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