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Definition
| Begins abruptly with marked intensity of severe signs and symptoms and then often subsides after a period of treatment. |
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Definition
| Chronic disease develops slowly and persists over a long period, often for a a person's lifetime. |
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Term
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Definition
| Sign are objective data as perceived by the examiner |
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Term
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Definition
| Symptom are subjective indications of illness that the patient perceives . |
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Definition
| Objective data as perceives by the examiner. |
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Term
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Definition
| In the subjective data collection, the interviewer encourages a full description by the patient of the onset, the course, and the character of the problem and any factors that aggravate or alleviate it. |
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Term
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Definition
| A pathologic condition of the body, is any disturbance of a structure or function of the body. |
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Term
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Definition
Or purposeful observation, is the technique the nurse uses most frequently.
==> Use inspection to systematically collect data about significant behaviors or physical features. |
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Term
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Definition
Is the process of listening to sounds produced by the body.
==> For auscultation of the respiratory, cardiovascular, and gastrointestinal systems, the nurse uses stethoscope, an instrument that amplifies sounds produced by internal organs. |
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Term
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Definition
Use hand and sense of touch to gather data.
==> Use palpation to detect tenderness, temperature, texture, vibration, pulsations, masses, and other changes in structural integrity. |
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Term
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Definition
| is the initial step in the assessment process. |
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Term
| Nursing physical assessment |
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Definition
| The skill of physical assessment provide the nurse with powerful tools to detect changes in the patient's condition. |
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Term
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Definition
Is use of the fingertips to tap the body surface to produce vibration and sound.
==> The sound indicate the density of the underlying tissue and thus help the nurse detect the location of body organs and structures. |
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Term
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Definition
| Level of consciousness: alert drowsy, lethargic, oriented to: 1 (person); 2 (person, place); 3 person, place, and time); 4 (person, place, time and purpose). |
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Term
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Definition
| Skin condition, color, temperature, turgor, skin impairments, moist, dry. |
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Term
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Definition
| Apical pulse (strength and regularity), capillary refill (less than 3 seconds) in upper and lower extremities, pedal pulses (1+ to 4+), pitting derma (1+ to 4+), non pitting edema, type of intravenous fluid with rate, site condition (without edema or erythema). |
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Term
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Definition
| Posterior (lower lobes), anteriorly (upper lobes), right axilla (right middle lobe); auscultate for crackles, wheezes (sibilant and sonorous), pleural friction rub, respiration characteristics (tachypnea, orthopnea, dyspnea - resting or exertional); assess arterial oxygen saturation (SaO2)via pulse oximeter, oxygen therapy with route (cannula, mask), and liters per minute of oxygen flow (O2 2 L/min per nasal cannula) |
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Definition
| Diet, appetite,fluid intake; observe for distention; auscultate for presence of bowel sounds X 4 quadrants (active, hypoactive , hyperactive, absent by quadrants); palpate masses, tenderness, bowels movement with description, including colostomy or ileostomy stoma assessment, amount and consistency ; nasogastric suction (color and amount) |
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Term
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Definition
| Urine amount, color, odor; presence of catheters (Foley, nephrostomy, suprapublic, ureteral); voiding; include ureterostomy stoma assessment. |
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Term
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Definition
| Activity level: best rest, chair up and lib; gait and level of tolerance; ambulation aides needed, such as walker, cane, or crutches. |
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Term
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Definition
| Perform continuously process a head-to toe assessment begin with neurologic assessment, skin, the hair, the head and the neck, the assessment of head includes the eyes, ears, nose, and mouth, examine the chest, the legsm and the feet. |
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