Studied by 126 people
Alopecia
Hair loss
Cyanosis
Blueness or purpleness of skin
Erythema
Redness or pinkness of skin
Jaundice
Yellow skin coloring
Lesion
Broad term referring to a region of the skin that has damage from injury or disease
ex. acne, birthmarks, wounds, sunburn, insect bites
Pallor
Paleness of skin
Pruritus
Itching
Edema
Swelling
Turgor
The skin's elasticity.
It is the ability of skin to change shape and return to normal
Exudate
Discharge
Macules
Freckles
Lanugo
Fine body hair
Vernix caseosa
white, creamy, naturally occurring biofilm covering the skin of the fetus during the last trimester of pregnancy
Velus hair
fine, present all over body
Terminal hair
Thicker hair on head, axilla, genital, and facial regions
PERRLA (acronym)
-Pupils equal + Round
-React to Light and Accomodation (direct constriction in one eye) (open pupil when looking away from light, close when looking close)
How should you check skin temperature?
With the back of your hand
Capillary refill
assessing the blood flow through peripheral tissues
Respiratory retractions
When the area between the ribs and in the neck sinks in when a person with asthma attempts to inhale.
Retractions are a sign someone is working hard to breathe.
Adventitious
Coming from an external source or occurring in an unusual place or manner (abnormal)
Palpate
Examine by touch
Auscultate
Examine by listening
(ex. using a stethoscope to listen to the heart, lungs, and bowels)
Venous pattern
The pattern of blood vessels (arteries and veins), usually referring to the blue vessels located directly under the skin
Integrity
The quality / health of the skin
Objective data
Measurable data collected by the nurse
ex. vital signs
Subjective data
From the client, based on their experiences and perceptions. Includes feelings, sensations, or expectations.
ex. pain
OPQRSTU
O- Onset
P- Provocative, Palliative
Q- Quality
R- Region
S- Severity
T- Timing
U- (Pt’s) Understanding
What are the 4 aspects of general survey?
Physcial appearance
Body structure
Mobility
Behaviour
Gait
Walk
What is the expected range for temperature?
35.8 - 37.3 °C
What is the expected range for heart rate for adults?
60 - 100 bpm
Bradycardia
< 60 bpm
Tachycardia
over 100 bpm, fast heart rate
What are the 4 levels of pulse force?
3+ = full, bounding
2+ = normal
1+ = weak, thready
0 = absent
What side of the wrist is the radial pulse?
thumb side
What is the expected respiratory rate for adults?
10 - 20 breaths/min
Systolic pressure
Maximum pressure felt on the arteries when the heart contracts
Diastolic pressure
Resting pressure in the blood vessels between contractions
What is the expected blood pressure in adults?
120/80
What is the expected finding for oxygen saturation?
< 95%
Whisper test
Standing arms length behind the person, test one ear at a time while masking the hearing in the other ear by palpating the tragus. Say a 2 syllable word.
What should the tips of the ears align with?
The corners of the eyes
What is the expected finding for the anteroposterior-transverse ratio?
1:2
Where is the apical pulse?
At the apex (bottom) of the heart, at the 5th intercostal space (between ribs 4 and 5)
What is the expected finding for bowel sounds?
5-30 sounds per minute
Why do you begin in the RLQ when auscultating bowel sounds?
We start in the RLQ because that is where the large intestine begins, so the bowel sounds are most prominently heard
Dorsiflexion against resistance
point toes to nose
Plantar flexion against resistance
Gas pedal
How do you test sensory function?
light and sharp touch across face, arms, hands, legs, and feet
How do you test fine motor function?
Finger to thumb, rapid, alternating movements
How do you test cerebellar function?
move each heel down alternate shin
How do you assess a nevus / mole?
A- Asymmetry (one half is unlike the other)
B- Border (blurry or jagged edges)
C- Colour (more than one shade)
D- Diameter (greater than 6mm)
E- Evolution (growth)
What is the 4-point scale for edema?
1+ = mild pitting: slight indent felt but not visible.
2+ = moderate: indentation visable, subsides rapidly.
3+ = deep pitting: indent remains a short time.
4+ = very deep pitting: indentation lasts a long time ; swelling distorts limb / area.
What angle indicates nail clubbing?
180°
Strabismus
abnormal eye alignment (crossed eyes, lazy eye)
Diplopia
double vision
Glaucoma
group of diseases that effect the eye nerves, increased pressure within the eyeball damages the optic nerve causing loss of sight peripherally
Diabetic retinopathy
disease of the retina causing vision impairment or loss
Presbyopia
farsightedness caused by loss of elasticity in the lens of the eye (common after age 40)
Cataracts
cloudy vision
Macular degeneration
Aging causes damage to the macula which blurs central vision.
Snellen chart
measures visual acuity
Jaeger chart
measures near vision
Nystagmus
rapid involuntary movements of the eye
Ptosis
eyelid drooping
Palpebral fissures
eyelids
Cerumen
Earwax
Otalgia
Ear pain
Otorrhea
Ear discharge
Presbycusis
Age-related hearing loss
Tinnitus
Ringing / buzzing in the ears
Subjective vertigo
Feeling like you are spinning
Objective vertigo
Feeling like the room is spinning around you
Myopia
Nearsightedness
Dysphagia
Difficulty swallowing
Epistaxis
Nosebleeds
Halitosis
Bad breath
Olfaction
Smell
Pharyngitis
Sore throat
Melasma
“mask of pregnancy”, hyperpigmentation from hormones
What is conductive hearing loss
Hearing loss caused by something that stops sounds from getting through the outer or middle ear.
What is sensorineural hearing loss
Hearing loss caused by damage to the inner ear
What is mixed hearing loss
A combination of sensorineural and conductive hearing loss
Where is Stenson’s duct located?
Bump on the side of the inside of the cheek
Where is Wharton’s duct located?
Under tongue, lateral to frenulum
What is nasal patency?
a measure of how open the nose is
Rhinorrhea
Runny nose
Anorexia
Loss of appetite
Ascites
Buildup of fluid in abdomen
Borborygmus
a rumbling or gurgling noise made by the movement of fluid and gas in the intestines
Bruit
an audible vascular sound associated with turbulent blood flow
can be created by a blockage or plaque in blood vessels
Emesis
Vomiting
Hepatitis
inflammation of the liver
Hernia
occurs when part of your organs bulges through an opening or weakness in the muscle or tissue barrier that contains it
Melena
Black stool (from blood)
Pyrosis
Heartburn
Tympany
A hollow drum-like sound that is produced when a gas-containing cavity is tapped sharply
Hyperemesis
Nausea and vomiting
Nociceptive pain
Caused by tissue injury
Somatic pain
Sharp, localized, injury to muscle, skin, or bones
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