Basics of Physical Assessment and General Survey

Comprehensive vocabulary flashcards covering nursing assessment fundamentals, the nursing process (ADPIE), communication skills (ISBARR), and physical assessment techniques including the General Survey.

Nursing Assessment

The systematic and dynamic process of collecting and analyzing patient health data (ANA), considered the cornerstone of patient care.

ADPIE

The nursing process framework consisting of Assessment, Diagnosis, Planning, Implementation, and Evaluation.

Assessment (ADPIE)

Collecting data related to physical, emotional, functional, nutritional, pain, medication, risk, and health history.

Diagnosis (ADPIE)

Analyzing information to identify the problem.

Planning (ADPIE)

The step of generating solutions and goals.

Implementation (ADPIE)

Carrying out specific nursing actions.

Evaluation (ADPIE)

Determining if goals were met and completing documentation.

Objective Data

Verifiable facts and evidence observed by the nurse to create a complete clinical picture for diagnosis.

Subjective Data

Information based on a person’s opinions, beliefs, or emotions, documented in quotes as what the person says.

ISBARR

A communication tool standing for Identify, Situation, Background, Assessment, Recommendations, and Read Back.

I.P.P.A.

The standard physical assessment sequence: Inspection, Palpation, Percussion, and Auscultation.

I.A.P.P.

The specific physical assessment sequence used for the abdomen: Inspection, Auscultation, Palpation, Percussion.

Inspection

The skill of health assessment involving visual observation of overall appearance, skin, posture, behavior, and nonverbal pain indicators.

Palpation

Feeling for abnormalities using light versus deep pressure to identify masses, edema, tenderness, pulses, or organ enlargement.

Percussion

Tapping quickly and sharply on body parts to identify organ locations, borders, shape, position, and the presence of fluid or gas; can be direct or indirect.

Auscultation

The process of listening to internal body sounds (cardiac, respiratory, and GI) using a stethoscope.

General Survey

The initial appraisal of a client's overall presentation and behaviors, which leads to more focused assessments.

General Survey Components

Assessment of Appearance, Behavior, Indicators of abuse/neglect/human trafficking, Body structure, Mobility, Height/weight/$BMI$, Vital signs, and Pain.

Unexpected Facial Features

Findings including an expressionless face, asymmetry, involuntary movements, swelling, or lesions.

Unexpected Level of Consciousness Findings

Abnormal cognitive states including Confusion, Lethargy, Stupor, Obtundation, and Comatose.

Unexpected Speech Findings

Speech patterns such as whispering, disarticulation, absence of speech, or abnormal tone or pace.

Diaphoresis

An unexpected skin finding characterized by excessive sweating.

Personal Hygiene Assessment

Observation of grooming, clothing, hair, nails, odor, and dental hygiene.

Direct eye contact

The expected finding for eye contact, unless deemed culturally inappropriate.