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VN 1323 EXAM 3

Documentation & Nursing Diagnosis

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
Created by: Shevina