Health assessment week 2 vocabulary

Amplitude

intensity

a loud or soft sound

duration

“How long did the symptom last?

How long the sound lasts or lingers.

pitch

• How many vibrations occur per second.
  Higher frequency = higher pitch.

• Quality (timbre):

• 
  The unique “color” or character of a sound, created by overtones.
  

Consciousness:

Being aware of one’s own existence, feelings, and thoughts and of the environment. This is the most elementary of mental status functions.

Delirium

is an acute confusional change or loss of consciousness and perceptual disturbance; it may accompany acute illness

(e.g., pneumonia, alcohol/drug intoxication), and it is usually resolved when the underlying cause is treated.

Dementia

gradual, progressive process, causing decreased cognitive function even though the person is fully conscious and awake; it is not reversible. Alzheimer disease accounts for about two-thirds of cases of dementia in older adults

Memory

The ability to lay down and store experiences and perceptions for later recall. Recent memory evokes day-to-day events; remote memory brings up years’ worth of experiences.

Mood

Both of these elements deal with the prevailing feelings. Affect is a temporary expression of feelings or state of mind, and mood is more durable, a prolonged display of feelings that color the whole emotional life.

Orientation

The awareness of the objective world in relation to the self, including person, place, and time.

Perceptions

An awareness of objects through the five senses.

Thought content

What the person thinks—specific ideas, beliefs, the use of words.

Thought process

The way a person thinks; the logical train of thought.

Visuospatial

o a person’s capacity to understand, perceive, organize, and manipulate visual information in space.

Acute pain

is short term and self-limiting, often follows a predictable trajectory, and dissipates after an injury heals.

Examples of acute pain include surgery, trauma, and kidney stones. Acute pain has a self-protective purpose; it warns the individual of actual or threatened tissue damage. Incident pain is an acute type that happens predictably when certain movements take place

Breakthrough pain

is a transient spike in pain level, moderate to severe in intensity, in an otherwise controlled pain syndrome. It can result from end-of-dose medication failure. This occurs when a patient taking a long-acting opioid has a recurrence of pain before the next scheduled dose.

Chronic pain

diagnosed when the pain continues for 6 months or longer. Chronic pain can be divided into malignant (cancer-related) and nonmalignant. Malignant pain often parallels the pathology created by the tumor cells. The pain is induced by tissue necrosis or stretching of an organ by the growing tumor. It fluctuates within the course of the disease.

Cutaneous pain

is derived from skin surface and subcutaneous tissues. Deep somatic pain often is described as aching or throbbing, whereas cutaneous pain is superficial, sharp, or burning.

Neuropathic pain

is pain that does not adhere to the typical and rather predictable phases in nociceptive pain. It is pain due to a lesion or disease in the somatosensory nervous system.3 Neuropathic pain implies an abnormal processing of the pain message from an injury to the nerve fibers. This type of pain is the most difficult to assess and treat. Pain is often perceived long after the site of injury heals, and it evolves into a chronic condition.

Pain

can be classified by its duration into acute or chronic categories (chronic is called persistent because it carries a less negative, malingering connotation). The duration provides information on possible underlying mechanisms and treatment decisions.

According to Jarvis, pain is defined as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.”

Referred pain

Pain that is felt at a particular site but originates from another location

Somatic pain

originates from musculoskeletal tissues or the body surface

Visceral pain

originates from the larger internal organs (i.e., stomach, intestine, gallbladder, pancreas). It often is described as dull, deep, squeezing, or cramping. The pain can stem from direct injury to the organ or stretching of the organ from tumor, ischemia, distention, or severe contraction.

Anthropometry

the measurement of the body and its proportions to assess nutritional status and growth patterns.

Body mass index

s a practical marker of healthy weight for height and an indicator of obesity or malnutrition. Traditionally, BMI is used to guide patient progress toward a healthy weight and is used to identify people at high risk for developing health problems such as cardiovascular disease. BMI expresses the relationship between height and weight but does not consider other variables such as muscle mass.

Diet history

is the detailed record of a person’s usual food intake, eating patterns, and nutritional habits. It helps the nurse understand the patient’s nutritional status, cultural influences, access to food, and potential risk factors.

Subjective Data

Malnutrition

thin, shiny, atrophic skin; thick-ridged nails; loss of hair; ulcers; gangrene. Malnutrition, pallor, and coolness occur with arterial insufficiency.

Nutritional monitoring

ongoing, repeated assessment of a patient’s nutritional status to evaluate progress toward goals and determine the effectiveness of nutritional interventions

Nutrition screening

is the first step in assessing nutritional status. Based on easily obtained data, nutrition screening is a quick and easy way to identify individuals at nutrition risk such as those with weight loss, inadequate food intake, or recent illness.

obesity

caused by caloric excess refers to weight more than 20% above ideal body weight or body mass index (BMI) of 30.0-39.9. The causes are complex and multifaceted—genetic, social, cultural, pathologic, psychological, and physiologic factors.

Recommended dietary allowance

The average daily nutrient intake level that is sufficient to meet the requirements of nearly all (97–98%) healthy individuals in a particular life stage and gender group.”

Sarcopenic obesity

is characterized by low muscle mass with excess fat and puts individuals at greater risk for poor health outcomes.7 Sarcopenic obesity results in a loss of muscle strength and function, decreased quality of life, physical frailty, and increased mortality rates.

allopecia

is a significant loss. A full head of hair equates with vitality in many cultures. If treated as a trivial problem, the person may seek alternative, unproven methods of treatment.

annular

or circular, begins in center and spreads to periphery (e.g., tinea corporis or ringworm, tinea versicolor, pityriasis rosea)

bulla

Larger than 1 cm diameter; usually single chambered (unilocular); superficial in epidermis; thin-walled and ruptures easily. Examples: friction blister, pemphigus, burns, contact dermatitis.

crust

The thickened, dried-out exudate left when vesicles/pustules burst or dry up. Color can be red-brown, honey, or yellow, depending on fluid ingredients (blood, serum, pus).

Cyanosis

This is a bluish mottled color from decreased perfusion (Fig. 13.5); the tissues have high levels of deoxygenated blood. This is best seen in the lips, nose, cheeks, ears, and oral mucous membranes and in artificial fluorescent light.

Erythema

Intense redness of the skin is from excess blood (hyperemia) in the dilated superficial capillaries. This sign is expected with fever, local inflammation, or emotional reactions such as blushing in vascular flush areas (cheeks, neck, and upper chest).

Excoriation

self-inflicted abrasion; superficial; sometimes crusted; scratches from intense itching. Examples: insect bites, scabies, dermatitis, varicella.

Fissure

Linear crack with abrupt edges; extends into dermis; dry or moist. Examples: cheilosis—at corners of mouth caused by excess moisture; athlete’s foot.

Furuncle

exquisitely painful, reddened, infected hair follicle. It may occur on tragus on cartilaginous part of ear canal.

Jaundice

A yellowish skin color indicates rising amounts of bilirubin in the blood.

Keloid

A benign excess of scar tissue beyond sites of original injury: surgery, acne, ear piercing, tattoos, infections, burns.16 Looks smooth, rubbery, shiny, and “clawlike”; feels smooth and firm. Found in ear lobes, back of neck, scalp, chest, and back; may occur months to years after initial trauma. Most common ages are 10-30 years; higher incidence in Black, Latino, and Asian people

Lichenification

Prolonged, intense scratching eventually thickens skin and produces tightly packed sets of papules; looks like surface of moss (or lichen).

Lipoma

A benign, fatty tumor located in the subcutaneous tissue that feels soft, rubbery, and well‑defined. It is usually movable under the skin and is not tender.

Maceration

The softening, breakdown, or “soggy” appearance of skin that occurs when it has been exposed to moisture for a prolonged period.

Macule

Solely a color change, flat and circumscribed, of less than 1 cm. Examples: freckles, flat nevi, hypopigmentation, petechiae, measles, scarlet fever.

nevus

A benign skin lesion commonly known as a mole. It is usually a flat or raised, uniformly colored area resulting from a proliferation of melanocytes

nodule

Solid, elevated, hard or soft, larger than 1 cm. May extend deeper into dermis than papule. Examples: xanthoma, fibroma, intradermal nevi.

pallor

When the red-pink tones from the oxygenated hemoglobin in the blood are lost, the skin takes on the color of connective tissue (collagen), which is mostly white

Plaque

Papules coalesce to form surface elevation wider than 1 cm. A plateaulike, disk-shaped lesion. Examples: psoriasis, lichen planus.

Pruritus

excessive itching

An unpleasant sensation of the skin that provokes the desire to scratch.

purpura

confluent and extensive patch of petechiae and ecchymoses; >3 mm, flat, red to purple, macular hemorrhage. Seen in generalized disorders such as thrombocytopenia, coagulation disorders, and scurvy. Also occurs in old age as blood leaks from capillaries in response to minor trauma and diffuses through dermis.

pustule

Turbid fluid (pus) in the cavity. Circumscribed and elevated. Examples: impetigo, acne.

scale

Compact, desiccated flakes of skin, dry or greasy, silvery or white, from shedding of dead excess keratin cells. Examples: after scarlet fever or drug reaction (laminated sheets), psoriasis (silver, micalike), seborrheic dermatitis (yellow, greasy), eczema, ichthyosis (large, adherent, laminated), dry skin.

telengastia

Caused by permanently enlarged and dilated blood vessels that are visible on the skin surface. May use cosmetics or other treatment (e.g., specialized injection sclerotherapy and laser).

Ulcer

Deeper depression extending into dermis, irregular shape; may bleed; leaves scar when heals. Examples: stasis ulcer, pressure injury, chancre.

Vesicle

bubble fluid small

wheal

superficial, raised, transient, and erythematous; slightly irregular shape from edema (fluid held diffusely in the tissues). Examples: mosquito bite, allergic reaction, dermographism.