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Yoost Chapter 7: Nursing Diagnosis

Terms in this set (35)

Cheyne-Stokes respiration
repeated breathing pattern characterized by fluctuation in the depth of respiration: first deeply, then shallow, then not at all
Kussmal Respirations
Deep labored breathing pattern; increased rate, large volumes often seen in Diabetic Ketoacidosis
fremitus
a palpable vibration from the spoken voice felt over the chest wall
pectus excavatum
sunken sternum and adjacent cartilages
pectus carinatum
pigeon chest, protrusion of the sternum and ribs
barrel chest
a condition characterized by increased anterior-posterior chest diameter caused by increased functional residual capacity due to air trapping from small airway collapse. A barrel chest is frequently seen in patients with chronic obstructive diseases, such as chronic bronchitis and emphysema.
Vesicular
the soft, low-pitched, normal breath sounds heard over peripheral lung fields
Bronchovesicular
normal breath sounds heard over the upper anterior chest and intercostal area
Rhonchi
Rattling noise of mucous in the lungs
crackles
fine, crackling sounds made as air moves through wet secretions in the lungs
wheeze
high-pitched, musical, squeaking adventitious lung sound
friction rub
a coarse, grating, adventitious lung sound heard when the pleurae are inflamed
Where do you feel for the point of maximum impulse? (PMI)
Between 4th and 5th intercostal space
What is the first heart sound?
closing of AV valves (Tricuspid and Mitrial)
What is the second heart sound?
closing of semilunar valves (aortic and pulmonary)
Where is the apex of the heart?
bottom
What is the time between s1 and s2
systole
what is the time between s2 and s1
diastole
What does APE TO MAN stand for? (APETM)
Aortic Pulmonary Erbs point Tricuspid Mitrial
Pericordium
area of the chest overlying the heart
Pericardium
Membrane surrounding the heart
Angle of Louis
the junction between the body of the sternum and the manubrium
manubrium
upper portion of the sternum
Scaphoid
Sunken in abdomen when laying in supine position
CVA tenderness
Costo-vertebral Angle tenderness; tenderness over the kidney's
CRANIAL NERVES PG 558?
...
Kinesthetics sense
Move patients fingers up and down while patients eyes are closed, have them tell which way they are
Graphesthesia
ability to "read" a number by having it traced on the skin
stereognosis test
With the person's eyes closed, place a familiar object in his/her hand and ask the person to identify it. Normally, a person will explore it with the fingers and correctly identify it. (Sensory function)
Romberg test
-ask client to stand with feet at comfortable distance apart, arms at sides, and eyes closed
-expected finding: client should be able to stand with minimal swaying for at least 5 seconds
Akinesia
inability to initiate movement
Agnosia
the inability to recognize familiar objects.
aphasia
inability to speak
atrophy
to waste away
hypertrophy
excessive development
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