vital signs, height and weight, head and neck assessment, mental and neurological status and affect, skin assessmnet, thoracic assessment, abdominal assessment, muskuloskeletal and extremity assessment
- Head-to-toe assessment
- introduction, general state of health and any signs of distress ie pain, breathing difficulties. Patient's awareness of the surroundings, body type and posture, fascial expressions and mood
- General Survey
-
noraml temperature is between 36.5C - 37.5C
Axillary - under arm
Tympanic - ear
Oral - mouth
Rectal - rectum - Normal temperature and temperature points
- normal pulse is 60 -100 BPM
- Normal Pulse
- normal respirations is 16 - 20 RPM
- Normal Respirations
- normal blood pressure is 90/60 - 140/90
- Normal Blood Pressure
- under breast on right side
- Apical Pulse Point
- inside upper arm
- Brachial Pulse Point
- outside wrist
- Radial Pulse Point
- inside wrist
- Ulnar Pulse Point
- behind knee
- Popliteal Pulse Point
- behind ankle
- Posterior Tibial Pulse Point
- front of ankle
- Dorsalis Pedis Pulse Point
- the force exerted by the blood against the wall of the artery as the heart contracts and relaxes
- Arterial pressure
- when the ventricals contract and blood is forced into the aorta and pulmonary arteries, first sound heard
- Systolic Arterial Pressure
- when the heart is in the filling or relaxed stage, last sound heard
- Dialostolic Blood Pressure
- difference between the systolic and diastolic
- Pulse Pressure