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Theory Exam 1 Vocab.

Nursing Process

QuestionAnswer
Stuporous A lower level of consciousness; reduced responsiveness.
Comatose Unresponsive even to painful stimuli; Not conscious; in a coma; Unable to awake
Pallor Paleness, ↓ in color of skin; ↓ amount of oxyhemoglobin; Causes: anemia Area: face, conjunctivae, nail beds, palms of hand ↓ visibility of oxyhemoglobin, resulting from ↓ bloodflow; Causes: shock Area: skin, conjunctivae, nail beds, lips
Erythema Red discolor of skin; ↑visibility oxyhemoglobin Cause:dialation/↑ blood flow, circulatory chgs ex: sunburn,edema,fever,direct trama, blushing,alcohol intake Area:face,trauma area,sacrum,shoulders, pressure ulcers Dark skin: palpate for heat to note
Jaudice Yellow-orange discolor skin/sclera ↑ deposit of bilirubin in tissues, ↑ levels of bile pigments in the blood, Causes: liver disease, destruction RBC's; Location: sclera, mucous membrane, skin
Cyanosis Bluish discolor skin/mucous membrane; ↑ deoxygenated hemoglobin (assoc. w/hypoxia; Causes: heart or lung disease, cold temp, smothering (Infants: heat defects, RDS, lung/breathing problems); Areas: nail beds, lips, mouth, skin (severe cases)
Turgor Skin elasticity; Causes: edema,dehydration, age; Test on back of forearm/sternal area; ↓ in turgor predisposes to skin breakdown.
Alopecia Partial or complete absence of hair from areas of the body where it normally grows; Baldness/Edema
Macule Flat, nonpalpable change in skin color; Smaller than 1cm; Ex: Freckles, Petechia
Papule Palpable, circumscribed, solid elevation in skin; Smaller than 1cm (>Salt, < Pepper corn))
Ecchymosis Larger hemorrhages of purpura with superficial bleeding under the skin/mucous membranes; Ex: bruise
Petechiae 1) Small, purplish, pinpoint purpuric, hemorrhagic spots on skin; Appear with platelet deficiences (thrombocytopenia) & many febrile illnesses. 2) Red spots from the bite of a flea (Macule)
Purpura Any rash which blood cells leak into the skin/mucous membranes, usually at multiple sites; Purpuric rashes often are assoc. w/ disorders of coagulation/thrombosis; Pinpoint Purpuric - "petechiae" Larger Hemorrhages - "ecchymoses"
Wheal / Hives Irregular shaped, elevated area of superficial localized edema; Varies in size; Ex: hive, mosquito bite
Cyst Closed sac/pouch with a definate wall that contains fluid, semifluid, or solid material; Usually abnormal structures resulting from developmental abnormalities, obstruction of ducts, or parasitic infection.
Vesicle Circumscribed elevation of the skin; Filled with serous fluid; Smaller than 1cm Ex: herpes simplex, chickenpox
Pustule Circumscribed elevation of the skin; Similar to Vesicle, but filled with Pus; Varies in size; Ex: acne, staphylococcal infection
Keloid Overgrowths of fibrous tissue/scars Occurs after skin injury; Spreads beyond borders of original lesion; Made-up of swirling mass of collagen fibers/fibroblasts; Grossly appears to have shiny surface/rubbery consistency; Common area:shoulders,chest,b
Fissure An ulcer or cracklike sore; A grove, natural division, cleft, slit, or deep furrow in the brain, liver, spinal cord, & other organs; A break in the enamel of a tooth
Ulcer Deep loss of skin surface that extends to dermis and frequently bleeds/scars; Result of prolonged ischemia (↓ blood supply) in tissues; Inflammation & usually over bony prominence Varies in size; Ex: venous stasis ulcer
Atrophy ●Thinning of skin w/loss of normal skin furrow, appears shiny/translucent; Varies in size; Ex: arterial insufficiency ●Wasting away; diminution in size of a cell tissue/organ/part; ↓ muscle mass, due to extended immobility; from death/cell reabsorbti
Hypertrophy Enlargement/overgrowth of organ, part, or skin; Due to ↑ in size of constituent cells
Exudate ●Exudate describes amount, color, consistency, & odor of drainage; Excessive exudate indicates infection ●Fluid w/ high content of protein/cellular debris, which escaped from blood vessels, & deposited in tissues surface, usually result of inflammation.
Clubbing Change in angle between nail & nail base (eventually larger than 180⁰); Nail bed softening, with nail flattening; Often enlargement of fingertips; Causes: chronic lack of O₂/ hear or pulmonary disease
Edema Areas of skin become swollen or edematous; From buildup of fluid in the tissues; Common causes: direct trauma & impairment of venous return Measure: 1+ = 1 penny heighth/mm 2+ = 2 pennies 3+ = 3 pennies 4+ = 4 pennies
Mucosa Mucous membrane/moist tissue layer that lines hallow organs & cavities of the body that open to environment; -epithelial layer -basement membrane -connective tissue (lamina propria)
Gingivitis -Inflamation of gums. -Redness, swelling, tendency to bleed. -Improper hyigene, poorly fitted dentures, or appliances, or poor occlusion. -Stomatitis, scurvy, blood dyscrasias, metallic poisoning.
Hyperplasia(or "hypergenesis") -Increase in number of cells/proliferation of cells. -Result in gross enlargement of an organ and the term is sometimes mixed with benign neoplasia / benign tumor.
Dental Caries (Cariology: study of dental caries) -Tooth decay/cavity -Disease where bacterial processes damage hard tooth sturctures(enamel,dentin,cementum) -2 bacteria responsible; Streptococcus mutans/Lactobacillus -Lead to: pain,tooth loss,infection,death -Most common disease throughout world
Accomodation -Process which vertebrate eye change optical power to maintain a clear image. -Focusing on an object as its distance changes.
Peripheral Vision -Vision that occurs outside the very center of gaze. -Loss of peripheral vision: Tunnel vision -Loss of central vision: Central Scotoma
Retina -Light-sensitive tissue lining inner surface of eye -Optics of the eye create image of visual world on the retina -creates nerve impulses sent to brain through fibers of the optic nerve II
Lens -Posterior to the Iris -Changes shape to change focal distance of the eye -Transparent, biconvex, refract light to be focused on retina
Cornea -Transparent, colorless portion of the eye. -Covers the pupil & iris -Side view; looks like crystal of watch
Conjunctiva -Covers exposed surface of eyeball -Delicate membrane lining the eyelid & eyeball
Glaucoma -Intraocular structural damage -Resulting from elevated intraocular pressure -Cause: obstruction of outflow of aqueous humor. -Without treatment the disorder will lead to blindness
Cataracts -↑ opacity of the lens -blocks light rays -develops slowly & progressively after age 35 or suddenly after trauma -Most common eye disorder -Most 65+ have evidence of visual impairment from cataracts
Eustachian Tube (Auditory Tube) -Narrow channel connecting the middle ear & the nasopharynx
Septum -a dividing wall/partition
Turbinate Bones -Small curved bone, extends horizontally along the lateral wall of the nasal passage. (nasal concha)
Friction Rub -Heard over anterior lateral lung field (sitting upright) -Inflamed pleura, parietal pleura rubbing against visceral pleura -Dry, rubbing/grating quality heard during inspiration/expiration -Doesn't clear w/cough -Loudest @ lower lateral anterior surf
Wheezes (sibilant wheeze) -Heard over all lung fields -High-velocity airflow through severely narrowed/obstructed airway -High-pitched, continuous musical sounds like a squeak heard continuously during inspiration/expiration -Usually louder on expiration
Crackles -Common in dependent lobes, rt/lft lung bases -Random, sudden reinflation groups of alveoli; disruptive passage of air thru sm airways -Fine crackles, high-pitched fine, short, interrupted crackle heard at end of inspiration -Usually not cleared w/coug
Rhonchi (sonorous wheeze) -primarily over trachea & bronchi; loud enough, most lung fields -Muscular spasm, fluid/mucus in lrg airways, new growth/external pressure cause turbulence -Loud, low-pitched, rumbling course -Heard during inspiration/expiration -Sometimes clear w/cou
Bronchial -Loud & high-pitched w/hollow quality -Expiration last longer than inspiration (3:2ratio) -Only over trachea -Created by air moving thru trachea close to chest wall
Bronchovesicular -Blowing, medium pitched, medium intensity -Inspiratory phase is equal to expiratory phase -Best posteriorly btwn scapulae & anteriorly over bronchioles lateral to sternum @ 1st & 2nd intercostal spaces -Created by air moving thru lrg airways
Vesicular -Soft, breezy, low-pitched -Inspiratory phase 3X longer than expiratory phase -Best over lung's periphery (except over scapula) -Created by air moving thru smaller airways
Barrel Chest (emphysematous chest) -large, rounded thorax, as in inspiratory phase, considered normal in some stocky individuals & others who live in high-altitude areas & consequently have increased vital capacity. Barrel chest may also be sign of pulmonary emphysema.
Pectus Carinatum -pigeon breast or chest; a condition of the chest in which the sternum is prominent, due to obstruction of infantile respiration or to rickets.
Pectus Excavatum -funnel breast or chest; a congenital deformity in which the sternum is depressed.
Crepitus -peculiar crackling, crinkly, or grating feeling/sound under skin, around lungs, or in joints. In soft tissues often due to gas, most often air, penetrated & infiltrated an area it shouldn't be -Crepitus in joint indicates cartilage wear in joint space
Fremitus -A palpable vibration, as felt by the hand placed on the chest during coughing or speaking.
Dyspnea -Difficult or labored breathing; shortness of breath. Dyspnea is a sign of serious disease of the airway, lungs, or heart. The onset of dyspnea should not be ignored; it is reason to seek medical attention.
Hypoventilation -Reduced amt of air enters alveoli in lungs, resulting in decreased levels of oxygen & increased levels of carbon dioxide in blood. -Due to breathing that is too shallow (hypopnea) or too slow (bradypnea), or to diminished lung function
Hyperventilation Overbreathing It causes dizziness,lightheadedness,sense of unsteadiness, tingling around mouth/fingertips -Severe enough to mimic early warning symptoms of MI & common emergency room visits in US -can be caused by serious metabolism disease/anxiety
Kussmal Respirations -Tachypnea (increased RR & hyperpnea(normal but deep-emotional distress/diabetic ketoacidosis) -Causes: renal failure, metabolic acidosis, diabetic ketoacidosis
Cheyne-Strokes -Gradual increases & decreases in respirations w/periods of apnea -Causes: increasing intracranial pressure, brain stem injury, before death
Apnea -Absence of breathing -Causes: deceased pt, head injury, stroke
Bradypnea -Decreased respiratory rate (<12) -Causes: sleep, drugs, metabolic disorder, head injury, stroke
Tachypnea -Increased respiratory rate (>20) -Causes: fever, anxiety, exercise, shock
Eupnea Normal breathing rate & pattern
Pericardium The membrane enclosing the heart, consisting of an outer fibrous layer and an inner double layer of serous membrane
Thrill Continuous palpable sensation like cat purr Grade 1:Barely audible in quiet rm Grade 2:Clearly audible & quiet Grade 3:Moderate loud Grade 4:Loud-w/ associated thrill Grade 5:Very loud-thrill easily palpable Grade 6:Loud-w/o stethoscope-palpable&vis
Heave / Lift -To raise or lift, especially with great effort or force -To make rise or swell: exhausted & heaving chest
Murmur (asymptomatic/sign of heart disease) (common in children) -Sustained swishing/blowing heard at the beginning, middle, or end of systolic/diastolic phase. -Cause: ↑ blood flow thru normal valve, forward flow thru stenotic valve/into dilated vessel/heart chamber, or backward flow thru valve failed to close
Palpitations -irregularities of the heartbeat such as a rapid or irregular heartbeat
Tachycardia -A rapid heart rate, usually defined as greater than 100 beats per minute
Bradycardia -A slow heart rate, usually defined as less than 60 beats per minute
Arrythmia -An abnormal heart rhythm -too slow, too rapid, too irregular, or too early
Bruit heard over artery/vascular channel, reflecting turbulence of flow. Most commonly caused by abnormal narrowing of artery Listening in neck w/stethoscope is simple way to screen for narrowing(stenosis) carotid artery, can be result of chol plaque buildup
Angle of Louis the sternal angle between the manubrium and the body of the sternum
Manubrium 1.The upper segment of the sternum with which the clavicle and the first two pairs of ribs articulate
Apex & Base of the Heart Apex is the bottom tip of the heart and the base is the upper portion (what is heard better where?)
PMI (point of maximal impulse or apical impulse) -The apex actually touches the anterior chest wall at approximately the 4th to 5th intercostal space just medial to the left midclavicular line.
Bounding Pulse very strong pulse (+4)
Thready Pulse weak pulse or difficult to palpate ( +1)
Agnosia -Inability to recognize or comprehend sights, sounds, words, or other sensory information
Akinesia -Complete/partial loss of muscle movement
Aphasia -Absence or impairment of ability to communicate thru speech, writing, or signs -Due to brain dysfunction -Complete/total when both sensory & motor areas are involved
Dysphagia -Inability to swallow or difficulty in swallowing
Tremors Involuntary shaking of the body or limbs
Kinesthetics a sense that detects body position, weight or movement of muscle, tendons and joints
Graphathesia Writing something in a palm and figure out what was written
Stereognosis ability to perceive an object by using the sense of touch
Lethargic –Drowsy or mild impairment of consciousness , reduced alertness and awareness
Gait -A manner of walking
Lordosis Swayback, increased lumbar curvature
Kyphosis An exaggeration of the posterior curvature of the thoracic spine
Scoliosis abnormal lateral curvature of the spine (s or c-shaped)
Created by: TACINOEL