Nursing Health Assessment Fundamentals

Comprehensive vocabulary flashcards covering nursing health assessment types, data collection methods, symptom dimensions (OLDCART-M), vital signs, and physical examination techniques.

Health

The general condition of the body reported by the client; it is not just physical findings.

Nursing Health Assessment Purpose

To determine a patient’s health status, risk factors, and need for education as a basis for developing a nursing plan of care.

Comprehensive Assessment (Admission)

Performed when a patient enters or is admitted into the healthcare system (e.g., hospital).

Focused Assessment (Problem-Based)

A usually system-specific and targeted assessment (e.g., leg pain).

Time-Lapse Assessment (Follow-up)

An assessment conducted to follow up on a previous health problem, such as $HTN$.

Emergency Assessment

The rapid identification of life-threatening problems, such as chest pain.

Subjective Data

Information comprised of symptoms that the patient tells the nurse, including history, chief complaint, and Review of Systems (ROS).

Objective Data

Information comprised of signs, nurse’s observations, physical exam findings, vital signs, and lab/test results.

Therapeutic Communication Skills

Techniques used to obtain information successfully, including active listening, guided questions, nonverbal communication, validation, summarizing, and empowering the patient.

Past Medical History (PMH)

Component of subjective data including acute and chronic issues, allergies, medications, childhood and adult illnesses, OB/GYN history, and health maintenance.

Family History (FH)

Presence or absence of diseases with genetic pre-dispositions, including grandparents, parents, siblings, spouse, and children.

Social Determinants of Health

Factors affecting health including Education Access and Quality, Economic Stability, Health Care Access and Quality, Neighborhood and Built Environment, and Social and Community Context.

Review of Systems (ROS)

A list of questions organized by body systems to determine normal or abnormal function and gather information about the patient's reason for seeking care.

OLDCART-M

The eight dimensions of a symptom: Onset, Location, Duration, Characteristic symptoms, Associated manifestations, Relieving and exacerbating factors, Treatment, and Meaning.

Onset (OLDCART-M)

When the symptoms began and what the patient was doing when it happened.

Location (OLDCART-M)

Where the symptom began and if it spreads or radiates.

Duration (OLDCART-M)

How long the symptom has been going on, how long it lasts, and how often it occurs.

Characteristic symptoms (OLDCART-M)

What the symptom feels like (character/intensity) and its scale (rate $0-10$).

Associated manifestations (OLDCART-M)

Other symptoms that occur when the patient experiences the primary symptom.

Relieving and exacerbating factors (OLDCART-M)

Non-pharmacological measures (positioning, heat/ice, rest) that make the symptom better or anything that makes it worse.

Treatment (OLDCART-M)

Interventions tried, including prescribed medications, OTC, herbal, or holistic approaches (chiropractic, acupuncture), specifying amount and frequency.

Meaning (OLDCART-M)

How or why the patient believes the symptom has affected their life, including daily life, work, school, sleep, eating, and exercise.

5 Moments for Hand Hygiene

1. Before touching patient; 2. Before clean/aseptic procedure; 3. After body fluid exposure risk; 4. After touching patient; 5. After touching patient surroundings.

General Survey

Initial observations including apparent state of health, LOC, facial expression, posture, gait, skin color, odors, and signs of distress.

Anthropometric Measurements

Height and weight (usually in Metric) and Body Mass Index ($BMI$).

Pulse/Heart Rate (HR)

Auscultated on the chest for $60\,seconds$; if irregular, listen at the Apex of the Heart for another $60\,seconds$.

Pulse Oximetry

Measures arterial oxygenation saturation ($SpO_2$) by comparing light emitted to light absorbed.

Systolic Blood Pressure

The top number representing pressure in the arteries when the heart pumps.

Diastolic Blood Pressure

The bottom number representing pressure in the arteries when the heart rests between beats.

Blood Pressure Measurement Errors

Falsely high results can occur from a cuff being too small or deflating too slowly; falsely low results can occur from a cuff being too large or the arm being above the heart.

Respiratory Rate (RR)

Auscultated for $60\,seconds$ or inspected by watching the chest/abdomen rise and fall for $30\,seconds$ and multiplying by $2$.

Non-Verbal Pain Scale (NVPS)

Used to assess pain in patients who cannot communicate, evaluating indicators like facial expression, body movements, and muscle tension.

Inspection

The use of vision to examine and observe the patient.

Palpation

The use of touch utilizing hands and fingers to feel size, texture, and other qualities.

Auscultation

The use of hearing to detect movement.

Percussion

The use of hearing and touch to detect density and sounds.

Health Promotion

Assisting patients to change behaviors and lifestyles to obtain optimal health through education.

Nursing Process Steps

Assessment, Diagnosis (Nursing), Planning/Outcome, Implementation, and Evaluation.