Comprehensive Nursing Assessment: Fluids, Electrolytes, Acid-Base, Abdomen, Nutrition, Breast, Urinary, and Musculoskeletal Systems

Vocabulary practice flashcards covering health assessment and clinical interventions across body fluids, electrolytes, acid-base balance, nutrition, abdomen, breasts, urinary tract, and the musculoskeletal system.

Intracellular Fluid (ICF)

The fluid compartment contained within cells, accounting for approximately $2/3$ of total body water (about $20\,\text{liters}$ in an adult), in which potassium ($\text{K}^+$) serves as the primary active cation.

Extracellular Fluid (ECF)

The fluid compartment outside the cells, comprising approximately $1/3$ of total body water, subdivided into interstitial fluid (about $11\,\text{liters}$) and intravascular blood plasma (about $3\,\text{liters}$), with sodium ($\text{Na}^+$) functioning as the primary active cation.

Hydrostatic Pressure

The physical force exerted by fluid pressing outward against a surface or capillary wall that drives filtration from areas of higher pressure to areas of lower pressure.

Hypovolemia

An isotonic extracellular fluid volume deficit where fluid and electrolyte loss exceeds intake with normal osmolality, presenting clinically with hypotension, tachycardia with a weak and thready pulse, decreased skin turgor, oliguria, increased blood urea nitrogen ($\text{BUN} > 20\,\text{mg/dL}$), and elevated urine specific gravity ($> 1.030$).

Hypervolemia

An isotonic extracellular fluid volume excess where fluid and sodium intake exceeds output, characterized by hypertension, bounding peripheral pulses, jugular vein distention (JVD), weight gain, peripheral edema, crackles on pulmonary auscultation, decreased hematocrit, and low blood urea nitrogen ($\text{BUN} < 7\,\text{mg/dL}$).

Clinical Dehydration

A hypertonic fluid volume deficit resulting from a combined loss of extracellular fluid volume and disproportionate water loss relative to sodium (hypovolemia plus hypernatremia), causing body fluids to become hypertonic and cells to shrink.

Hyponatremia

A serum sodium level below $135\,\text{mEq/L}$ (or $< 136\,\text{mEq/L}$), indicating a hypotonic state and water excess that causes fluid to shift into cells, potentially resulting in cerebral edema, headache, confusion, lethargy, muscle weakness, and seizures.

Hyperkalemia

A serum potassium level exceeding $5.0\,\text{mEq/L}$, commonly associated with renal failure, massive burns, crushing injuries, or acidosis, which leads to anxiety, irritability, hyperactive deep tendon reflexes, muscle weakness, flaccid paralysis, and life-threatening cardiac dysrhythmias including bradycardia and heart block.

Hypocalcemia

A serum calcium level below $8.5\,\text{mg/dL}$ (or $< 9.0\,\text{mg/dL}$), resulting in neuromuscular irritability, muscle cramping that may progress to tetany and seizures, hyperactive reflexes, cardiac dysrhythmias, and positive Chvostek and Trousseau signs.

Hypomagnesemia

A serum magnesium level below $1.3\,\text{mEq/L}$, leading to heightened neuromuscular excitability, hyperactive deep tendon reflexes, tremors, seizures, dysphagia, and tachyarrhythmias.

Respiratory Acidosis

An acid-base disturbance characterized by an arterial $\text{pH} < 7.35$ and a elevated $\text{PaCO}_2 > 45\,\text{mm Hg}$, caused by alveolar hypoventilation (from conditions such as chest injury, asthma attack, pulmonary edema, or opioid/sedative administration) resulting in carbonic acid retention.

Metabolic Acidosis

An acid-base disturbance characterized by an arterial $\text{pH} < 7.35$ and a decreased bicarbonate concentration ($\text{HCO}_3^- < 21\,\text{mEq/L}$), caused by excessive accumulation of metabolic acids (e.g., diabetic ketoacidosis, shock, lactic acidosis) or severe bicarbonate loss (e.g., chronic diarrhea), which triggers compensatory Kussmaul respirations.

Infiltration (IV)

The inadvertent leakage of non-vesicant intravenous fluid into the surrounding subcutaneous tissue, presenting with site coolness, pallor, localized edema, tenderness, and a sluggish infusion rate.

Phlebitis (IV)

Inflammation of a vein wall associated with mechanical irritation, chemical factors (such as potassium chloride or acidic infusions), or lack of aseptic technique, manifesting as warmth, erythema, localized edema, and pain along the venous path.

Cachexia

A state of profound undernutrition characterized by severe muscle and adipose tissue wasting, commonly occurring as a complication of chronic illnesses such as cancer, chronic heart failure, tuberculosis, and advanced AIDS.

Metabolic Syndrome

A cluster of metabolic abnormalities that significantly increases the risk for coronary artery disease, type 2 diabetes mellitus, and mortality, diagnosed by the presence of at least $3$ of the following $5$ biomarkers: elevated blood pressure ($\ge 130\,\text{mm Hg}$ systolic or $\ge 85\,\text{mm Hg}$ diastolic), elevated fasting blood glucose ($\ge 100\,\text{mg/dL}$), hypertriglyceridemia ($\ge 150\,\text{mg/dL}$), abdominal obesity (waist circumference $\ge 102\,\text{cm}$ in men or $\ge 88\,\text{cm}$ in women), and reduced high-density lipoprotein cholesterol ($< 40\,\text{mg/dL}$ in men or $< 50\,\text{mg/dL}$ in women).

Hemoglobin A1C (HbA1c)

A blood assay that measures average glycemic control over the preceding $2\text{--}3\,\text{months}$, where a result $\ge 6.5\%$ is diagnostic of diabetes mellitus, $5.7\text{--}6.4\%$ indicates prediabetes, and $< 7.0\%$ indicates good diabetic control.

Scaphoid Abdomen

An abnormal concave abdominal contour where the anterior wall appears sunken or caved inward, associated with severe malnutrition, wasting states, or diaphragmatic hernia in neonates.

Borborygmi

Loud, high-pitched, rushing, hyperactive bowel sounds occurring at a rate greater than $30/\text{min}$, indicative of accelerated peristalsis seen in diarrhea or early mechanical bowel obstruction.

Murphy's Sign

A clinical examination maneuver for acute cholecystitis in which the clinician palpates deeply at the right costal margin while the patient takes a deep breath; sudden stoppage of inspiration accompanied by sharp pain constitutes a positive finding.

Rovsing's Sign

A diagnostic sign of peritoneal irritation and acute appendicitis where deep pressure applied to the left lower quadrant (LLQ) elicits referred pain in the right lower quadrant (RLQ).

Blumberg's Sign

A test for peritoneal inflammation (rebound tenderness) performed by depressing the abdominal wall slowly and deeply and releasing abruptly; an exacerbation of pain upon release indicates a positive test.

Ascites

The abnormal accumulation of serous fluid within the peritoneal cavity, commonly secondary to hepatic cirrhosis, portal hypertension, or heart failure, presenting with abdominal distention, bulging flanks, a downward-pointing umbilicus, shifting dullness on percussion, and a positive fluid wave.

Salem Sump Tube

A double-lumen nasogastric tube used for gastric decompression that features a large lumen for suctioning contents and a smaller vented blue pigtail lumen that admits atmospheric air to prevent mucosal adherence and trauma.

Melena

Black, tarry, foul-smelling stools resulting from the degradation of hemoglobin by gastrointestinal enzymes and bacteria, signifying bleeding occurring in the upper gastrointestinal tract.

Suspensory Ligaments of Cooper

Fibrous bands of connective tissue that extend vertically from the deep pectoral fascia to the overlying skin of the breast, providing structural support and maintaining breast contour.

Fibrocystic Breast Disease

A benign breast condition involving fluid-filled mammary cysts and epithelial proliferation, characterized by bilateral, tender, freely mobile cysts that fluctuate in size and pain cyclically with the menstrual cycle.

Fibroadenoma

The most common benign solid breast tumor in women under $30\,\text{years}$ of age, presenting as a solitary, firm, rubbery, nontender, well-delineated, and freely movable mass that does not alter with menstrual cycles.

Peau d'Orange

A thickened, dimpled skin surface resembling an orange peel, caused by cutaneous lymphatic obstruction and localized edema that accentuates hair follicles; an ominous clinical indicator of locally advanced or inflammatory breast cancer.

Mastitis

An acute infection and inflammation of breast tissue that most commonly develops during postpartum lactation, presenting with unilateral localized pain, erythema, warmth, engorgement, fever, chills, and malaise.

Oliguria

A marked reduction in urinary output to less than or equal to $400\,\text{mL}$ per $24\,\text{hours}$ in an adult (or less than $30\,\text{mL/hour}$), signaling fluid volume deficit, renal failure, or urinary tract obstruction.

Stress Incontinence

The involuntary loss of urine resulting from increased intra-abdominal pressure (e.g., during coughing, sneezing, laughing, lifting, or physical exertion) against relaxed pelvic floor musculature or a compromised urethral sphincter.

Urge Incontinence

The involuntary leakage of urine preceded by a sudden, intense desire to void, caused by involuntary detrusor muscle contractions or bladder hypersensitivity associated with urinary tract infections or neurological dysfunction.

Costovertebral Angle (CVA) Tenderness

Pain and tenderness elicited by indirect percussion over the 12th rib at the costovertebral angle on the back, indicating inflammation of the renal capsule or parenchyma as seen in pyelonephritis or obstructing renal calculi.

Nephrolithiasis

The formation of mineral or acid-salt deposits (calculi) within the renal system, presenting with severe, acute colicky flank pain radiating to the groin, diaphoresis, nausea, and hematuria.

Ankylosis

The abnormal stiffening, immobility, or complete bony and fibrous consolidation of a joint following chronic disease, trauma, or prolonged immobilization.

Phalen's Test

A diagnostic assessment for carpal tunnel syndrome where the patient holds both wrists in acute 90-degree flexion back-to-back for $60\,\text{seconds}$; the reproduction of numbness, paresthesia, or burning along the median nerve distribution signifies a positive result.

Tinel's Sign

A test for carpal tunnel syndrome performed by lightly percussing over the median nerve at the flexor retinaculum of the wrist; a positive result is characterized by tingling or an electrical sensation radiating along the nerve's distribution.

Heberden's Nodes

Hard, bony nodules and osteophytes that develop along the distal interphalangeal (DIP) joints of the fingers, characteristic of advanced osteoarthritis.

Bouchard's Nodes

Hard, bony protuberances and osteophytes that form at the proximal interphalangeal (PIP) joints of the hands in patients diagnosed with degenerative osteoarthritis.

Boutonnière Deformity

A joint abnormality featuring fixed flexion of the proximal interphalangeal (PIP) joint accompanied by hyperextension of the distal interphalangeal (DIP) joint, classically seen in chronic rheumatoid arthritis.

Kyphosis

An exaggerated posterior thoracic curvature of the vertebral column resulting in a rounded or hunchbacked posture, frequently secondary to osteoporosis and vertebral wedge compression fractures in older adults.

Tophi

Subcutaneous, nodular accumulations of monosodium urate crystals located in and around joints, cartilage, and soft tissues in patients suffering from chronic, advanced gout.

Orthostatic Hypotension

A posturally triggered decline in arterial blood pressure defined as a drop of at least $20\,\text{mm Hg}$ systolic or $10\,\text{mm Hg}$ diastolic occurring within $3\,\text{minutes}$ of assuming an upright sitting or standing position, commonly induced by hypovolemia or prolonged immobility.