Abnormal Assessment in Nursing Practice

Acute change in clients status

Example: giving pain medication and the pt's respiratory rate drops

Chronic findings due to previous illness

Example: barrel chest, 2LPM at home and comes in with 2LPM

Acute on Chronic

Example: 2LPM at home comes in on 6LPM

Lethargic

Slow moving, a step down from drowsiness, take awhile to open eyes

Obtunded

A level down below lethargy- requires repeated stimuli to stay awake, painful stimuli, eyes open 15 seconds or less

Stuporous

Firm stimuli to stay awake

Aphasia

Unable to speak, try to speak nothing comes out, pt's can get very anxious/aggravated, use a communication board to help these pt's. Usually occurs suddenly, often following a stroke or head injury, and impairs the client's expression and understanding of language

Dysphasia

Difficulty speaking

Neuropathy

Nerve damage causes numbness

Paresthesia

Described as burning. Pins and needle feeling

Dysarthria

Slurred or slow speech that can be difficult to understand

Tachycardia

Heart rate greater than 100

Bradycardia

Heart rate less than 60

Hypotension

BP less than 90/60

Hypertension

BP anything over 120/80

Murmur

Abnormal heart sound

Arrhythmia

Irregular rhythm

Edema

Swelling, pitting/non pitting- determined by indention

Palpitations

Pt may say they feel like their heart is racing or fluttering

Clubbing

Enlargement of fingers or toes that causes the normal angle of skin and nail plate to be lost as a result of chronic hypoxia

Tachypnea

A respiratory rate greater than 20

Bradypnea

Respiratory rate less than 12

Retractions

Abnormal breathing that involves the abdomen/diaphragm- abdominal caving

Dyspnea

Shortness of breath, difficulty breathing

DOE

Dyspnea on exertion

Orthopnea

Difficulty breathing while lying down but resolved when sitting up or standing

Apnea

Period of not breathing

Cyanosis

Bluish discoloration of the skin and mucous membranes

Circumoral

Blue around the mouth

Emesis

Vomiting

Ascites

Fluid collection in the peritoneal cavity of the abdomen

Dysphagia

Difficulty swallowing

Enema

Procedure used to relieve constipation

Polyuria

Frequent urination

Nocturia

Frequent urination at night

Oliguria

Decrease urination output less than 30mL's per hour

Anuric

No urine output

Retention

Holding on to urine

Dysuria

Difficulty urinating

Hematuria

Blood in urine

Weakness

Lack of physical strength and energy

Flaccid

Lacking firmness, resilience, or muscle tone- dropping without elasticity

Paralysis

The loss of the ability to move (and sometimes to feel anything) in part or most of the body, typically as a result of illness, poison, or injury. No sensation

Contracture

The permanent tightening of muscles, tendons, skin, and other tissues, leading to a decrease in flexibility and mobility

Scoliosis

Spine twists and curves to the side

Kyphosis

Forward curvature of the spine

Ecchymosis

Bruising

Mottling

Spotting of the skin that's discolored

Tinting

Skin does not go back down example: dehydration (poor turgor)

Non tinting

Skin goes back down

Proximal

Closer to the point of identifying

Distal

Further from the point you identifying

Anterior

Front side

Posterior

Back side

Lateral

Away from midline

Medial

Closer to midline

Superior

Upper, towards the head of the body

Dorsal

Back part of the body

Inferior

Towards the bottom or away from the head-end of the body