Medical Terms + Assessments

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