Term
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Definition
| orderly collection of information concerning the patient’s health status – ongoing and continuous |
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Term
| Why do we ID the patient’s current health status? |
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Definition
| (baseline for comparison) |
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Term
| Why ID actual and potential health problems – normal vs. abnormal? |
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Definition
| formulate nursing diagnosis; Early intervention / treatment |
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Term
| Why Monitor patient outcomes. |
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Definition
| (note changes in condition) |
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Term
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Definition
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Term
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Definition
| what the patient tells us; cannot see or be measured |
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Term
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Definition
| things we can see and measure [ex: laboratory and diagnostic studies] |
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Term
| Factors influencing the interview: |
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Definition
| client, interviewer, approach, enviornment, confidentiality, time, length, duration, communication skills…open ended q's. |
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Term
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Definition
| 1st: inspection, 2nd: Olfactory, 3rd: auscultation, 4th: Percussion, 5th: Palpation |
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Term
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Definition
| use visual and olfactory senses |
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Term
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Definition
| listen for sounds produced by the body (stethoscope) – listen before palpate - listen for bruits |
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Term
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Definition
| striking thumping or tapping a surface causing vibrations to produce sound; determines density, size, shape, location and position; demarcates boundaries; determines the presence of air, fluid or solids |
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Term
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Definition
| temp, thrills, texture, moisture, masses, size, shape, location, mobility, fluid/edema/turgor/hydration |
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Term
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Definition
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Term
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Definition
| high pitched sounds: breath sounds and normal heart sounds |
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Term
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Definition
| low pitched sounds; bruits, murmurs |
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Term
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Definition
| hand washing, standard precautions when necessary (gloves) |
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Term
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Definition
| privacy(keep covered all except what you’re assessing; adequate lighting; temp; noise and interruption control (need a quiet environment) |
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Term
| Physical preparation of patient – |
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Definition
| toileting; dressed/draped; comfort (warmth, pillow); positioning |
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Term
| Psychological prep of patient – |
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Definition
| introductions/ build rapport; professional approach; openness, receptiveness; nonjudgmental attitude; explanation of procedures |
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Term
| physical assessment = systematic and well organized – |
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Definition
| cephalocaudal (head to toe); body systems; compare right to left for symmetry; investigate all things abnormal in more detail |
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Term
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Definition
| provides information about characteristics of an illness, a client’s hygiene and body image, emotional state, recent changes in weight, and developmental status. |
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Term
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Definition
| Stated age vs. apparent age |
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Term
| Assess General appearance |
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Definition
| (well kept, disheveled, mask of illness, pale, weak) |
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Term
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Definition
| (thin, emaciated, well nourished...) |
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Term
| Assess Motor activity and stature |
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Definition
| (posture, gait, guarding and extremity, sitting slumped over?) |
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Term
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Definition
| dress, grooming, personal hygiene; Mood and manner; Speech |
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Term
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Definition
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Term
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Definition
| Labored breathing, wheezing, cough, labored speech; Painful facial expressions, sweating, guarding; Serious or life-threatening occurrences; Emotional distress or anxiety |
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Term
| 3 Point Scale for pulse volume |
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Definition
| 0.. 1+…2+…3+ where 2 is N, 0 is absent, 1+ is thread/ weak, 3+ is bounding |
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Term
| 4 Point Scale for pulse volume |
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Definition
| 0… absent, 1+ thread/ weak…2+ N…3+ increased…4+ bounding |
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Term
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Definition
| temporal, carotid, apical, brachial, radial, femoral, popliteal, posterior tibial, dorsalis pedalis |
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Term
| Types of pain by duration: |
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Definition
| acute, chronic malignant, chronic non-malignant |
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Term
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Definition
| location, radiation, quality, quantity, associated manifestations, aggravating factors, alleviating factors, setting, timing, meaning and impact, rebound tenderness |
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Term
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Definition
| Normal BMI – 18.5 – 24.9, Height (over 3 years) [length under 3 years], Weight – same time daily, same clothing, same scale, Head circumference – under 3 years [fontanels usually close around 18 months] |
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Term
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Definition
| Typically unintentional weight loss of 10 lbs or greater in a month would warrant further investigation. greater than 5 % in a month or 10% in 6 months. Rapid unwanted weight loss overnight is typically due to dehydration. Intentional rapid weight loss is due to diuretics either as medical treatment or a weight loss strategy (unhealthy). Rapid weight gain overnight is typically due to fluid retention problems |
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Term
| Typically unintentional weight loss of 10 lbs or greater in a month would warrant__________ |
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Definition
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Term
| Greater than________ % in a month or_____% in 6 months. |
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Definition
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Term
| Rapid unwanted weight loss overnight is typically due to _________. Intentional rapid weight loss is due to diuretics either as medical treatment or a weight loss strategy (unhealthy). |
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Definition
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Term
| Rapid weight gain overnight is typically due to___________ |
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Definition
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Term
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Definition
| weight (kg)/ Height (m)squared |
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Term
| Intentional rapid weight loss is due to diuretics either as ___________or _________________. |
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Definition
| medical treatment or a weight loss strategy (unhealthy). |
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Term
| Head and Scalp Inspection |
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Definition
| shape, symmetry, hydrocephalus, acromegaly, bleeding, masses, lesions |
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Term
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Definition
| abnormal accumulation on cerebrospinal fluid in the ventricles of the brain. |
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Term
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Definition
| chronic metabolic condition caused by overproduction of growth hormone and characterized by gradual, marked enlargement and elongation of bones of the face, jaw and extremities. |
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Term
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Definition
| shiny, intact, without lesions or masses |
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Term
| *Pediculus Humanus capitis |
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Definition
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Term
| *Pediculus Humanus corporis |
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Definition
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Term
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Definition
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Term
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Definition
| contour, masses, depression, tenderness [temporomandibularjoint – TMJ; check for clicking when jaw opens and closes] |
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Term
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Definition
| reduced w/ aging, arterial insufficiency, alopecia, hirsutism |
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Term
| · Arterial insufficiency [PAD especially in lower extremities] – |
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Definition
| hairless, shiny skin on legs |
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Term
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Definition
| partial or complete hair loss; baldness |
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Term
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Definition
| excessive body hair in a masculine distribution |
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Term
| [temporomandibularjoint – |
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Definition
| TMJ; check for clicking when jaw opens and closes] |
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Term
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Definition
| edema, color of conjunctivae, pupil responses, extraocular movements |
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Term
| § For edema around eye area – |
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Definition
| periorbital; ptosis: droopy eyelids |
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Term
| § Color of conjunctivae – |
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Definition
| bulbar (the exposed surface of the eyeball up to the outer edge of the cornea), palpebral fissures equal (from outer corner to inner campus equal) & sclera – use cotton tipped applicator to roll eyelid off the eyeball |
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Term
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Definition
| size and shape – PERRLA [pupils equal round reactive to light and accommodation] should see changes in pupil when they change from focusing on something up close to focusing on something far away (cover uncover test) normal pupil size = 2 – 6 mm deep, black, round and equal diameter |
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Term
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Definition
| with the client sitting 2 ft. away, facing you; have the client maintain fixed head position following the movement of your finger with their eyes only look L, R, Up L & R, Down L & R |
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Term
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Definition
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Term
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Definition
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Term
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Definition
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Term
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Definition
| assesses with Snellen Eye Chart – read at 20 ft.; near vision at 14 in – assess with Rosenbaum near vision card |
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Term
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Definition
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Term
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Definition
| when light shined to the back of the eye (will also see this in pictures), corneal reflex |
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Term
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Definition
| redness, unusual shape, low position, lesions |
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Term
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Definition
| tenderness, swelling; push gently on tragus (+pain with external ear infection) |
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Term
| →Otoscopic exam for adults: |
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Definition
| hold ear up and back (out) |
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Term
| →Otoscopic exam for children: |
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Definition
|
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Term
| →light reflex on tympanic membrane: present at_____o’clock in the right ear and _____ o’clock in the left ear |
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Definition
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Term
| →Tympanic membrane: is pearly _____ with well-defined________; moves when patient blows __________ |
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Definition
| grey, landmarks. Against resistence |
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Term
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Definition
| voice whisper, weber test, rinne test |
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Term
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Definition
| normal finding: able to repeat words whispered at a distance of 2 feet |
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Term
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Definition
| assessing ears hearing equally; able to hear sound equally in both ears with tuning fork on top of the head/ forehead |
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Term
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Definition
| air conduction is louder than bone conduction; bone conduction=touching the mastoid process; air conduction = put the tuning fork out to the side of the ear see how long they hear it |
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Term
| →Inspection of the nose – |
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Definition
| note color and consistency of discharge |
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Term
| →Palpate sinuses – normal findings |
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Definition
| percussed;: no discomfort during palpation or percussion; resonance heard on percussion |
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Term
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Definition
| check for patency w/ stethoscope will be able to hear if there might be blockage or congestion when breathes against the stethoscope |
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Term
| →Mouth and throat inspect |
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Definition
| breath, lips, tongue, Buccal mucosa, gums, teeth |
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Term
| Note abnormal mouth and throat |
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Definition
| : color (pallor redness), dryness, exudate, swelling, inflammation, lesions |
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Term
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Definition
| a yeast infection of the mucus membrane lining of the mouth and tongue. Symptoms: Thrush appears as whitish, velvety lesions in the mouth and on the tongue |
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Term
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Definition
| thick, raised, pearly-white patch of precancerous tissue found on the lips, buccal mucosa, penis, or vulva |
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Term
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Definition
| is a flat red patch or lesion in the mouth that cannot be attributed to any other pathology |
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Term
| Who gets a Breast exam? – |
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Definition
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Term
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Definition
| in supine position with their hand over their head; standing with hands on hips; standing while leaning forward. |
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Term
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Definition
| lesions, moles, drainage, peau d’orange skin (orange peel skin), prominent veins, any visible lumps or dimpling |
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Term
| →Palpate – systematic manner – |
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Definition
| circular, vertical, wedge/cone sections |
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Term
| · Note masses in breast for – |
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Definition
| size, location, shape, consistency borders, mobility, tenderness, axillary lymph nodes |
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Term
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Definition
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Term
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Definition
| have patient empty bladder, lie supine with knees bent and arms at side or across chest |
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Term
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Definition
| striae (stretch marks), scars, bruising (Cullen’s: sign of internal bleeding; Grey Turner’s sign: outward bruising: bleeding internally, car accident); note shape (scaphoid – sunken); pulsations (aneurysms) or peristaltic movements |
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Term
| →Auscultation abdomen – listen to all 4 quadrants – |
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Definition
| normal bowel sounds (5 – 35 per minute) – high pitched gurgling sounds; must listen 5 minutes in each quadrant to determine no bowel sounds |
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Term
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Definition
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Term
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Definition
| determine gas from solid masses (organs, tumors, stool) |
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Term
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Definition
| light palpations – check for tenderness |
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Term
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Definition
| left lateral Sims position |
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Term
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Definition
| hemorrhoids, fissures, rashes, etc… |
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Term
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Definition
| gloved finger – note tone, internal hemorrhoids |
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Term
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Definition
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Term
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Definition
| cervix thru abdominal wall |
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Term
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Definition
| check for occult blood (hemacult) |
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Term
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Definition
| have patient empty bladder – best to perform while standing |
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Term
| →Inspect genital hair distribution – |
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Definition
| diamond shape; skin characteristics for lesions, drainage |
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Term
| · Assess for inguinal hernias – |
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Definition
| ask patient to strain or bear down – assess for bulging in inguinal area – hernia |
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Term
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Definition
| have patient empty bladder; use lithotomy or dorsal recumbent position; drape patient |
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Term
| →Inspect female genital external structures for – |
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Definition
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Term
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Definition
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Term
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Definition
| be sure to lubricate speculum |
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Term
| →Inspect muscularskeletal– |
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Definition
| extremities – color, temp, hair distribution, alignment and position |
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Term
| § Compare limb lengths – shortened extremity: |
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Definition
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Term
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Definition
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Term
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Definition
| exaggeration of the posterior curvature of the thoracic spine (hump-back) |
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Term
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Definition
| : Increased lumbar curvature (as in pregnancy/ people with large stomachs – sway back) |
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Term
| →Palpate muscularskeletal – |
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Definition
| pulses – techniques used, pulse scale 0 – 4 |
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Term
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Definition
| dorsiflex foot – check for deep vein thrombosis |
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Term
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Definition
| have patient move against resistance – arms, shoulders, legs, feet, hand grasp |
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Term
| § Use goniometer to assess |
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Definition
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Term
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Definition
| crunching grating sound or sensation (when joint moved or if move bone with fracture) once determined do not try to elicit again. Immobilize area. |
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Term
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Definition
| ribs, RR, and capillary refill |
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Term
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Definition
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Term
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Definition
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Term
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Definition
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Term
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Definition
| thoracic expansion, tactile fremitus, tracheal position |
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Term
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Definition
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Term
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Definition
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Term
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Definition
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Term
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Definition
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Term
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Definition
| resonant (there is a sequence to percussing) |
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Term
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Definition
| breath sounds, adventitious sounds, voice sounds |
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Term
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Definition
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Term
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Definition
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Term
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Definition
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Term
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Definition
| 12 – 20 breaths per minute |
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Term
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Definition
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Term
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Definition
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Term
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Definition
| no respirations for 10 or more seconds |
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Term
| Normal breathing patterns: |
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Definition
| regular and even in rhythm |
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Term
| Abnormal breathing patterns: |
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Definition
| Cheyne-Stokes – slow, irregular; a pattern of breathing you see when a person is near death: very deep breathing to shallow breathing, then apnea. Ex: COPD |
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Term
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Definition
| trying to get trapped air out |
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Term
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Definition
| (to open muscles in the back, lung expansion) orthopneic |
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Term
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Definition
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Term
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Definition
| (anterior posterior) associated with COPD and aging, Barrel chest |
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Term
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Definition
| rock type resp; abdomen goes like a rocking chair (acidosis) |
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Term
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Definition
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Term
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Definition
| long term lack of O2 (hypoxia) angulation in nail. Normal: tapered |
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Term
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Definition
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Term
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Definition
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Term
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Definition
| thoracic expansion, tactile fremitus |
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Term
| Assess for Thoracic Expansion |
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Definition
| (symmetry, rise and fall bilaterally) |
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Term
| Assess for Tactile Fremitus |
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Definition
| – hands on – palms down, fingers up – start at voice box on front (increased vibration near voice box and decreases as you move down – if fremitus increases where it’s supposed to decrease, something could be there ( tumor/ mass) |
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Term
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Definition
| N is 5-6cm, performed by percussion, measure of diaphram movement, <5cm indicates decreased diaphram movement |
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Term
| Less than 5 cm indicates decreased diaphragm movement by problems such as |
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Definition
| pneumonia and pneumothorax |
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Term
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Definition
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Term
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Definition
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Term
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Definition
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Term
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Definition
|
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Term
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Definition
| (use the diaphragm of stethoscope to listen to) |
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Term
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Definition
| coarse (sonorous) hear in inspiration/exhalation (in the bronchi) |
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Term
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Definition
| musical (mucous in bronchi) |
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Term
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Definition
| heard at the end of inspiration (fluid in alveoli) heard best at the bases of the lungs (bottom, back) fine |
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Term
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Definition
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Term
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Definition
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Term
| Bronchial sound over trachea: |
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Definition
| sound coarse (bronchovesicular) |
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Term
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Definition
| breezy, normal breath sounds of lung periphery |
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Term
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Definition
| Checked if auscultation or tactile fremitus abnormal, Use stethoscope over usual areas, patient say “99” |
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Term
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Definition
| normally muffled; clear is abnormal |
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Term
| Whisper “99” usually faint and indistinct; abnormal = |
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Definition
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Term
| changes in elderly’s lung functioning: |
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Definition
| does not cause disease, but in worse shape than a 20 year old |
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Term
| In the elderly, Everything decreases except; |
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Definition
| anterior posterior diameter is the only thing that increases, , |
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Term
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Definition
| 5th intercostal space – the point of maximal intensity (PMI) |
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Term
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Definition
| inspection-auscultation-percussion- palpation |
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Term
| for all other assessments |
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Definition
| inspection-palpation-percussion-auscultation |
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Term
| adventitious breath sounds |
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Definition
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Term
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Definition
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Term
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Definition
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Term
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Definition
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Term
| breasts use __________ and ____________. |
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Definition
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Term
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Definition
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Term
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Definition
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Term
| rectum/ anus digital inspection done by |
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Definition
|
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Term
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Definition
| moisture, temp, texture, turgor |
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