Chapter 19 Health Assessment - Vocabulary Flashcards

Vocabulary terms and concise definitions covering the major concepts from the Health Assessment lecture notes.

Comprehensive interview and exam

Full health history plus complete head-to-toe physical assessment.

Focused examination

Exam directed at the presenting problem or specific body system.

System-specific examination

Examination limited to one body system.

Ongoing assessment

Repeated assessments as needed to monitor status or outcomes.

Privacy

Protection of client confidentiality and modesty during assessment.

Noise control

Reducing ambient noise to improve concentration and communication.

Environment preparation

Setting up room, temperature, lighting, and equipment for assessment.

Rapport

Building trust and a positive relationship with the client.

Positioning

Proper placement of the client to enhance comfort and assessment accuracy.

Inspection

Visual observation of body surfaces, movements, and behavior.

Palpation

Using touch to assess texture, size, tenderness, and temperature.

Percussion

Tapping body surfaces to assess underlying structures by sound.

Auscultation

Listening to body sounds with a stethoscope (heart, lungs, abdomen).

Olfactory examination

Using the sense of smell to detect abnormal aire odors or cues.

Infants (age modification)

Parents hold the infant; ensure safety during examination.

Toddlers (age modification)

Allow exploration or sitting on a parent’s lap; perform invasive procedures last; offer choices; use praise.

Preschoolers (age modification)

Use dolls for demonstration; parental contact allowed; involve child in examination.

School-age children (age modification)

Show approval, develop rapport, allow independence, teach about the body.

Adolescents (age modification)

Provide privacy; address normal concerns; use exam to teach healthy lifestyle; screen for suicide risk.

Older adults (age modification)

Adapt positioning for mobility; account for vision/hearing changes; assess ADLs and need for rest.

General Survey

Overall impression including appearance, behavior, posture, speech, mental state, hygiene, vitals, height/weight.

Integumentary system

Skin, hair, nails; includes color, temperature, moisture, texture, turgor, and lesions.

Skin color

Pigmentation and uniformity of skin tone.

Skin temperature

Warmth of the skin indicating perfusion and hydration.

Skin moisture

Level of hydration reflected by skin dampness.

Skin texture

Surface feel of skin (smooth, rough, flaky, etc.).

Turgor

Elasticity of the skin, indicating hydration status.

Lesions

Any abnormal skin findings such as rashes, ulcers, or moles.

Nails

Nail color, shape, texture, and capillary refill affecting circulation assessment.

The head: skull and face

Size and shape assessment of skull and facial structures.

Visual acuity

Clarity of vision; assessed through vision testing and fields.

Pupils

Size, equality, and reaction to light; part of pupil examination.

CN I – Smell

Olfactory nerve tested by smelling substances to assess sensory function.

Ears: tympanic membrane

Eardrum integrity examined via otoscopy; part of hearing assessment.

Weber’s test

Tuning fork test to detect lateralization of hearing loss.

Rinne’s test

Air vs bone conduction hearing test using a tuning fork.

Nose/Mouth & oropharynx

Examination of lips, mucosa, teeth, tongue, and oropharynx.

Cervical lymph nodes

Nodes along the neck checked for size, consistency, and tenderness.

Trachea and thyroid gland

Assessment of tracheal position and thyroid enlargement.

PMI (point of maximal impulse)

Best point to hear the heart beat; location gives cardiac size/health clues.

Heart sounds S1 and S2

S1 = mitral/tricuspid closure; S2 = aortic/pulmonic closure.

S3 and S4

S3 = early diastolic filling; S4 = late diastolic filling (stiff ventricle).

Murmurs

Abnormal heart sounds from turbulent blood flow, often indicating pathology.

Auscultation sites (heart)

Aortic (right 2nd rib), Pulmonic (left 2nd rib), Erb’s point (left 3rd), Tricuspid (left lower sternal border), Mitral (left 5th intercostal).

Central vessels

Carotid arteries palpated for pulse; assess for bruit; jugular venous pressure.

Peripheral vessels

BP, peripheral pulses, signs of hypoxemia, varicosities.

Abdomen examination order

Inspect, Auscultate, Percuss, Palpate (note the reverse order from exam of other systems).

Musculoskeletal system

Assessment of body shape, posture, gait, ROM, strength, and joint function.

Romberg’s test

Balance test assessing vestibular function and proprioception.

Cranial nerves

12 paired nerves tested to assess sensory and motor function.

Glasgow Coma Scale (GCS)

Tool to assess level of consciousness; scores for Eye, Verbal, and Motor responses (3–15).

Motor/cerebellar function

Assessment of movement, coordination, tone, balance, and proprioception.

Sensation tests

Stereognosis, Graphesthesia, Two-point discrimination, Point localization, Extinction.

Genitourinary system (male/female)

Assessment of external genitalia; presence of hernias; regional lymph nodes.

CV A tenderness (CVAT)

Costovertebral angle tenderness; test for kidney pathology (stone/pyelonephritis).