Medical Terms + Assessments

Hair loss

Blueness or purpleness of skin

Redness or pinkness of skin

Yellow skin coloring

Broad term referring to a region of the skin that has damage from injury or disease

ex. acne, birthmarks, wounds, sunburn, insect bites

Paleness of skin

Itching

Swelling

The skin's elasticity.

It is the ability of skin to change shape and return to normal

Discharge

Freckles

Fine body hair

white, creamy, naturally occurring biofilm covering the skin of the fetus during the last trimester of pregnancy

fine, present all over body

Thicker hair on head, axilla, genital, and facial regions

-Pupils equal + Round

-React to Light and Accomodation (direct constriction in one eye) (open pupil when looking away from light, close when looking close)

With the back of your hand

assessing the blood flow through peripheral tissues

When the area between the ribs and in the neck sinks in when a person with asthma attempts to inhale.

Retractions are a sign someone is working hard to breathe.

Coming from an external source or occurring in an unusual place or manner (abnormal)

Examine by touch

Examine by listening

(ex. using a stethoscope to listen to the heart, lungs, and bowels)

The pattern of blood vessels (arteries and veins), usually referring to the blue vessels located directly under the skin

The quality / health of the skin

Measurable data collected by the nurse

ex. vital signs

From the client, based on their experiences and perceptions. Includes feelings, sensations, or expectations.

ex. pain

O- Onset

P- Provocative, Palliative

Q- Quality

R- Region

S- Severity

T- Timing

U- (Pt’s) Understanding

• Physcial appearance

• Body structure

• Mobility

• Behaviour

Walk

35.8 - 37.3 °C

60 - 100 bpm

< 60 bpm

over 100 bpm, fast heart rate

3+ = full, bounding

2+ = normal

1+ = weak, thready

0 = absent

thumb side

10 - 20 breaths/min

Maximum pressure felt on the arteries when the heart contracts

Resting pressure in the blood vessels between contractions

120/80

< 95%

Standing arms length behind the person, test one ear at a time while masking the hearing in the other ear by palpating the tragus. Say a 2 syllable word.

The corners of the eyes

1:2

At the apex (bottom) of the heart, at the 5th intercostal space (between ribs 4 and 5)

5-30 sounds per minute

We start in the RLQ because that is where the large intestine begins, so the bowel sounds are most prominently heard

point toes to nose

Gas pedal

light and sharp touch across face, arms, hands, legs, and feet

Finger to thumb, rapid, alternating movements

move each heel down alternate shin

A- Asymmetry (one half is unlike the other)

B- Border (blurry or jagged edges)

C- Colour (more than one shade)

D- Diameter (greater than 6mm)

E- Evolution (growth)

1+ = mild pitting: slight indent felt but not visible.

2+ = moderate: indentation visable, subsides rapidly.

3+ = deep pitting: indent remains a short time.

4+ = very deep pitting: indentation lasts a long time ; swelling distorts limb / area.

180°

abnormal eye alignment (crossed eyes, lazy eye)

double vision

group of diseases that effect the eye nerves, increased pressure within the eyeball damages the optic nerve causing loss of sight peripherally

disease of the retina causing vision impairment or loss

farsightedness caused by loss of elasticity in the lens of the eye (common after age 40)

cloudy vision

Aging causes damage to the macula which blurs central vision.

measures visual acuity

measures near vision

rapid involuntary movements of the eye

eyelid drooping

eyelids

Earwax

Ear pain

Ear discharge

Age-related hearing loss

Ringing / buzzing in the ears

Feeling like you are spinning

Feeling like the room is spinning around you

Nearsightedness

Difficulty swallowing

Nosebleeds

Bad breath

Smell

Sore throat

“mask of pregnancy”, hyperpigmentation from hormones

Hearing loss caused by something that stops sounds from getting through the outer or middle ear.

Hearing loss caused by damage to the inner ear

A combination of sensorineural and conductive hearing loss

Bump on the side of the inside of the cheek

Under tongue, lateral to frenulum

a measure of how open the nose is

Runny nose

Loss of appetite

Buildup of fluid in abdomen

a rumbling or gurgling noise made by the movement of fluid and gas in the intestines

• an audible vascular sound associated with turbulent blood flow

• can be created by a blockage or plaque in blood vessels

Vomiting

inflammation of the liver

occurs when part of your organs bulges through an opening or weakness in the muscle or tissue barrier that contains it

Black stool (from blood)

Heartburn

A hollow drum-like sound that is produced when a gas-containing cavity is tapped sharply

Nausea and vomiting

Caused by tissue injury

Sharp, localized, injury to muscle, skin, or bones