Yoost Chapter 20 Terms

1 / 95
Click the card to flip 👆
Terms in this set (95)
Cataractscause the lens of the eye to become cloudy and impair visionCerumenear waxCheilitisdry, cracked lipsChief ComplaintThe patient's presenting problem, reason for seeking care.Clinical ManifestationsSigns and symptomsClonusrepetitive vibratory contraction of the muscle that occurs in response to muscle and tendon stretchComorbidTwo or more medical conditions existing simultaneously.Consistencymeasures organ location and size against the expected anatomic norm, any distention or masses, vibration or pulsation associated with movement.Crepitationcrackling or rubbingCyanosisblue discoloration of the skin, nail beds, or mucous membranes that results from vasoconstriction or deoxygenated hemoglobin in blood vessels near the skin's surface.Diplopiaseeing doubleDysrhythmiafailure of the heart to beat at regular, successive intervalsEcchymosisbruisingEdemaswelling caused by a build up of fluid in underlying tissues.EpistaxisnosebleedErythemaredness of the skin caused by congestion or dilation of the superficial blood vessels in the skin, signaling circulatory changes to an areaExorationabrasion due to rubbing or scratchingFocused AssessmentAn examination in which only specific, relevant areas are examined.Guardingpositioning to prevent movement of a painful body partHirsutismcondition effecting both men and women in which hair growth on the upper lip, chin, and cheeks becomes excessive and vellus body hair becomes thicker and coarserHydrocephalusenlargement of the skull, accumulation of cerebrospinal fluid in the ventricles of the brainHypertonicityincrease in muscle tonesHypotonicitydecrease in muscle toneInspectionThe use of vision, hearing, and smell to closely scrutinize physical characteristics of a whole person and individual body systems.Jaundiceyellow hue to the skin, mucous membranes, or eyes seen in both light and dark skinned people. the yellow pigment results from excess bilirubin, a by-product of rbc destruction or liver failure.Kyphosisoutward curvature of the thoracic spineLordosisincreased lumbar curvature just above the buttocks areaNystagmusrapid, shaking, involuntary movement of the eyesPallorlack of color, palenessPalpationtouch to assess body organs and skin texture, temperature, moisture, turgor, tenderness, and thicknessParesthesianumbness or tinglingPercussiontapping the patients skin with short, sharp strokes that cause a vibration to travel through the skin and to the upper layers of the underlying structures.Peristalsisprogressive wave action causing movement of contents through the gastrointestinal systemPetechiaetiny dark red spots that indicate hemorrhage under the skinPhlebitisInflammation of a veinPhysical AssessmentPruritusitchingPtosisabnormal drooping of the eyelidPulse deficitpresent when the patients radial pulse is slower than the apical pulse rate because of cardiac contractions that are weak or ineffective at pumping blood to peripheral tissues and extremitiesPurpurableeding underneath the skin, does not blanch, purple/red (stage I ulcer)Purulentdischarge containing pusRebound Tendernessdiscomfort experienced after stimulation is discontinuedScoliosissideways or S shaped curvature of the spine and is always abnormalSmegmawhitish substance under the foreskinStenosisnarrowing of the blood vesselsStrabismuscrossed eyes, usually due to muscle weakness or paralysisStriaestretch marks resulting from pregnancy or from weight loss or gainTactile Fremituspalpable vibration transmitted through the chest wall that occurs with the movement of the vocal cords during speech.Thrillabnormal vibration felt on palpationTinnitusringing, buzzing, or roaring in the earsTortuositybending and twistingTurgortension due to fluid contentVertigodisequilibrium ,spinning sensationVitiligoloss of skin pigment, thought to be autoimmune response.Supine positionTo examine the head and neck, anterior thorax and lungs, breasts, axillae, heart, abdomen, extremities, and pulses -Relaxed position; easy access to critical anatomy -Patient may become short of breath; this position is difficult for a patient who has back pain or kyphosis of the spineDorsal recumbent positionTo examine the head and neck, anterior thorax and lungs, breasts, axillae, heart, and abdomen -Promotes relaxation of abdominal muscles and removes pressure from the lower spine -Patients with weak lower extremities and knees will find this position challengingFowler positionTo examine the head and neck, anterior thorax and lungs, breasts, axillae, heart, abdomen, lower extremities, and pulses -Comfortable position for patients who are short of breath; most relaxing position -Difficult to assess the abdomen owing to shortened spaceLithotomy positionTo examine the female genitalia -Provides maximal exposure of genitalia and facilitates the progress of speculum examination -Uncomfortable and embarrassing position; minimize patient's time in lithotomy positionProne positionTo examine the back, spine, posterior aspect of the head, neck, thorax, buttocks, and lower extremities -Promotes airflow and facilitates assessment of skin and lungs -Uncomfortable for large-breasted women; excessive pressure on neck and spineSims positionTo examine the rectal and perineal areas -Left side-lying flexion of the right hip and knee improves exposure of rectal anatomy -Not tolerated well by patients with shortness of breath or other breathing difficultyKnee-chest positionProvides maximal exposure of rectal area -Uncomfortable; many patients will not be able to assume this position owing to physical limitationsBluish (cyanosis)Condition: Increased amount of deoxygenated hemoglobin (associated with hypoxia) Causes: Heart or lung disease, cold environment Assessment Locations: Nail beds, lips, mouth, skin (severe cases)Pallor (decrease in color)Condition: Reduced amount of oxyhemoglobin Reduced visibility of oxyhemoglobin resulting from decreased blood flow Causes: Anemia, Shock Assessment Locations: Face, conjunctivae, nail beds, palms of hands Skin, lipsLoss of pigmentationCondition: Vitiligo Causes: Congenital or autoimmune condition causing lack of pigment Assessment Location: Patchy areas on *skin* over face, hands, armsYellow-orange (jaundice)Condition: Increased deposit of bilirubin in tissues Causes: Liver disease, destruction of red blood cells Assessment Locations: Sclera, mucous membranes, skinRed (erythema)Condition: Increased visibility of oxyhemoglobin caused by dilation or increased blood fl ow Causes: Fever, direct trauma, blushing, alcohol intake Assessment Locations: Face, area of trauma, sacrum, shoulders, other common sites for pressure ulcersTan-brownCauses: Increased amount of melanin Conditions: Suntan, pregnancy Assessment Locations: Areas exposed to sun: face, arms, areolas, nipplesScreening for Melanoma: ABCDEA = ASYMMETRY One half of lesion does not match the other half B = BORDER Irregular, uneven, or notched borders C = COLOR Variable in color Ranges from tan, brown, or black to white, red, or blue D = DIAMETER Typically exceeds size of pencil eraser: >6 mm E = EVOLVING Looks different from other moles Changes in size, shape, or colorCranial Nerve I: Olfactory (Sensory)Origin: Upper nasal passages Function: Transmits the sense of smell Assessment: After assessing patency of both nares, have the patient close the eyes, obstruct one nare, and inhale to identify a common scent. Symptoms of Damage: Bilateral decreased sense of smell occurs with age, tobacco smoking, allergic or chronic rhinitis, overexposure to chemical substances, and cocaine use. Unilateral loss of sense of smell can indicate a frontal lobe lesion.Cranial Nerve II: Optic (Sensory)Origin: Eyes Function: Transmits visual information to the brain; located in the optic canal Assessment: Check visual acuity (have the patient read newspaper print or use a Snellen chart), and test visual fields for each eye. Symptoms of Damage: Unilateral blindness can indicate a lesion or pressure in the globe or on the optic nerve. Loss of the same half of visual field in both eyes can indicate a lesion of the opposite-side optic tract, as in a CVA.Cranial Nerve III: Oculomotor (Motor)Origin: Midbrain Function: Innervates four of the six muscles that collectively execute most eye movements; responsible for papillary constriction and dilation Assessment: Assess pupil size and light reflex; note direction of gaze. Symptoms of Damage: A unilaterally dilated pupil with unilateral absent light reflex and/or an eye that will not gaze upward can indicate an internal carotid aneurysm or increased intracranial pressure.Cranial Nerve IV: Trochlear (Motor)Origin: Midbrain Function: Innervates muscles responsible for downward and inward gaze of the eyes Assessment: Ask the patient to gaze downward, temporally, and nasally. (Note: Cranial nerves III, IV, and VI are examined together because they control eyelid elevation, eye movement, and pupillary constriction.) Symptoms of Damage If the eyes will not move through the inward and downward gazes, the patient may have a fracture of the eye orbit or a brainstem tumor.Cranial Nerve V: Trigeminal (Sensory and Motor)Origin: Pons Function: Is responsible for the corneal reflex; receives sensation from the face and innervates the muscles of mastication Assessment: Motor: Palpate jaws and temples while patient clenches teeth. Sensory: With the patient's eyes closed, gently touch a cotton ball to all areas of the face. Symptoms of Damage: Unilateral deficit is seen with trauma and tumors.Cranial Nerve VI: Abducens (Motor)Origin: Pons Function: Innervates muscles responsible for outward gaze of the eyes Assessment: Assess directions of gaze. Symptoms of Damage: Inability to gaze outward may indicate a fracture of an orbit or a brainstem tumor.Cranial Nerve VII: Facial (Sensory and Motor)Origin: Pons Function: Provides motor innervation to the muscles of facial expression; receives the sense of taste from the anterior two thirds of the tongue; provides innervation to the salivary glands (except parotid) and the lacrimal gland Assessment: Motor: Check symmetry of the face by having the patient frown, close eyes, lift eyebrows, and puff cheeks. Sensory: Assess the patient's ability to recognize taste (sugar, salt, lemon juice). Symptoms of Damage: An asymmetric deficit can be found in traumatic injury, Bell's palsy, CVA, tumor, and inflammation.Cranial Nerve VIII: Vestibulocochlear or Auditory-Vestibular (Sensory)Origin: Medulla oblongata Function: Vestibular branch: Carries impulses for equilibrium Cochlear branch: Carries impulses for hearing Assessment: Assess the patient's ability to hear a spoken and whispered word. Symptoms of Damage: Impairment may result from inflammation or occlusion of the ear canal, infection, drug toxicity, or a possible tumor or may cause vertigo.Cranial Nerve IX: Glossopharyngeal (Sensory and Motor)Origin: Medulla oblongata Function: Receives taste from the posterior third of the tongue; provides innervation to the parotid gland; and provides motor innervation for swallowing Assessment: Sensory: Assess the patient's ability to taste sour or sweet on last two thirds of tongue. Motor: Check for presence of the gag reflex by inserting a tongue blade two-thirds into the pharynx. Symptoms of Damage: Deficits in taste or gag reflex can indicate a brainstem tumor or neck injury.Cranial Nerve X: Vagus (Sensory and Motor)Origin: Medulla oblongata Function: Supplies innervation to the larynx and soft palate responsible for speech and swallowing; provides parasympathetic fibers to nearly all thoracic and abdominal smooth muscles Assessment: Depress the tongue with a tongue blade, and have the patient say "ah" or yawn. The uvula and soft palate should rise and be symmetric. Assess speech for hoarseness. Symptoms of Damage: Dysphagia can indicate swallowing problems and the potential for aspiration.Cranial Nerve XI: Accessory (Motor)Origin: Medulla oblongata (cranial root) and spinal cord (spinal root) Function: Cranial root: Works with vagus nerve to control the muscles of the soft palate, pharynx, and larynx Spinal root: Innervates muscles of the neck and back Assessment: Have the patient rotate the head and shrug the shoulders against passive resistance. Symptoms of Damage: If the patient is unable to perform a shoulder shrug or head rotation, this may indicate a neck injury.Cranial Nerve XII: Hypoglossal (Motor)Origin: Medulla oblongata Function: Provides motor innervation to muscles of the tongue not innervated by the vagus nerve and to other glossal muscles; is important for swallowing and speech articulation Assessment: Assess tongue control (e.g., have the patient stick out the tongue and move it from side to side). Symptoms of Damage: Inability to stick out the tongue may be associated with swallowing or articulation difficulties.Allen testThis test helps to assess the patency of the hand arteries before arterial blood tests. is used to evaluate for collateral circulation to determine the patency of the arteries of the hand before arterial blood tests. The Allen test is performed by having the patient elevate the extremity and make a fist. The examiner occludes the radial and ulnar arteries, using pressure. The patient's hand should lose color. The patient then opens the fist, and the pressure is released from the ulnar artery. The normal pink color should return to the hand within 10 seconds, showing good circulation.Rinne testThis test helps to compare bone and air conduction of sound during hearing. It is carried out by gently placing the base of a vibrating tuning fork against the mastoid process behind the ear. The nurse asks the patient to indicate when sound is no longer audible. After the patient has indicated that sound is no longer audible, the tines of the tuning fork are placed in front of the external auditory canal and the patient is again asked to indicate when sound is no longer heard (Figure 20-17). The length of time sound was heard by bone conduction (BC) versus air conduction (AC) is determined. Air-conducted sound should be heard twice as long as bone-conducted sound. Patients with conductive hearing loss will hear bone conduction sound for longer than, or as long as, air conduction sound (BC ≥ AC). If the patient has sensorineural hearing loss, air conduction sound is heard for only slightly longer than bone conduction sound (AC > BC), if sound is heard at all.Weber testThis test is used to determine the nature of hearing loss in the patient (i.e., conductive or sensorineural). can be conducted if a patient complains of hearing loss in one ear. Through use of a tuning fork, the advanced practice nurse can determine whether the patient is experiencing conductive or sensorineural hearing loss. If the patient reports "hearing" sound from the tuning fork in the poor ear, lateralization of sound to the poor ear has occurred, and conductive hearing loss is indicated. If the patient reports lateralization of sound to the good ear, sensorineural hearing loss is the most likely cause. To conduct the test, strike the tuning fork softly with the back of the hand and place the base of the vibrating tuning fork against the center of the patient's head or forehead. Placement on the midline is critical. Ask the patient if the sound is heard better in one ear or the other or heard the same in both. Vibration detected equally in both ears indicates no hearing loss.Romberg testhelps to assess the patient's equilibrium. In this test, the nurse asks the patient to stand with the feet together and the arms at the sides. The nurse performs the assessment first by instructing the patient to keep the eyes open and then by instructing the patient to keep the eyes closed. If the patient fails to maintain balance for at least 20 seconds, vestibular damage in the patient is present.