Lecture 1: General Survey, Assessment Techniques, & Nursing Fundamentals

Vocabulary flashcards covering assessment types, examination techniques, bedside routines, patient rights, and data documentation based on Lecture 1 notes.

General Survey

The initial "first impression" check performed the moment a nurse enters a patient's room to observe overall appearance, posture, breathing, and safety cues before starting a detailed physical assessment.

Admission Assessment

A deep, complete, top-to-bottom health history and physical exam performed when a patient first enters the facility.

Shift Assessment

A quick, focused check performed at the start of a shift to note changes from the previous shift.

Head-to-Toe Assessment

A systematic, top-to-bottom scan across all body systems to determine overall current status.

Focused Assessment

An examination limited to one specific problem area (e.g., examining only the mouth and jaw for a patient complaining of a toothache).

Inspection

Always the first step of the physical exam; uses sight, sound, and smell to observe color, size, symmetry, body shape, and movement.

Light Palpation

Physical examination technique using finger pads to press down 1/2 to 3/4 inch (<1Cm) to check surface texture, tenderness, moisture, and temperature.

Deep Palpation

Physical examination technique using one or both hands to press down 1 1/2{2} to 2 inches to feel deep internal organs or abnormal masses.

Dorsal Surface of Hand

The back of the hand; hand placement guide best for checking temperature during palpation.

Ulnar Surface

The base of fingers / palm edge of the hand; hand placement guide best for feeling vibrations during palpation.

Finger Pads

Hand placement guide best for checking pulses, tissue texture, size, and fluid during palpation.

Golden Rule of Palpation

Always palpate painful or tender areas last.

Percussion

Tapping on skin to determine if underlying organs are solid, filled with fluid, or filled with air, as well as checking for organ size and reflexes.

Auscultation

Listening with a stethoscope to sounds produced within the body.

Diaphragm (Stethoscope)

The flat side of a stethoscope pressed firmly against the skin to hear high-pitched sounds (breath sounds, normal heart sounds, bowel sounds).

Bell (Stethoscope)

The cupped side of a stethoscope placed lightly on the skin to hear low-pitched sounds (heart murmurs, abnormal blood flow).

10-Second Quick Survey

A 10-second mental checklist performed upon entering the room evaluating FACE, POSTURE, TUBES IN, DRAINS OUT, and ENVIRONMENT.

Folstein Mini-Mental State Examination (MMSE)

A quick 0–30 point cognitive test where a score above 24 indicates normal mental functioning.

COLDSPA / OLDCARTS

Pain mnemonics representing Character/Characteristics, Onset, Location, Duration, Severity (0 to 10), Pattern/Aggravating-Alleviating factors, and Associated factors/Radiation.

Confidentiality

A principle under HIPAA stating that patient health information is strictly private and cannot be shared without written consent.

Need-to-Know Standard

A HIPAA standard establishing that healthcare workers may only access medical records for patients directly under their care.

Bedside Entry Routine

A 5-step procedure upon entering a room: 1. Knock on door, 2. Wash hands & put on gloves, 3. Introduce yourself, 4. Identify patient 3 ways, 5. Provide privacy & comfort.

Subjective Data

Everything the patient or family tells you verbally (e.g., "My lower back hurts" or "I feel tired").

Objective Data

Everything measured, observed, or tested directly by the nurse (e.g., Blood Pressure 120/80 mmHg, Temperature 98.6°F, pale skin).

Electronic Health Record (EHR / SimChart)

A legal, permanent document used to record patient findings, guide care plans, justify insurance billing, and communicate patient changes to the rest of the care team.