Physical Assessment Vocabulary

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lindseyjknight
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127121
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Physical Assessment Vocabulary
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2012-01-11 20:03:24
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Physical Assesment Vocabulary
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Nursing Skills Physical Assessment Vocabulary
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  1. Pallor
    • Refers to the paleness of skin in one area when compared to another part of the body.
    • In light-skinned clients: extreme paleness; skin appears white; loss of pink or yellow tones.
    • In dark-skinned clients: a loss of red tones.
    • May be related to poor circulation or a low hemoglobin level (anemia).
    • Best sites to assess for pallor include the oral mucous membranes, conjunctiva, nail beds, palms, and soles of feet.
  2. Cyanosis
    • A blue-gray coloration of the skin, often described as ashen.
    • If seen in the lips, tongue, mucous membranes, and facial features, it is known as central cyanosis and is associated with hypoxia.
    • In newborns, acrocyanosis, which is bluish discoloration of palms and soles in the first few hours to days of life, if normal.
    • Cold causes the lips to turn blue but the tongue is not affected. Cyanosis may also be seen in the extremities, especially hands and feet, after exposure to extreme cold.
  3. Jaundice
    • Yellow discoloration caused by accumulation of bile pigments in the skin.
    • Often associated with liver disorders.
    • Best sites to assess for jaundice include the sclear, mucous membranes, hard palate of the mouth, palms, and soles.
    • Jaundice in the newborn is a normal finding in the first few weeks of life unless there is blood incompatibility or a congenital disorder.
  4. Flushing
    • A widespread, diffuse area of redness.
    • Generalized redness of the face and body may occur as a result of fever, excessive room temp, sunburn, polycythemia (an abnormal increase in red blood cells), vigorous exercise, or certain skin conditions, such as rosacea.
  5. Erythema
    • A reddened area.
    • Associated with rashes, skin infections, prolonged pressure on the skin, or application of heat or cold.
  6. Ecchymosis
    • Bruised (blue-green-yellow) area.
    • May be seen anywhere on the body.
    • The color will vary based on the age of the injury.
    • May indicate physical abuse, internal bleeding, side effect to medication, or bleeding disorder.
    • Refer to Chapter 9 to review assessing for abuse.
  7. Petechiae
    • Tiny, pinpoint red or reddish-purple spots.
    • Visible in the skin due to extravasation (leakage from vessels) of blood into the skin.
    • May be associated with a variety of disorders and medications.
  8. Mottling
    • Bluish marbling of the skin.
    • Occurs in light-skinned clints, especially when cold.
    • In newborns mottling indicates overstimulation of the autonomic nervous system.
  9. Turgor
    • Refers to the elasticity of the skin.
    • Provides data about hydration status.
    • To assess turgor:
    • Life ("pinch up") a fold of skin and allow it to return to its normal position
    • Normally, skin returns immediately to its original position.
    • Skin that tends to stay pinched for a few seconds (tenting) may be a sign of dehydration.
    • Elasticity decreases with ae, so tenting may also be seen with normal aging.
    • Edema or scleroderma creates tension, preventing the skin from being pinched up.
  10. Edema
    • An excessive amount of fluid in the tissues.
    • Common in clients with CHF, kidney disease, peripheral vascular disease, or low albumin levels.
    • Assessing Edema
    • Trace: A minimal depression is noted with pressure.
    • +1: Creates a depression of about 2mm. No visible distortion and rapid return of skin to position.
    • +2: Creates a depression up to 4mm in depth that disappears in about 10-15 seconds.
    • +3: Creates a depression of approximately 6mm in depth that lasts about 1-2 minutes. The area appears swollen.
    • +4: Creates a depression up to 8mm in depth that persists for about 2-3 minutes. The area is grossly edematous.
  11. Lesion
    • Variation in pigment.
    • Break in continuous tissue.
    • Normal variations include:
    • Millia: White raised areas on the nose, chin, and forehead of newborns.
    • Nevi: Moles, freckles, birthmarks.
    • Skin Tags: Tiny tags or buds of skin usually around skin creases in middle and older adults.
    • Striae: Silver-to-pink stretch marks in pregnant women, women who have had children, and anyone who has experienced significant weight fluctuations.
    • Abnormal Lesions-
    • Primary Skin Lesions: develop as a result of disease or irritation. The pustules of acne are an example.
    • Secondary Skin Lesions: Develop from primary lesions as a result of continued illness, exposure, injury, or infection, such as the crusts that form from ruptured pustules.
    • When you observe a lesion-
    • Evaluate it for size, shape, pattern color, distribution, texutre, surface relationship, exudate, tenderness, pain, or itching.
    • Evaluate all skin lesions for the possibility of malignancy, especially those located in a site exposed to chronic rubbing or other trauma.
    • Warning signs of malignant lesions with ABCDE
    • A-Asymmetry
    • B-Border Irregularity
    • C-Color Variation
    • D-Diameter Greater than 0.5 cm
    • E-Elevation Above the Skin Surface
    • See: The table at the end of Procedure 19-2, Abnormal Atlas at the end of Chapter 19 (V2)
  12. Albinism
    Lack of pigment.
  13. Alopecia
    • Hair Loss
    • Occurs along the temples and in the conter of the scalp
    • Alopecia Areata: a benign autoimmune disorder.
  14. Hirsutism
    • Excess facial or trunk hair
    • may be due to endocrine disorders or steroid use
  15. Pediculosis
    Head Lice Infestation
  16. Onychomycosis
    A fungal infection of the nail
  17. Acromegaly
    • A large head in an adolescent or adult
    • A disorder associated with excess growth hormone
  18. Microcephaly
    • An abnormally small head size
    • Seen in clients with certain types of mental retardation
  19. Hydrocephalus
    • An accumulation of excessive cerebrospinal fluid
    • A head that is growing disproportionally faster than the body in infants and children can be an indicator
  20. Ectropion
    • An everted eyelid
    • Commonly seen in older adults secondary to loss of skin tone
  21. Entropion
    • An inverted eyelid
    • Can lead to corneal damage
  22. Ptosis
    • Drooping of the eyelid
    • May be seen in clients who have experienced a stroke or Bell's Palsy
    • See: Chapter 19, Procedure 19-5, and Abnormal Atlas (V2)
  23. Sclera
    The white of the eye
  24. Icterus
    Jaundice or yellowing of the skin and/or the sclera (white) of the eye
  25. Mydriasis
    • Enlarged Pupils
    • May be seen with glaucoma (an increase in intraocular pressure)
  26. Miosis of Pupils
    • Constricted Pupils
    • Often results from medications to treat glaucoma
  27. Anisocoria
    • Unequal Pupils
    • May be seen with central nervous system disorders such as stroke, head trauma, or cranial nerve injuries.
    • In some individuals, anisocoria may be normal
  28. PERRLA
    • Pupils
    • Equal
    • Round
    • Reactive to Light
    • Accomodation
  29. Romberg Test
    • Used to assess equilibrium
    • Have client stand with feet together and eyes closed.
    • The client should be able to maintain balance with minimal swaying.
    • Swaying and moving (positive Romberg) may indicate a vestibular or cerebellar disorder.
  30. Stomatitis
    Inflamation of the oral mucosa
  31. Leukoplakia
    • Thick, elevated white patches in the mouth that do not scape off
    • May be precancerous lesions
    • White, curdy patches that scrape off and bleed indicate thrush (a fungal infection)
  32. Glossitis
    Inflamation of the tongue
  33. Kyphosis
    Excessive curvature of the thoracic spine
  34. Lordosis
    Accentuated lumbar curve
  35. Scoliosis
    Lateral "S" deviation of the spine
  36. Adventitious
    Developed in an unusual position
  37. Systole
    Contracting, or emptying, of the ventricles
  38. Diastole
    Relaxation, or filling, phase of the ventricles
  39. Precordium
    The area of the chest over the heart
  40. PMI
    • Point of Maximal Impulse
    • A small pulsation at the 5th ICS midclavicular line
  41. Aortic Valve
    • Base Right
    • 2nd ICS Right Sternal Border
  42. Pumonic Valve
    • Base Left
    • 2nd ICS Left Sternal Border
  43. Tricuspid Valve
    • Lef Lateral
    • 4th ICS Left Sternal Border
  44. Mitral Valve
    • Apex
    • 5th ICS MCL
  45. Bruit
    A whooshing sound caused by turbulent blood flow through the carotid artery
  46. Stenosis
    Narrowing from plaque
  47. CN I
    Olfactory-Sense of smell
  48. CN II
    Optic-Sight
  49. CN III
    Occulomotor-Controls pupillary reaction to light
  50. CN IV
    Trochlear-Eye movement
  51. CN V
    Trigeminal-Recieves sensations from the face
  52. CN VI
    Abducens-Abducts the eye
  53. CN VII
    Facial-Facial Expression
  54. CN VIII
    Auditory-Senses sound
  55. CN IX
    Glossopharyngeal-Taste
  56. CN X
    Vagus-Swallowing, Speach
  57. CN XI
    Spinal Accessory-Shrug and head movement
  58. CN XII
    Hypoglossal-Swallowing, Speach, Tongue Movement
  59. Clonus
    Involuntary contraction, when testing reflexes, that continue after the first contraction is elicited by the hammer
  60. Proprioception
    Body positioning
  61. Percussion
    Tapping your fingers on the skin using short strokes to produce sounds that allow you to dtermine location, size, and density of underlying structures.
  62. Ausculation
    The use of hearing to gather data.
  63. Palpation
    The use of touch to gather data
  64. Cachectic
    The loss of body mass that can not be reversed nutritionally

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