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VN 1323 EXAM 3
Documentation & Nursing Diagnosis
Question | Answer |
---|---|
thin, undernourished;appearance | emaciated |
fat, greatly overweight;appearance | obese |
large amount;blood or drainage | profuse, copious, excessive, measured amount |
moderate amount;blood or drainage | moderate, unual, measured |
small amount;blood or drainage | small amount, scanty, slight, very little, measured amount |
containing pus;drainage | purulent |
bloody;drainage | sanguineous |
conaining serum and blood;drainage | serosanguineous |
consists of feces;drainage | fecal |
of lymphatic fluid;drainage | serous |
contains mucus and pus;drainage | mucopurulent |
tough sticky;drainage | tenacious |
consistency of drainage--watery | liquid |
consistency of drainage--thick, sticky | concentrated, tenacious |
consistency of drainage--containing or resembling muccous | mucoid |
bleeding very ittle | oozing |
bleeding is stopped | hemorrhage controlled |
unpleasant odor;bleeding | offensive;foul |
temperature above normal;bleeding | pyrexia |
speech runs together;bleeding | slurring |
descriptive terms of skin | pale, moist, rough, dry, tough |
hives;skin | uticaria |
lips have tiny cracks;skin | fissure;cracked |
itching;skin | pruritus |
skin is yellow | jaundice |
rubing medicaion into the skin | inunction |
scars present;skin | scarified |
had a bedsore when admitted;skin | describe the decubitus |
decay of tissue;skin | necrosis |
second added to first;dressings | dressing reinforced |
removed, another applied;dressings | dressing changed |
baldness, absence of hair;hair and scalp | alopecia |
drooping eyelids;eyes | ptosis |
eyes are staring;eyes | eyes fixed |
wax in ears;ears | cerumen |
ringing sensation in ears;ears | tinnitus |
watery drainage from nose;nose and sinus | coryza |
nosebleed;nose and sinus | epistaxis |
decay of teeth;mouth and pharynx | dental cavities |
accumulation of foul brown material on teeth;mouth and pharynx | sordes |
difficulty in swallowing;mouth and pharynx | dysphagia |
gums are pulling away from teeth;mouth and pharynx | receding;shrunken |
unpleasant breath;mouth and pharynx | halitosis |
foul breath;mouth and pharynx | fetid |
sweet, fruitlike odor of breath;mouth and pharynx | fruity or sweet |
short time without breathing;thorax and lungs | apnea |
increasing dyspnea with periods of nonbreathing;thorax and lungs | cheyne-stokes |
cannot breathe lying down;thorax and lungs | orthopnea |
rapid breathing;thorax and lungs | hyperpnea, tachpnea |
difficulty breathing;thorax and lungs | dyspnea |
coughs all the time | continous cough |
coughs up material | productive cough |
occurring in spasms | spasmodic cough |
coughs often | frequent cough |
doesnt produce material | nonproductive cough |
occurs in attacks | paroxysmal cough |
other | loose, deep, dry, hacking, harsh, and tight |
amount;expectoration | profuse, scant |
spitting up blood;expectoration | hemoptysis |
pulse over 100/min;heart/vascular | rapid, tachycardia |
pulse beats hardly perceptible;heart/vasuclar | thready |
pulse beats indistinct(rapid);heart/vasuclar | running |
irrigular heartbeat;heart/vascular | arrhythmia |
slow heart beat;heart/vascular | bradycardia |
how to describe rythm of pulse;heart/vascular | irregular; regular |
pulse missed beat;heart/vascular | intermittent |
nipple always depressed;breast | inverted nipple |
large and extends outward;abdomen | enlarged, proturding |
soft, flabby,flat;abdomen | relaxed, flaccid, flat |
hurts when touched;abdomen | sensitive to touch, tender |
appears swollen, rounded;abdomen | distended |
filled with gas;abdomen | tympanites |
constipated;abdomen | pellet-like:hard formed stool expelled with difficulty |
abdomen is board like | rigid |
blood in vomitus | hematemesis |
very fussy, refuses to eat many foods;appetite | defintie likes and dislikes concerning food |
loss of appetite | anorexia |
refuses to eat | refused food(state reason) |
amount of food eaten;appetite | described in percentage |
produced by clients effort;emesis | induced |
ejection of vomit with great force | projectile |
blood noted in vomitus | blood-tinged |
agent given to produce emesis | emetic |
in digestive tract;gas | flatus |
distention caused by accumulation of gas | flatulence |
discharge from vagina(after delivery) | lochia |
menstruation present when admitted | catamenia present |
menstruation starts after admission | catamenia established |
menstruation painful | dysmenorrhea |
total absence of menstruation | amenorrhea |
profuse flow;menstruation | menorrhagia |
occurs between periods | metrorrhagia |
cessation of;menstruation | menopause |
loss of muscle size;musculoskeletal system | atrophy |
joints bending | flexion |
to straighten joints | extension |
joints turn downward | pronation |
joints turn upward | supinaton |
joints revolved around | rotation |
joints move away form median | abduction |
joints move toward median | adduction |
upper back | interscapular region |
small of back | lumbar region |
end of spine | sacral region |
gluteal area | buttocks |
hump back | kyphosis |
sway back | lordosis |
aware of surroundings, fuly conscious | alert, fully conscious |
responds only to very painful stimuli | coma;unresponsive |
drowsy at inappropriate times; but can be aroused | lethargic, somnolent |
aroused only by vigorous and continous stimulation | stuporous |
indifferent;showing little or no emotion | apathetic |
fainting | syncope |
dizzy | vertigo |
loss of memory | amnesia |
tension or contraction of cuscle | tonic tremor |
alternately contracting and relaxing muscles | clonic tremor |
beginning of convulsion | onset |
how long seizure lasted | duration(minutes or seconds) |
hallucintion of hearing | auditory hallucination |
hallucination fo sight | visual hallucination |
hallucination of smell | olfactory hallucination |
hallucination of taste | gustatory hallucination |